Il semble que la mise en oeuvre des droits reconnus par les législateurs et les tribunaux en contexte d’avortement tardif et d’aide médicale à mourir connaît, en pratique, un problème d’effectuation. En effet, nous nous trouvons actuellement dans une ère où le droit accorde énormément d’importance à l’autonomie individuelle dans le domaine médical, mais où les pratiques et les autres normativités viennent considérablement limiter cette autonomie. Il convient, dès lors, de poser un regard critique sur le concept d’autonomie en contexte (...) d’avortement tardif et d’aide médicale à mourir. Ces constats soulèvent des questionnements sur le rôle et les limites du droit étatique lorsque transposé en contexte clinique, ainsi que sur le peu d’attention que porte le droit aux destinataires de la norme. Le défi consiste alors à faire cohabiter les différentes normes et valeurs afin que les mécanismes de prises de décisions traduisent un souci réel d’assurer le vivre ensemble. (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness (...) as the sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advi sory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-medical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.6769504. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)

There is a gap in the clinical bioethics literature concerning the approach to assessment of medical decision-making capacity of adolescents or young adults who demonstrate diminished maturity due to longstanding reliance on caregiver support, despite having reached the age of majority. This paper attempts to address this question via the examination of a particular case involving assessment of the decision-making capacity of a young adult pregnant patient who also had a physically disabling neurological condition. Drawing on concepts from (...) adolescent bioethics and feminist critiques of bioethical theory, we argue that limited life experience, secondary to a disabling neurological condition, can result in a lack of adult-like capacity even in a patient who is legally an adult. In such cases, it may be that autonomy, to the extent that it is to be relevant and meaningful, must be viewed through a relational lens. Furthermore, clinicians may avoid unjustifiably paternalistic practices by working with the patient help her gain a better appreciation of the consequences of her decision, thereby calling forward her capacity rather than resorting to being directive in counseling. We conclude that lessons from this case can be used to approach ethically complex instances of medical decision-making in adult patients with normal cognition but diminished experiential maturity. (shrink)

Photo by Hannah Busing on Unsplash INTRODUCTION Religion has long provided guidance that has led to standards reflected in some aspects of medical practices and traditions. The recent bioethical literature addresses numerous new problems posed by advancing medical technology and demonstrates an erosion of standards rooted in religion and long widely accepted as almost axiomatic. In the deep soul-searching that pervades the publications on bioethics, several disturbing and dangerous trends neglect some basic lessons of philosophy, logic, and history. (...) The bioethics discourse on medical aid in dying emphasizes similarity over previously recognized important distinguishing features. For example, it overplays a likeness between assistance in dying and the withdrawal of life-saving technology. In many bioethics’ topics, arguments based on a logical continuum are used to question the lines demarcating important moral differences. l. The Line Between Ethical and Not: Logic Based on Continuum Careful case selection, often either end of a continuum, allows the tearing down or ridiculing of many rules and codes across most professions and fields of interest. This situation holds true for traffic laws as well as medical ethics guidelines. It is relatively simple for those who desire to attack a particular viewpoint by selecting a case that makes that position seem untenable. In the ethics realm, good and bad medicine exist at opposite ends of an ethical continuum, with many practices lying in between. For example, much of medical ethics exists between the Nazi criminal physicians and the most sainted nurse or physician. A gradual progression occurred over less than two decades from a utilitarian position that supported limited euthanasia for those with certain mental illnesses to genocide. German society embraced a utilitarian ethic in which the value of human life no longer was intrinsic but instrumental.[1] Many morally significant points on a continuum were then ignored as the misguided utilitarian policy rampantly continued. A point in the continuum to distinguish between ethically justifiable and that which is not can be difficult to identify compared to the two extremes. This continuum is not unique to ethics but can be applied to almost any other aspect of human life and endeavor. Between a severely ill schizophrenic person and a superbly well-adjusted individual, there is a continuum of mental and psychological function. The existence of a continuum should not paralyze thinking and prevent us from drawing lines and identifying moral differences based on objective criteria as well as moral philosophy. Yet, by focusing on a continuum, many bioethicists use logic to disregard dividing lines between an "ethical" and an "unethical" act. Unfortunately, sometimes bioethicists draw revolutionary conclusions that would change the scope of medical practices which is accepted as ethical. There are many examples of similar shifts on the continuum. Many authors argue for the ethical permissibility of abortion by pointing out that the human fetus is no different in various characteristics, one arguing it is as like an ape or chick as it is like a person,[2] and does not achieve unique human and individual characteristics until well into the first year of life.[3] While human fetuses arguably do not have certain distinctive qualities of personhood, most people shy away from the logical next conclusion: permitting infanticide. For example, Joshua Lederberg condemns infanticide, in the face of biological illogic, because of our emotional commitment to infants, to me, a relatively weak explanation. Sir Francis Crick suggests we might consider birth at two days of life in order to decide whether an infant is a "suitable" member of society.[4] Giublini and Minerva suggest that infanticide should be permissible since late pregnancy abortions are permissible, arguing there is no significant difference between a fetus just before birth and an infant just after birth.[5] Clearly the continuum approach would allow for subjective arguments in favor of later infanticide at other points many days post-birth. Years ago, with a cynical tone, I mentioned infanticide as a further step on the continuum beyond abortion, and I was rightly shouted down as being deliberately provocative to assert the logic would ever stretch so far. While it is not an accepted mainstream position, the movement in academic settings from widespread condemnation to limited possible acceptance of infanticide has taken place in an incredibly short time. Public opinion and medical opinion in these areas have shifted dramatically in a short time. In another area, from a biological and chemical point of view, there is a continuum from man down to a single carbon atom. Yet, it would not seem logical to ignore the emotional differences, the meaning of personhood, or the moral distinction between killing an insect and killing a person. ll. A False Continuum: Medical Aid in Dying I assert that there has been an erosion of ethical guidelines in recent years attributable to using continuums to camouflage important distinctions. James Rachels’ work on active and passive euthanasia, which contends that the two are ethically identical, exemplifies that logic.[6] He illustrates this thesis, using a continuum to compare different scenarios with like consequences as morally equivalent, by comparing the deliberate drowning of a child with a deliberate failure to rescue a drowning child when easily able to do so. The author's comparison proposes that since much of the medical profession has already made peace with withholding treatment in order to hasten death, consistency inexorably demands that we permit active euthanasia as well.[7] When permission for active euthanasia was first introduced, it was limited exclusively to patients suffering severely from an intractable, incurable, and irreversible disease. These guidelines have been continuously eroded. There is now a substantial serious consideration for permitting active euthanasia of healthy elderly individuals who feel that they have completed their lives and are "tired of living."[8] There are many moral and factual differences along the ethical continuum. In human life, there is a difference between a live baby and a fetus, between a viable fetus and one that is not, between a fetus and a zygote, and between a zygote and a sperm cell. Similarly, there is a difference between pulling a trigger to kill someone and not interfering in preventing his death, which is reprehensible though both may be. There is a difference between not resuscitating an 80-year-old man with cancer when his heart stops and injecting him with a fatal dose of potassium chloride. I argue that an overt act of taking life repels civilized human beings is to be commended and encouraged as the reverence for human life or even for just a moment of human life is one of the great contributions of our civilization. CONCLUSION As an orthodox Jew, I feel that divinely inspired guidelines that have stood the test of centuries shape my beliefs, and such guidelines contradict medical aid in dying. I cannot speak to the viewpoint of those who do not access religion in defining their moral stance, nor do I implicate them in the current bioethics' trends, as I am not aware of the personal role of religion in the lives of most such authors. While many nonreligious people have a firm philosophical grounding and oppose medical aid in dying, I suggest that in the absence of any religious or other absolute standards, developing logically defensible ethical guidelines may be challenging. At the least, religion may play a role in defining the points on the continuums that are ethically meaningful and refuting the trending beliefs that if the endpoint is the same, allowing different methods of arriving at that end are somehow ethically equal. The continuum of ways death may result does not negate analysis of whether death is brought about in ways that recognize the importance of life. The German philosopher Hans Jonas said, "It is a question whether without restoring the category of the sacred, the category most thoroughly destroyed by the scientific enlightenment, we can have an ethics able to cope with the extreme powers that we possess today and constantly increase and are compelled to use."[9] While countries vary on the role of religion in policy, with many emphasizing freedoms of religion, a recent position paper released by a group of Jewish, Christian, and Moslem leaders suggested the need for agreement on the unique sanctity of human life.[10] I would recommend that such a document serve as an example of consensus on critical foundational bioethical guidelines for democratic secular societies. - [1] Alexander L Medical science under dictatorship. New England Journal of Medicine, 241, p39-47 DOI10.1056/NEJM194907142410201 [2] Lederberg J. A geneticist looks at contraception and abortion, Annals of Internal Medicine 67, sup 2, 25-27. https:/doi.org/10.7326/0003-4819-67-3-25 [3] Ibid. [4] Editorial, Sociology: Logic of biology. Nature 220, 429 https://www.nature.com/articles/220429b0 [5] Giublini A Minerva F After-birth abortion: why should the baby live. J Med Ethics 39, 261- [6] Rachels J Active and passive euthanasia. New England Journal of Medicine 292, 78-80 [7] Ibid. [8] Cohen-Almagor R Euthanizing people who are "tired of life". in Euthanasia and Assisted Suicide-Lessons from Belgium. Ch 11 of Euthanasia and Assisted Suicide, Cambridge University Press pp173-187. 2017 and DOI; https://doi.org/10.1017/9781108182799.012 [9] Hans Jonas, Technology and Responsibility: Reflections on the New Tasks of Ethics, 1972, found as Chapter IX, Philosophical Essays, 1980. https://inters.org/jonas-technology-responsability [10] A position paper of the Abrahamic Monotheistic religions on matters concerning the end-of-life. Vatican Press 28 October 2019 https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2019/10/28/191028f.html. (shrink)

In this paper I look at various ways that interpersonal and social relations can be seen as required for autonomy. I then consider cases where those dynamics might play out or not in potentially paternalistic situations. In particular, I consider cases of especially vulnerable persons who are attempting to reconstruct a sense of practical identity required for their autonomy and need the potential paternalist’s aid in doing so. I then draw out the implications for standard liberal principles of paternalism, specifically (...) in clinical or therapeutic situations. The picture of potential paternalism that emerges here is much more of a dynamic, interpersonal scenario rather than a case of two separate individuals making decisions independent of each other. (shrink)

Because of the emphasis on individualism and self-governance, medical interventions and medical research in Western nations are preceded by attempts to obtain informed consent from the individual patient or potential research subject. Individual autonomy expresses our belief that persons are ends in themselves and not merely instrumentalities to achieve the goals of others. By respecting the patient or potential research subject in the context of medical decisionmaking, we acknowledge that these individuals are moral agents. (...) Thus, individual autonomy is an important feature of morality as it is practiced in the West. However, there are at least two circumstances in which individual autonomy appears to be threatened. One is embodied in nonwestern societies that favor collective decisionmaking over that of the individual. The other is related to the need for family histories and family testing to determine the susceptibility of family members to some genetically based disease. In both cases, individual judgment appears to be made subordinate to collective judgment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:preface This issue of Feminist Studies explores the ways institutions—legal, governmental, medical, educational, and household—participate in the gendering of bodies and are themselves gendered. At any given historical moment, dominant and resistant meanings of “women,” “gender,” and “sexuality” are socially and politically constituted in institutions through cultural struggles. The authors in this issue discuss how birth control, assisted reproduction, transsexual transition, hegemonic masculinity, abortion, and domestic violence are (...) each articulated and contested in imperial law and economic discourses (Sreenivas), in medical procedures (Whitehead et al. and DasGupta), in university research regulations (Barnes and Munsch), and in the official practices of presidents (Mattingly ). Our authors elucidate how such institutions are gendered, not just in terms of staffing by males, females, and nongender conforming people, but also in the ways they constitute gender relations in their everyday operations. The articles point to the continuing need for institutional histories and ethnographies that are feminist in conception and design. They also provide openings into more progressive gender and sexuality politics by underscoring the contradictions within all institutions. Mytheli Sreenivas’s “Birth Control in the Shadow of Empire: The Trials of Annie Besant, 1877–1878” visits the contradictory history of institutions of reproduction control. She traces Besant’s contraception advocacy in the 1870s, reminding us of its intimate and unsavory entanglements with the politics of empire. Annie Besant is a complicated figure. South Asianists familiar with her later campaign against British colonialism in India might well be surprised by this earlier incarnation, but Sreenivas demonstrates how and why the early Besant held contradictory positions. As an individual, Besant questioned gender norms and challenged the inequality of women in marriage and divorce. She recognized sexual desire as “natural” (albeit only properly expressed via heterosexual marriage). Yet a signature feature of her political writing 504Preface was an embrace of neo-Malthusianism. Over the course of her activist life, Besant redirected her attention from poverty and women’s health in Britain to contraception as the solution to starvation and overpopulation in India. She did so in “a broader context in which a defense of empire and class-race hierarchy enjoyed far greater legitimacy than a critique of gender and sexual norms.” The repercussions of her actions were global: “Besant’s efforts rendered contraception into a sexual technology that claimed to address the economies of impoverishment in an emerging imperial world. Birth control thus emerged as both an imperial responsibility and as a demonstration of British humanitarianism in support of starving colonized populations.” Sreenivas explicates what the Besant trials reveal about the multiple histories of reproduction control and the conditions under which birth control continues to be both a technology for large-scale population control and “a vehicle for women’s reproductive freedom and gender justice.” Institutions are saturated with power, but they are also arenas where political struggles between different social groups are staged. This is especially evident in White House politics in the United States. In the late 1970s, President Jimmy Carter appointed a large number of women to bureaucratic offices. Many were feminists. Why did they fail to deliver gender justice? This is the puzzle Doreen J. Mattingly seeks to answer in “The Limited Power of Female Appointments: Abortion and Domestic Violence Policy in the Carter Administration.” The article is set in the broader context of a moment in history when the US feminist movement was moving from the streets to state bureaucracies, when women of color had broadened the movement’s mandate, and when the need for government programs to support poor women was a clearly articulated feminist goal. There was an excitement about transforming gender relations as feminists populated multiple organizations and came together to collaborate. However, two important legislative efforts—government funding for abortions for poor women and a national anti-domestic violence bill—failed. Mattingly traces the back and forth between Carter and his Assistant Secretary for Public Liaison, Margaret “Midge” Costanza, drawing on new archival sources. Mattingly’s article underscores how women in public office can be discursively valorized as symbols of change even while politically powerful men oppose meaningful policy that would provide women greater autonomy over their reproductive or violently transgressed bodies. Mattingly’s careful reconstruction... (shrink)

This book addresses the moral, social and political problems emerging from the practice of healing and caring, biomedical research and the provision of health care services. The primary aim of many professional bioethicists is, of late, to solve as efficiently as possible, the problems encountered by health care providers and scientists in clinical, laboratory and administrative settings. Seen from the viewpoint of applied philosophy, however, this is a dangerous tendency if the grounds for the suggested solutions are not (...) properly examined. Even choices which are harmless and seem to involve no immoralities can be indirectly hazardous if those making choices appeal to dubious ethical principles or inaccurate data. This is why this book is dedicated to the examination of the reasons that people can and should have for their health care related decisions as well as to the formulation of good solutions to difficult problems. It covers criterial in life and death decisions, voluntary euthanasia and medical paternalism, wrongful medical authoritarianism, health education, preventive medicine and the welfare of the population, AIDS, discrimination and legal restrictions, and health care policy-making. (shrink)

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

Context: In most jurisdictions where medical-aid-in-dying is available, this option is reserved for individuals suffering from incurable physical conditions. Currently, in Canada, people who have a mental illness are legally excluded from accessing MAiD. Methods: We developed a questionnaire for mental health care providers to better understand their perspectives related to ethical issues in relation to MAiD in the context of severe and persistent suffering caused by mental illness. We used a mixed-methods survey approach, using a concurrent embedded model (...) with both closed and open-ended questions. Findings: 477 healthcare providers from the province of Québec completed the questionnaire. One third of the sample were nurses, one quarter psychologists and one quarter psycho-educators. Nearly half of the respondents considered that people with a severe mental illness should be granted the right to opt for MAiD as a way to end their suffering. Respondents were more likely to feel comfortable listening to the person and participating in discussions related to MAiD for a mental illness than offering care or the means for the person to access MAiD. Most reported that they had not received adequate/sufficient training, education or preparation in order to address ethical questions surrounding MAiD. Conclusions: The findings highlight how extending MAiD to people with a mental illness would affect daily practices for mental healthcare providers who work directly with people who may request MAiD. The survey results also reinforce the need for adequate training and professional education in this complex area of care. (shrink)

Background Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups (...) with persons with lived experience of mental illness.Methods We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.Results A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.Conclusions Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk. (shrink)

Introductory and advanced textbooks in bioethics focus almost entirely on issues that disproportionately affect disabled people and that centrally deal with becoming or being disabled. However, such textbooks typically omit critical philosophical reflection on disability, lack engagement with decades of empirical and theoretical scholarship spanning the social sciences and humanities in the multidisciplinary field of disability studies, and avoid serious consideration of the history of disability activism in shaping social, legal, political, and medical understandings of disability over the last (...) fifty years. For example, longstanding discussions on topics such as euthanasia, physician aid-in-dying, pre-implantation genetic diagnosis, prenatal testing, selective abortion, enhancement, patient autonomy, beneficence, non-maleficence, and health care rationing all tend to be premised on shared and implicit assumptions regarding disability, especially in relation to quality of life, yet with too little recognition of the way that “disability” is itself a topic of substantial research and scholarly disagreement across multiple fields. This is not merely a concern for academic and medical education; as an applied field tied to one of the largest economic sectors of most industrialized nations, bioethics has a direct impact on healthcare education, practice, policy, and, thereby, the health outcomes of existing and future populations. It is in light of these pressing issues that the Disability Bioethics Reader is the first reader to introduce students to core bioethical issues and concepts through the lens of critical disability studies and philosophy of disability. The Disability Bioethics Reader will include over thirty-five chapters covering key areas such as: critical histories and state-of-the-field analyses of modern medicine, bioethics, disability studies, and philosophy of medicine; methods in bioethics; concerns at the edge- and end-of-life; enhancement; disability, quality of life, and well-being; prenatal testing and abortion; invisible disabilities; chronic illness; healthcare justice; genetics and genomics; intellectual disability and neurodiversity; ethics and diagnosis; and epistemic injustice in healthcare. (shrink)

One criticism of medical aid in dying (MAID) is the expressivist objection: MAID is morally wrong because it expresses judgments about disabilities or persons with disabilities, that are offensive, disrespectful, or discriminatory. The expressivist objection can be made at the level of individual patients, medical providers, or the state. The expressivist objection originated with selective abortion, and responses to it in that context typically claim either that selective abortion does not express specific judgments about disabilities, or that (...) any judgments expressed are not offensive. This response is inadequate: MAID often does express negative judgments about disabilities, which could reasonably be seen as offensive. But, does this offensiveness make MAID wrong? Drawing on Joel Feinberg’s account of offense, I argue that it is unlikely that the offensiveness of the judgments expressed by individuals who seek MAID or through the state’s legalization of MAID is enough to make it morally impermissible. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Fallout from Government-Sponsored Radiation ResearchCarol Mason Spicer (bio)On December 28, 1993, Energy Secretary Hazel R. O'Leary publicly appealed to both the executive and legislative branches of the United States Government to consider compensation for individuals who were harmed by their exposure to ionizing radiation while enrolled in government-sponsored studies conducted between 1940 and the early 1970s.1 The call for compensation was issued three weeks after Secretary O'Leary disclosed that (...) radiation experiments involving humans, sometimes without their consent, had occurred under the auspices of the Atomic Energy Commission (AEC), a forerunner of the Department of Energy (DOE). Secretary O'Leary directed her department to investigate the nature and extent of the experiments, report on their medical and ethical acceptability, and locate the research subjects or their families.Background to the Federal Advisory CommitteeDespite the fact that the existence of many government-sponsored radiation experiments was not a secret—much of the research was reported at the time in scientific journals, and in 1986, Representative Edward J. Markey (D-MA) conducted congressional hearings on such radiation research—Secretary O'Leary's disclosure of the AEC experiments and her call for compensation made the experiments common knowledge and sparked a swift and complex governmental response involving both the executive and legislative branches.It is curious that the "radiation experiments" have garnered so much attention now, since they were virtually ignored in the wake of the 1986 hearings. Secretary O'Leary's disclosure of the radiation studies grew out of a general reassessment of secrecy in government. In April 1993, the Clinton administration set out to review the system of government secrecy that evolved during the Cold War, and in May 1993, DOE began reviewing and declassifying files pertaining to nuclear weapons research. When Dan Reicher, a top aide to Secretary O'Leary, informed her in November of the impending publication of an Albuquerque Tribune investigative report (Welsome 1993) on an experiment conducted between 1945 and 1947 in which 18 subjects were injected with plutonium, [End Page 147] the topic of questionable research involving the exposure of human subjects to radiation was added to the DOE list of information to be disclosed. At the time, it was thought to be but one small part of a massive quantity of DOE information to be made public.As part of its effort to investigate the radiation experiments, DOE established a toll-free telephone hot line for individuals who thought they might have been the subjects of radiation exposure experiments. The hot line, originally staffed by three people to handle the anticipated few dozen calls per day, received more than 2,000 calls in the first week. By early January the hot line was flooded with 6,000 to 10,000 calls daily, and its staff had increased more than ten-fold. Although many of the calls were deemed not to be candidates for further investigation, the extent of the radiation-related experiments, sponsored not only by AEC, but also by the military and other government departments and agencies, took officials by surprise.On December 30, the Department of Defense, the Department of Veterans Affairs, and the National Aeronautics and Space Administration all announced that they were initiating thorough reviews of their files to determine the extent and nature of any radiation experiments conducted under their auspices.2 In January, the CIA and the Department of Health and Human Services, including the National Institutes of Health, followed suit.The White House publicly entered the arena in late December announcing that it would hold a meeting on January 3, 1994, to help coordinate the government's investigative effort. At the same time, Senator Edward M. Kennedy (D-MA) called for a mid-January congressional hearing to investigate experiments conducted between 1946 and 1956 in which mentally retarded boys at the Fernald State School in Massachusetts were fed radioactive iron supplements or milk containing radioactive calcium to enable researchers to trace the absorption of those nutrients. Senator Kennedy's hearing, conducted by the Subcommittee on Health of the Senate Committee on Labor and Human Resources, was the first of a number of congressional hearings held earlier this year to investigate the... (shrink)

In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors' personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue (...) that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: removing a right to conscientious objection; selecting candidates into relevant medical specialities or general practice who do not have objections; demonopolizing the provision of these services away from the medical profession. (shrink)

Shavelson and colleagues (2023) describe how medical aid-in-dying laws in the United States prohibit assistance in administering aid-in-dying medication. This prohibition distinguishes aid in dying...

Background Relational autonomy is an alternative concept of autonomy in which an individual is recognized as embedded into society and influenced by relational factors. Social context, including social location, political structure, and social forces, significantly influence an agent to develop and exercise autonomy skills. The relational approach has been applied in clinical practice to identify relational factors impacting patient autonomy and decision-making, yet there is a knowledge gap in how these factors influence the demonstration (...) of relational autonomy in the context of medical decisions of adults. Objective The present study targeted the existing knowledge of what and how relational factors impact individuals making medical decisions using the theoretical framework of relational autonomy. Methods A meta-synthesis study was utilized. Four electronic databases, including Embase, OVID Medline, CINAHL, and PubMed, were searched, along with gray literature and reference lists, to identify relevant studies. Results 23 studies reporting 21 qualitative and two mixed-method studies were reviewed. Four themes emerged from the qualitative findings: (1) supportive relationships facilitate an individual’s relational autonomy; (2) obtaining comprehensive information from broader sources helps individuals exercise relational autonomy; (3) undue family pressure impedes the exercising of patient relational autonomy; and (4) healthcare providers’ dominant voice hampers the demonstration of relational autonomy. Conclusions Applying relational autonomy to assist adults in making well-considered decisions is essential. The meta-synthesis suggests establishing a supportive relationship between individuals, healthcare providers, and family. A supportive relationship will allow healthcare providers to make judgments in line with an individual’s values and wishes with the aim of promoting relational autonomy. Advance care planning was proposed as the effective solution to obtain a consensus between individuals and their families while respecting an individual’s values and preferences. Furthermore, it is considered crucial for healthcare providers to appreciate an individual's values and incorporate their preferences into recommendations. (shrink)

The clinical introduction of medical devices often occurs with relatively little oversight, regulation and (long-term) follow-up. Some recent controversies underscore the weaknesses of the current regime, such as the complications surrounding the metal-on-metal hip implants and the scandal surrounding the global breast implant scare of silicone implants made by France's Poly Implant Prothese (PIP) Company. The absence of national registries hampered the collection of reliable information on the risks and harms of the PIP breast implants. To warrant long-term (...) safety, a case can be made for mandatory post-marketing surveillance by means of the establishment of compulsory registries. In this edition of Public Health Ethics, Schofield calls for debate on how such a registry system should be initiated and maintained and how it would relate to the ethical requirement of consent. Here we use breast implant registries as a case to discuss whether and when a so-called ‘thick opt-out’ would be an appropriate method to include people in medical device registries. We conclude that a thick opt-out procedure for medical device registries is only justifiable in cases where inclusion does not involve burdens (or very low), when it does not involve a sensitive subject and when the data are stored anonymously (or at least not directly linked to the medical record). Otherwise, inclusion should be sought by means of an opt-in. (shrink)

BackgroundThe terminal illness of late-stage Alzheimer’s and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die—which many advance directives cannot provide. Proxies/agents’ substituted judgment may not be concordant with patients’ requests. While advance directives can be patients’ (...) last resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive’s requests to cease assisted feeding.AimThis article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters’ selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are implemented. The article includes excerpts from “dementia-specific” directives or supplements that exemplify each flaw—mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests “Cease assisted feeding” but the incapacitated patient apparently expresses the desire to “Continue assisted feeding.” Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities’ additional clinical criteria as a prerequisite to honor the requests in patients directives.ConclusionThis critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients’ wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care? (shrink)

The principle of individual medical confidentiality is one of the moral principles that Africa inherited unquestioningly from the West as part of Western medicine. The HIV/AIDS pandemic in Southern Africa has reduced the relevance of the principle of individual medical confidentiality. Individual medical confidentiality has especially presented challenges for practitioners among the Bantu communities that are well known for their social inter-connectedness and the way they value their extended family relations. Individual confidentiality has (...) raised several unforeseen problems for persons living with HIV/AIDS, ranging from stigma and isolation to feelings of dejection as it drives them away from their families as a way of trying to keep information about their conditions confidential. The involvement of family members in treatment decisions is in line with the philosophy of Ubuntu and serves to respect patients’ and families’ autonomy while at the same time benefiting the individual patient. (shrink)

In June 2015, the Supreme Court of Canada struck down the Criminal Code's prohibition on assisted death. Just over a year later, the federal government crafted legislation to entrench medical assistance in dying (MAiD), the term used in Canada in place of physician‐assisted death. Notably, Canada became the first country to allow nurse practitioners to act as assessors and providers, a result of a strong lobby by the Canadian Nurses Association. However, a legislated approach to assisted death has proven (...) challenging in a number of areas. Although it facilitates a degree of accountability, precision and accessibility, it has also resulted in particular challenges negotiating the diverse perspectives of such a morally contentious act. One of these challenges is the tendency to conflate what is legal and what is moral in a modern liberal constitutionalism that places supreme value on autonomy and choice. Such a conflation tends to render invisible the legal and moral/ethical considerations necessary for nurses and nurse practitioners to remain ethical actors. In this paper, we introduce this conflation and then discuss the process of lawmaking in Canada, including the legalization of MAiD and the contributions of nursing to that legalization. We then engage in a hypothetical dialogue about the legal and moral/ethical implications of MAiD for nursing in Canada. We conclude with an appeal for morally sustainable workspaces that, when implementing MAiD, appropriately balance patient choices and nurses’ moral well‐being. (shrink)

BackgroundMedical aid in dying was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.MethodsA retrospective chart review of all MAiD requests between December 2015 and June 2017 at (...) two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.ResultsOf 80 patients requesting MAiD, 54% received the intervention. The median number of days between the request for MAiD and the patient’s death was 6 days. The majority of palliative care consults came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 at the time of the MAiD request and 19% were receiving life-prolonging interventions.InterpretationWe highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians’ approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Navigating Hard Situations that Medical School Cannot Prepare You ForJenna BennettI imagined my first experience with grief as a medical student would be peaceful and measured, prompted by the quiet and peaceful [End Page 88] passing of an elderly individual who lived a long life, surrounded by loving family members comforting each other and reminiscing. Of course, I knew things would get harder—I just didn't expect (...) it to be during my first clinical experience as a medical student.My vision for my first experience with grief as a medical student was idealistic, but I was not unfamiliar with grief on a professional or personal basis. Prior to medical school, I was an aide at a long-term care facility. Many patients were on hospice, so end-of-life care and conversations took place daily without fear or shame. Deaths in this setting had happened as I envisioned—a natural course after a long life. Most of the time, the patients and their families were prepared and accepting. It was, of course, a somber occasion no matter how prepared everyone was, but death was almost never unexpected or met with anything other than tearful acceptance. As an aide, I felt honored to provide care at the end of one's life.In my personal life, I had similarly lost elderly family members. Although it was upsetting to have my loved ones pass away, no matter how much time we had to prepare, my family and I were never blind-sided and had time to discuss final wishes and cherish time together; however, for my family, there was one exception to this. When I was young, my father unexpectedly passed away from a heroin overdose. He was alone when he died, not even 30 years old.For a long time, I was ashamed of my father's death. I was very young, and I didn't understand the nature of addiction. I was angry, confused, and embarrassed. As a result, I created my own version that I thought was more palatable, for years telling everyone he had passed away surrounded by a loving family after a long battle with lung cancer.Over the years, I came to terms with my father's death. I learned that substance use is a disease, not a choice. I forgave my dad, along with eventually also forgiving myself for my years of denial and shame. His struggles and death ended up being a large motivation to pursue a career in the medical field, along with being a key part of my identity that I no longer hesitate to share. Despite having matured in this way long before starting medical school, I now recognize I still had some lingering rejection of the wide reality of tragedies that exist in our world.My first clinical experience as a medical student was a 3-week rotation with pediatric hospitalists. By the halfway point of this rotation, I was having a great time and was excited to finally be working with patients after months of sitting in lecture halls and late nights in the library. Of course, all the children we saw were sick, which was hard to see, but all the patients either had viral infections or chronic, but usually non-life-threatening, conditions. Therefore, everyone in our service rapidly improved with minimal interventions, and almost everyone was able to go home after just a few days. I was also encouraged by how loving and knowledgeable all of the family members of the patients were. Even when family members were upset and occasionally took frustrations out on the physicians I was working with, I was not shaken and empathized entirely, as I knew the families' reactions resulted from love and concern for their children. Overall, these initial experiences with patients and their families maintained my optimism that things wouldn't get emotionally hard for me anytime soon, but life, and subsequently medicine, do not wait for you to be ready.I was chatting with my attending one morning toward the latter half of this rotation. Another care team came into our small workroom, which was not unusual, but I could immediately tell something was different... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Institute of MedicineRuth Ellen Bulger (bio)IN 1863 the National Academy of Sciences (NAS) was established by federal charter to advise the government on scientific matters. Almost 100 years later, in 1971, the Academy created the Institute of Medicine within the NAS to focus on health-related problems and issues. Today the IOM has a program budget of about $13 million, which includes both private and government funds, and is (...) regarded as a leading center for health policy research.After briefly explaining the structure and general goals of IOM, this article describes several new or anticipated projects as well as some recently completed reports that have a strong ethical component.The IOMThe IOM's distinguished membership is made up of health care professionals of all sorts, scientists working in health-related disciplines, and lawyers, economists, and others knowledgeable in and involved with policies and activities associated with health issues. It is organized around eight working groups or divisions: Health Sciences Policy; Health Care Services; Health Promotion and Disease Prevention, including AIDS activities; International Health; Biobehavioral Sciences and Mental Disorders; the Food and Nutrition Board; the Medical Follow-up Agency; and the Health Policy Fellowship Programs. Each of these divisions is assisted by an oversight board that provides advice on its activities.It is important to know at the outset that IOM has decided that each of the divisions will include consideration of human values and ethical issues in their activities. Therefore, no separate locus was established within the IOM to deal with these matters. I am director of the Division of Health Sciences Policy, which is the only division that has made ethics a priority in its work, and it is the focus of this article.We have addressed questions of ethics, human values, social values, decision making, and priority setting in many of the division's reports. In fact, most of our reports at least raise ethical questions. In addition, a portion of the interest from endowment funds given to IOM by the Howard Hughes Medical Institute has been devoted to work in this area. [End Page 73]The division's advisory board, headed by Claude Bennett, chairman of the Department of Medicine, University of Alabama at Birmingham School of Medicine, has decided on two major priorities for the division: (1) foster an environment conducive to productive research, and (2) anticipate the impact of scientific—especially biomedical—advances on society, monitoring and considering the social and ethical factors that accompany basic scientific and technological progress. These two priorities are interdependent because the fostering of a good environment for research presupposes that the results of this research will produce beneficial effects for the society that supports the research.Upcoming StudiesSociety has been unable to establish a mechanism for discussing in a meaningful way—and possibly resolving—a number of pressing national issues with social, ethical, legal, and scientific ramifications. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research considered several such issues and produced important reports about them. However, the commission was funded only until 1983. The Congressional Biomedical Ethics Advisory Committee was authorized in 1985 to address these contentious issues, but it was caught in the crossfire of congressional abortion politics and subsequently died. A new model is needed to attempt to develop national consensus on these complex, contentious issues.The Board on Health Sciences Policy has wrestled with this idea. Recently, it approved a proposal to establish a study committee charged with developing effective alternative methodologies for anticipating and addressing the social, legal, and ethical issues that may accompany rapid advances in biomedical science and technology. This multidisciplinary committee will be given a series of tasks: (1) to explore past experiences with some of these varying methodologies (i.e., town meetings, consensus conferences, forums, commissions, etc.); (2) to develop an agenda of issues likely to arise in the future; (3) to define and test a variety of alternative methodological approaches to these questions; (4) to evaluate strengths, weaknesses, and impact of the various approaches; and (5) to make recommendations on the process and structure by which this fact-finding, analytical, and decision-making function could be... (shrink)

Background: While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women’s experiences with these encounters have rarely been examined. Objective: The objective of this study was to explore ambivalent abortion-seeking women’s experiences of their encounters with health personnel. Research design: The data were collected in individual interviews and analysed with dialogical narrative analyses. Participants and research context: A total of 13 women (aged 18–36 years), who were uncertain of whether (...) to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics. Ethical considerations: Approval was granted by the Regional Committee for Medical and Health Research Ethics. Findings: The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women’s experiences with encounters with health personnel were identified: the respected women; the identified women; and the abandoned women. Discussion: The findings are discussed in terms of the ambivalent pregnant woman’s autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel. Conclusion and implication: Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women’s values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence. (shrink)

Every year approximately 18 million people die prematurely from treatable medical conditions including infectious diseases and nutritional deficiencies. The deaths occur primarily amongst the poorest citizens of poor developing nations. Various groups and individuals have advanced plans for major international medical aid to avert many of these unnecessary deaths. For example, the World Health Organization's Commission on Macroeconomics and Health estimated that eight million premature deaths could be prevented annually by interventions costing roughly US$57 bn per year. This (...) essay advances an argument that human rights require high-income nations to provide such aid. The essay briefly examines John Rawls' obligations of justice and the reasons that their applicability to cases of international medical aid remains controversial. Regardless, the essay argues that purely humanitarian obligations bind the governments and citizens of high-income liberal democracies at a minimum to provide major medical aid to avert premature deaths in poor nations. In refusing to undertake such medical relief efforts, developed nations fail to adequately protect a fundamental human right to life. (shrink)

Medical assistance in dying (MAiD) was legalized in Canada in 2016. Canadians’ opinions on the service are nuanced, particularly as the legislation changes over time. In this paper, we outline findings from our review of representations of MAiD in Canadian news media texts since its legalization. These stories reflect the concerns, priorities, and experiences of key stakeholders and function pedagogically, shaping public opinion about MAiD. We discuss this review of Canadian news media on MAiD, provide examples of four key (...) themes we identified (vulnerability, autonomy, dignity, and human rights), and discuss their implications for health policy and equity. Though key stakeholders share the values of autonomy, dignity, and human rights, they appeal to them in diverse ways, sometimes with conflicting policy demands. These representations offer a useful gauge of how views about MAiD continue to shift alongside changes in federal legislation. These stories can influence related policies, respond to the powerful voices that shape MAiD legislation, and have the potential to change national conversations. Our analysis adds to the existing body of scholarship on MAiD by examining post-Bill C-7 news media, identifying related health equity issues and tensions, and discussing potential impacts of MAiD’s representations in news media. (shrink)

Contemporary American medical ethics was born during a period of social ferment, a key theme of which was the espousal of individual rights. Driven by complex cultural forces united in the effort to protect individuality and self-determined choices, an extrapolation from case law to rights of patients was accomplished under the philosophical auspices of ‘autonomy’. Autonomy has a complex history; arising in the modern period as the idea of self-governance, it received its most ambitious philosophical elaboration in (...) Kant's moral philosophy. In examining the Kantian construction, it is evident that neither his universal moral imperative nor his rigorous application of self-legislated ethical action can sustain our own notions of moral agency in a pragmatic, pluralistic society. But the Kantian position is useful in highlighting that self-governance is not equivalent to ‘autonomy’, and this distinction defines the limits of autonomy in the clinical setting. A critique of Engelhardt's idea of ‘principle of permission’ is used to illustrate autonomy's eclipse as a governing principle for medical ethics. (shrink)

Background In February, 2015, the Supreme Court of Canada struck down the ban on medical assistance in dying. In June, 2016, the federal government passed Bill C-14, permitting MAiD. Current medical students will be the first physician cohort to enter a system permissive of MAiD, and may help to ensure equitable access to care. This study assessed medical student views on MAiD, factors influencing these views, and opportunities for medical education. Methods An exploratory cross-sectional survey was (...) developed and distributed to medical students across all years of a three-year Canadian undergraduate medical program. The investigators administered the survey to participants during academic sessions from November to December, 2015. Analysis of the results included summary descriptive statistics, Pearson’s chi-square test of independence to identify differences between participants by year of study, logistic regression to identify factors that influence students’ stances on MAiD, and Wilcoxon signed rank test to measure changes in student support for MAiD and comfort discussing MAiD. Results There were 405 participants for a response rate of 87%. The majority of students supported the Supreme Court’s decision, 61% would provide the means for a patient to end their life, and 38% would personally administer a lethal medication. Students who were more willing to provide the means for MAiD found medical education/clinical experience and patient autonomy to be important contributors to their stances on MAiD. Those students who were less willing to provide the means for MAiD found religious/spiritual beliefs and teachings, as well as concern about potential negative consequences, to be important contributors to their stances on MAiD. Educational training desired by participants included medicolegal, communication skills, technical skills, and religious. Conclusions Medical students generally supported and would provide the means for MAiD to patients. They also indicated a desire for directed medical education on MAiD. (shrink)

In the context of medical tourism, circumvention tourism consists of traveling abroad with the intention of participating in a health-related activity that is prohibited in one’s own country but not in the destination country. This practice raises a host of legal and ethical questions that focus on how the traveler should be treated once they have returned home. Joshua Shaw1 deftly shows that the question of whether circumvention tourists should be punished in their home countries is not something that (...) can be answered in principle and without reference to the prima facie morality of the prohibition. This implicates formalist accounts of circumvention tourism developed by Pennings2 and Huxtable3 that argue against punishing travelers who access fertility treatments and medical assistance in dying abroad on the grounds that civic peace and stability require opportunities for individuals to travel internationally to access domestically prohibited medical services. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryRathi Mahendran, Associate ProfessorThe doctor-patient relationship has an important role in medical practice and in medical ethics.1 In modern times, the word “boundary” is used to frame the relationship. In the context of therapy, Gutheil and Simon have described it as “the edge of appropriate or professional behaviour, transgression of which involves the therapist stepping out of the clinical role”.2 Boundaries establish for (...) class='Hi'>medical professionals the distinctions between professional and personal identity.3 In a therapeutic setting, boundaries distinguish acceptable and appropriate interactions and the parameters of professional conduct.4 Implicit in the concept of boundaries are the basic ethical principles of beneficence (doing good, acting in another person’s best interests), non-maleficence (doing no harm) and justice with respect for the individual’s needs and autonomy.The doctor-patient relationship is particularly important in psychological therapies where trust, integrity, confidentiality, a safe environment and empathy are fundamental to the therapeutic process. A person with BPD manifests emotional dysregulation with instability in interpersonal relationships, self-image, affect and impulsivity.5 This, together with identity disturbances, makes them a particularly vulnerable group with heightened reliance on their therapist.6Psychotherapy has been described as an interaction which serves to alleviate distress, change behaviour and alter the patient’s perspective of issues. This description however does not reflect the magnitude and significant power differentials in the relationship. Trust and a close bond are needed to allow issues to be addressed.7 In the process, patients’ fantasies and unmet emotional needs [End Page 191] might lead them to knowingly or unknowingly view their therapist differently and to seek a relationship. Similarly, multiple factors in the therapist (situational factors, intrapsychic and interpersonal factors) can undermine the therapeutic process.8Boundary TransgressionsThere is really no universal definition for a “therapeutic boundary” possibly because, as Simon explains, it is “a function of the nature of the patient, the treatment and the status of the therapeutic alliance”.9 Minor violations are referred to as boundary crossings which may arise because the therapist exhibits poor judgement.10 Such actions are non-exploitative and pose little risk to patients.11 Duckworth et al. describe how boundary crossings begin as “exaggerations of desirable attitudes”. Special arrangements and sessions for the patient and extending therapy sessions may be construed as desirable and arguably as effective for the therapeutic alliance.12 Yet, if not examined objectively, they become “subtle breaks in the therapeutic frame”.13Psychotherapists trained in analytic therapy hold very rigid views of doctor-patient interactions in psychological therapy. Some would argue that providing a personal telephone number for a patient in crisis situations is a permissible boundary crossing.14 Similarly, self-disclosure for modelling and on-site behaviour therapy interventions may be viewed as necessary for the therapeutic encounter.15The most commonly recognised boundary crossing, however, is self-disclosure.16 It occurs when the therapist relates a personal experience or information to the patient which is how the incident began in this case.17 It gradually progressed to an informal, friendly style of interaction, accepting a hug, thanking her for being a good friend, all of which are dissonant with the psychotherapeutic process.18In the first place, should the therapist have even offered to drive her home, notwithstanding the heavy downpour? While that offer could be viewed as helpful, the disclosure of marital problems was inappropriate and created confusion. We can only speculate upon the therapist’s behaviour. Was he trying to establish for his patient that they were both experiencing problems to gain her trust? Was he exhibiting some form of identification or did he have some unmet need for affirmation and for care and nurturance? It is difficult to rationalise the apparently thoughtless and impulsive behaviour.19The therapist was, at that point, vulnerable with marital problems and facing separation.20 Procci has highlighted that therapists who breach boundaries, “usually have serious personal problems and may have a psychiatric diagnoses”.21 Even though the relationship was non-sexual, it [End Page 192] moved beyond a boundary crossing and should be viewed as a boundary violation. While the most serious form of boundary violation is the sexual encounter... (shrink)

COVID-19 has turned many ethical principles and presuppositions upside down. More precisely, the principle of respect for autonomy has been shown to be ill suited to face the ethical challenges posed by the current health crisis. Individual wishes and choices have been subordinated to public interests. Patients have received trial therapies under extraordinary procedures of informed consent. The principle of respect for autonomy, at least in its mainstream interpretation, has been particularly questioned during this pandemic. Further reflection on the (...) nature and value of autonomy is urgently needed. Relational autonomy has been proposed as an alternative account of autonomy that can more adequately respond to contemporary ethical issues in general and to a pandemic such as the one we are currently facing in particular. As relational autonomy is an emerging notion in current bioethics, it requires further consideration and development to be properly operationalized. This paper aims to show how six different philosophical branches––namely, philosophy of nature, philosophical anthropology, existential phenomenology, discourse ethics, hermeneutics, and cultural anthropology––have incorporated the category of relation throughout the twentieth century. We first delve into primary philosophical sources and then apply their insights to the specific field of medical ethics. Learning from the historical developments of other philosophical fields may provide illumination that will enable bioethics to experience a successful “relational turn”, which has been partially initiated in contemporary bioethics but not yet achieved. (shrink)

Conceptions of autonomy in western philosophy and ethics have often centred on self-governance and self-determination. However, a growing bulk of literature also questions such conceptions, including the understanding of the autonomous self as a self-governing independent individual that chooses, acts, and lives in accordance with her or his own values, norms, or sense of self. This article contributes to the critical interrogation of selfhood, autonomy, and autonomous decision making by combining a feminist focus on relational dimensions of (...) selfhood and autonomy with phenomenological philosophy of the embodied self as being-in-the-world. It offers a philosophical investigation of different dimensions of bodily relational autonomy by turning to phenomenological accounts of the lived body as self-reflexive. When so doing, we hope to contribute to bridging the gap that sometimes exists between discussions of autonomy in analytic moral philosophy and of freedom and facticity in phenomenological philosophy. We see this gap as unfortunate, and hold that a nuanced understanding of autonomy and autonomous decision making can be reached if these strands of philosophy are brought into dialogue. (shrink)

In ethical debate the questions often matter more than the answers. By raising questions about the anomalies in clinical practice concerning the moral status of the fetus, Boyle et al are contributing to the debate.There can be no starker reminder of the legal anomaly around fetal/infant rights than the hospital which deals simultaneously with abortions and intensive care of neonates. In the course of my own clinical practice I have recoiled from the horror of late abortions being (...) whisked to the neonatal intensive care unit , and struggled with the ethical complexities of decision making for infants born at the edge of viability. But many years of detailed researching of the lived experiences of both staff and parents in relation to limitation of treatment,1,2 lead me to the conclusion that to focus discussion on fetal/infant rights is unhelpful. Theoretically the issues may well be conceptualised in this way, but the reality is very different.It is true that a mother has the right to request termination of her pregnancy at a stage where there is at least some possibility of a viable fetus . It is also true that the rights of the fetus may only be realised once it has passed through the birth canal and established itself as a separate individual. A sharp divide at 24 weeks seems illogical, and indeed the whole notion of viability is something of a legal fiction. But in reality things are not as confrontational or as irreconcilable as this paper seems to suggest. Viewed from the perspective of the doctors, nurses, and parents at the coalface of NICU, talk of the child’s rights and interests suddenly superseding those of the parents is a distortion; and a picture of arbitrary conflicting reactions on the two …. (shrink)

The introduction of medical assistance in dying (MAID) in Quebec and Canada raises the question of extending this service to minors. The constant presence of nurses at the patient’s bedside leads them to receive requests related to MAID. The aim of this study is to explore the perceptions of nurses working in paediatric oncology services concerning the possibility for adolescents over 14 years of age requesting MAID. Six nurses working in paediatric oncology or palliative care or in direct contact (...) with adolescents at the end of their lives as part of their nursing work took part in an individual semi-directed interview. The results of this research highlight that: 1) nurses recognise their supportive role in the care of patients at the end of life; 2) most have a professional opinion in favour of the MAID for adults and distinguish this from their personal opinion; 3) they value the discussions around the MAID and are concerned about the establishment of criteria for it; and 4) long experience as a nurse leads to more concerns about the expansion of the MAID, but at the same time makes nurses more comfortable providing information about this subject. In light of these findings, academic and paediatric health care institutions need to recognise and evaluate the need for training nurses on MAID to better equip them to deal with such situations and thus better meet the needs of their patients. (shrink)

Principle-based formulations of bioethical theory have recently come under increasing scrutiny, particularly insofar as they give prominence to personal autonomy. This essay critiques the dominant conceptualization of autonomy and urges an alternative formulation freed from the individualistic assumptions that pervade the prevailing framework. Drawing on feminist perspectives, I discuss the need for a vision of patient autonomy that joins relational experiences to individuality and acknowledges the influence of patterns of power and authority on the exercise of patient agency. Deficiencies (...) in the current models of science and social relations guiding medical practice are analyzed, particularly (1) the tendency to disregard the patients self-knowledge and (2) failure to recognize limitations on the generalizability of medical knowledge. Models of social relations such as mothering and friendship are explored to advance a conception of autonomy better suited to the practical activities of medicine. In conclusion, I consider how acknowledgement of the specificity and complexity of social relations can contribute to reconfiguration of other principles comprising the standard framework of bioethics, particularly beneficence, justice, and equality. (shrink)

Acentral promise of human embryonic stem cell research is the potential to develop viable therapeutic approaches to a range of devastating diseases and conditions. Despite excitement over such advances, there are scientific and medical reasons to be cautious as stem cells and their products are introduced into patients. In response to such concerns, the International Society for Stem Cell Research as well as ad hoc groups and individuals have offered approaches to governance of this research. While there are (...) similarities among these governance models and they are in principle easily endorsable, in this paper I raise a set of concerns related to their implementation, suggesting areas where gathering data may facilitate more appropriate oversight. Next, I suggest areas that seem to have been neglected as these governance models have been developed so that they may be on the agendas of those seeking to revise these models in the future. Finally, I describe how some of the concerns that have arisen in considering the appropriate governance of stem cell research may be useful in science and translational research more broadly. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, (...) how decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

Many AIDS-related issues are polarised. At the social level, civil rights or liberties are seen as being in conflict with general utility, and an analogous distinction is often assumed to exist at the one-to-one, individual level at which doctors work. In this paper the latter form of the distinction is argued to be false. By seeing autonomy as part of welfare, doctors can think more directly about such issues as paternalism, confidentiality, and consent. A number of these issues are (...) discussed in the light of the revised conception of welfare, in the form of simplified case studies. (shrink)

In _Discrimination Against the Dying_, Philip Reed argues, among other things, that ‘right to die laws (euthanasia and assisted suicide) also exhibit terminalism when they restrict eligibility to the terminally ill’. 1 Additionally, he suggests ‘the availability of the option of assisted death only for the terminally ill negatively influences the terminally ill who wish to live by causing them to doubt their choice’. 1 I argue that on scrutiny, neither of these two points hold. First, we routinely limit a (...) course of treatment to only those for whom we believe the treatment might provide a benefit. Typically, we do not think hastening death provides benefit when an individual is not experiencing a terminal illness. Thus, I conclude, either all treatments are discriminatory, or medical aid in dying is not. Second, I argue that permitting individuals to refuse or remove life sustaining care may very well cause... (shrink)

Developed in the past two decades, the clustered regularly interspaced short palindromic repeats‐associated protein 9 (CRISPR‐Cas9) technique offers greater accessibility and efficiency in editing genes. Its immediate success has transformed medical research and treatment in productive ways, but has also left questions about ethical consequences in its wake. These are questions familiar to bioethical inquiry. How do we balance short‐term and long‐term benefits and risks? How do we promote just and equitable access to new medical interventions? How do (...) we protect respect for individual autonomy? These questions require a balance between protecting individuals' liberties and the good of the communities in which they live. In this essay, I am interested in how the principle of respect for autonomy can be interpreted in light of CRISPR‐Cas9. I argue that a relational autonomy framework forges a middle ground between the need to respect individual freedom to pursue genetic treatments and the need to acknowledge the networks of dependence that define our moral worlds. I identify three thematic areas that relational autonomy brings into greater focus: the importance of trust, the acknowledgment of vulnerability/dependence, and the promotion of justice. Autonomy understood relationally allows us to see individual freedom as tethered to communal well‐being. (shrink)

Recent criticism of the role of respect for autonomy in bioethics has focused on that principle's status as ‘dogma’ or ‘ideology’. I suggest that lying beneath many applications of respect for autonomy in medical ethics are some influential dogmas — propositions accepted, not as explicit premises or as a consequence of reasoned argument, but simply because moral problems are so frequently framed in such terms. Furthermore, I will argue that rejecting these dogmas is vital to secure and protect an (...) autonomy worthy of respect. The concept of autonomy that is widely applied in clinical ethics emphasises decision-making competence, at the expense of considering the authenticity of those decisions. Respect for such autonomy is interpreted in largely synchronic and individual terms — concerned with the isolated decisions of individual agents — and thus neglects the diachronic and social dimensions of many moral dilemmas arising in the health care context. I will examine how these unwritten rules lead to an impoverished understanding of respect and a systematic neglect in bioethics of certain kinds of ethical consideration, and draw on insights from feminist and communitarian work on autonomy to sketch an alternative approach to understanding respect, modelled on the norms of respectful conversation — a respect that is firstly concerned with engaging with the another as a potential giver and bearer or reasons, and working with them to promote both individual and social flourishing. (shrink)

BACKGROUND: Patient autonomy has gradually replaced physician paternalism as an ethical ideal. However, in a medical context, the principle of individual autonomy has different meanings. More knowledge is needed about what is and should be an appropriate understanding of the concept of patient autonomy in clinical practice. AIM: To challenge the traditional concept of patient autonomy by applying a discourse analysis to the issue. METHOD: A qualitative case study approach with material from one consultation. The discourse is (...) interpreted according to pragmatic and text-linguistic principles and provides the basis of a theoretical discussion of different concepts of patient autonomy. RESULTS: The consultation transcript illustrates how the patient's wishes can be respected in real life. The patient, her husband and the doctor are all involved in the discourse dynamics, governed by the subject matter, namely her mental illness. CONCLUSION: We suggest a dynamic and dialogue-based conception of autonomy as adequate for clinical purposes. These perspectives, based on mutual understanding, take communication between patient and doctor as their starting point. According to this approach, autonomy requires a genuine dialogue, an interpersonal mode of being which we choose to call "authentic interaction". (shrink)

This book is the result of a long-standing clinical and educational cooperation between a medical psychologist (Bergsma) and a medical ethicist/philosopher (Thomasma). It is thoroughly interdisciplinary in its examination of the difficulties of honoring the patient's and the physician's autonomy, especially in light of the changes in health care worldwide today. Although autonomy has become the primary standard of bioethics, little has been done to link it to the ways people actually behave, nor to its roots in (...) the healing relationship. Combining as it does the disciplines of psychology and philosophy, this book is a step in that direction. (shrink)

continent. 1.2 (2011): 78-91. This article consists of three parts. First, I will review the major themes of Quentin Meillassoux’s After Finitude . Since some of my readers will have read this book and others not, I will try to strike a balance between clear summary and fresh critique. Second, I discuss an unpublished book by Meillassoux unfamiliar to all readers of this article, except those scant few that may have gone digging in the microfilm archives of the École normale (...) supérieure. The book in question is Meillassoux’s revised doctoral dissertation L’Inexistence divine (or The Divine Inexistence ), with its seemingly bizarre vision of a God who does not yet exist but might exist in the future. Without literally accepting this view, I will claim that it is philosophically interesting in ways that even a hardened sceptic might be able to appreciate. Third and finally, I will speculate on the possible future of Meillassoux’s speculative materialism itself. And here I mean its future development not by Meillassoux, but by those readers who might be inspired by his book. Plato could never have predicted the emergence of Aristotle’s philosophy, despite the obvious debt of the latter to the former. Nor could Descartes have predicted Spinoza and Leibniz, nor Kant the German Idealists, and neither could Husserl in 1901 have foreseen the later emergence of Heidegger. How are the works of interesting philosophers transformed by later thinkers of comparable importance? While it may seem that there are countless ways to do this, I think there are only two basic ways in which this happens: you can radicalize your predecessors, or you can reverse them. I will close this article with a few words about these two methods, and try to imagine how Meillassoux might be radicalized or reversed by some future admirer. My view is that the more important thinkers are, the easier they are to radicalize or reverse. This helps explain why the great philosophers of the West have so often appeared in clusters, succeeding one another at relatively brief intervals during periods of especial ferment. 1. After Finitude After Finitude is unusually short for such an influential book of philosophy: running to just 178 pages in the original French, and an even more compact 128 pages in the English version, despite the introduction of roughly eight pages of new material for the English edition. Rather than summarizing Meillassoux’s book in the order he intended, I will focus on six points that strike me as the pillars of his debut book. Along the way, I will offer a few criticisms as well. The first pillar of the book is Meillassoux’s own term “correlationism.”1 Although he introduces this term as the name for an enemy, it is striking that Meillassoux remains impressed by correlationism much more than his fellow speculative realists are. This continued appreciation for his great enemy influences the shape of his own ontology. Is there a world outside our thinking of it, or does the world consist entirely in being thought? Traditionally, this dispute between realism and idealism has been dismissed in continental philosophy as a “pseudo-problem,” in a strategy pioneered by Husserl and extended by Heidegger. We cannot be realists, since following Kant we have no direct access to things-in-themselves. But neither are we idealists, since the human being is always already outside itself, aiming at objects in intentional experience, deeply engaged with practical implements, or stationed in some particular world-disclosing mood. The centuries-old dispute between realism and idealism is dissolved by saying that we cannot think either real or ideal in isolation from the other. There is neither human without world nor world without human, but only a primordial correlation or rapport between the two. This is what “correlationism” means: philosophy trapped in a permanent meditation on the human-world correlate, trying to find the best model of the correlate: is it language, intentionality, embodiment, or some other form of correlation between human and world? Among other problems, this generates some friction between philosophy and the literal meaning of science. When cosmologists say that the universe originated 13.5 billion years ago, they do not mean “13.5 billion years ago for us ,” but literally 13.5 billion years ago, well before conscious life existed, and thus at a time when there was no such thing as a correlate. Meillassoux also coins the term “ancestrality” (10) for the reality that predated the correlate, and later expands this term to “dia-chronicity,” (112) to refer to events occurring after the extinction of human beings no less than to those occurring before we existed. Up to this point, Meillassoux’s focus on ancestral entities existing prior to consciousness might seem like a straightforward realist who wants to unmask correlationism as just another form of idealism. Yet Meillassoux also admires the correlationist maneuver, which can obviously be traced back to Kant. Unlike a thinker such as Whitehead, Meillassoux feels no nostalgia for the pre-critical realism that came before Kant: “we cannot but be heirs of Kantianism,” he says (29). What impresses Meillassoux about correlationism is something both simple and familiar. If we attempt to think a tree outside thought, this is itself a thought . Any form of realism which thinks it can simply and directly address the world the way it is fails to escape the correlational circle, since the attempt to think something outside of thought is itself nothing other than a thought, and thereby collapses back into the very human-world correlate that it pretends to escape. For Meillassoux this step, suggested by Kant but first refined by the ensuing figures of German Idealism, marks decisive forward progress in the history of philosophy that must not be abolished. Any attempt to break free from the correlate must first acknowledge its mighty intellectual power. Realist though he may seem, Meillassoux’s works are filled with praise of such figures as Fichte and Hegel, not of so-called “naïve realists.” It is also the case that for Meillassoux, not all correlationisms are the same. The second pillar of his book is a distinction between various positions that I have termed “Meillassoux’s Spectrum,” though of course he is never so immodest as to name it after himself. He distinguishes between at least six different possible positions, and perhaps we could add even subtler variations if we wished. But in its simplest form, Meillassoux’s Spectrum allows for just four basic outlooks on the question of realism vs. anti-realism. Three of these are easy to understand, since we have already been discussing them. At one extreme is so-called “naïve realism,” which holds that a world exists outside the mind, and that we can know this world. Meillassoux rejects this naïve realism as having been overthrown by Kant’s critical philosophy. At the other extreme is subjective idealism, in which nothing exists outside the mind. For to think a dog outside thought immediately turns it into a thought, and therefore there cannot be anything outside; the very notion is meaningless. In between these two is what we have called correlationism. And here comes a crucial moment for Meillassoux, since he distinguishes between the two forms of “weak” and “strong” correlationism, and chooses the strong form as the launching pad for his own philosophy. Weak correlationism is easy to explain, since we all know it from the philosophy of Kant. The things-in-themselves can be thought but not known. They certainly must exist, since there cannot be appearances without something that appears. And we can think about them, which idealism holds to be impossible. They are simply unknowable due to the finitude of human thought. Strong correlationism is the new position introduced by Meillassoux (though he sees it at work in numerous twentieth century thinkers), midway between weak correlationism and subjective idealism. The major difference between the three positions is as follows. Weak correlationism says: “The things-in-themselves exist, but we cannot know them.” The subjective idealist says: “This is a contradiction in terms, since when we think the things-in-themselves, we already turn them into thoughts.” But the strong correlationist says: “Just because ‘things-in-themselves’ is a meaningless notion does not mean that they cannot exist. No one has ever traveled to the world-in-itself and come back to make a report on it. Thus, the fact that we cannot think things-in-themselves without contradiction does not prove that they do not exist anyway. There may be things-in-themselves, we simply are not capable of thinking them without contradiction form within the correlational circle.” This step is crucial for Meillassoux, since strong correlationism is the position he attempts to radicalize into his own new standpoint: speculative materialism. As I see it, this step of the argument fails. Strong correlationism cannot avoid collapsing into subjective idealism, since the statements of the strong correlationist are rendered meaningless from within. All three of the other positions in the Spectrum make perfectly good sense even for those who disagree with them. The naïve realist says that things-in-themselves exist and we can know them; the meaning of this statement is clear. The weak correlationist can say that things-in-themselves exist but lie forever beyond our grasp; this too makes perfect sense, even though the German Idealists try to show a contradiction at work here. We can also understand the claim of the subjective idealist that to think anything outside thought turns it into a thought, and that for this reason we cannot think the unthought. The strong correlationist, alone among the four, speaks nonsense . This person says “I cannot think the unthought without turning it into a thought, and yet the unthought might exist anyway.” But notice that the final phrase “the unthought might exist anyway” is fruitless for this purpose. For we have already heard that to think any unthought turns it into a thought. But now the strong correlationist wants to do two incompatible things simultaneously with this unthought. On the one hand, he neutralizes the unthought by showing that it instantly changes into just another thought. But on the other hand, he wants to appeal to the unthought as a haunting residue that might exist outside thought, thereby undercutting the absolute status of the human-world correlate found in idealism. But this is impossible. If you accept the argument that thinking the unthought turns it into a thought, you cannot also add “but maybe there is something outside that prevents this conversion from being absolutely true,” because this “something outside” is immediately converted into nothing but a thought for us. In short, Meillassoux here seems to be offering a kind of Zen koan: his “strong correlationism” is reminiscent of the gateless gate, or the sound of one hand clapping, or the command to punch Hegel in the jaw when meeting him on the road. We cannot at the same time both destroy the realist challenge of the things-in-themselves in order to undercut realism and reintroduce that very realist sense in order to undercut idealism. In a world where everything is instantly converted into thought, we cannot claim that there might be something extra-mental anyway, because this “might be something” is itself converted into a thought by the same rules that condemned dogs, trees, and houses to the idealist prison. This brings us to the third pillar of Meillassoux’s argument, which is the key to all the rest: the necessity of contingency. His strategy is to transform our supposed ignorance of things-in-themselves into an absolute knowledge that they exist without reason, and that the laws of nature can change at any time for no reason at all. In this way the cautious agnosticism of Kantian philosophies is avoided, but so is the collapse of reality into thought as found in German Idealism. Meillassoux does try to prove the existence of things-in-themselves existing outside thought; he simply holds that they must be proven after passing through the rigors of the correlationist challenge, not just arbitrarily decreed to exist in the manner of naïve realism. As he puts it, “Everything could actually collapse: from trees to stars, from stars to laws, from physical laws to logical laws; and this not by virtue of some superior law whereby everything is destined to perish, but by virtue of the absence of any superior law capable of preserving anything, no matter what, from perishing” (53). If idealism thinks that the human-world correlate is absolute, for Meillassoux it is the facticity of the correlate that is absolute. He tries to show this with a nice brief dialogue between five separate characters (55-59) which is covered in detail in my forthcoming book,2 but which I will simplify here for reasons of time. In this simplified version, we first imagine a dogmatic realist arguing with a dogmatic idealist. The realist says that we can know the truth about the things-in-themselves; the idealist counters that we can only the truth about thought, since all statements about reality must be turned into statements concerning our thoughts about reality. Here the correlationist enters and proclaims that both of these positions are equally dogmatic. For although we have access to nothing but thoughts, we cannot be sure that these thoughts are all that exist; there could be a reality outside thought, there is simply no way to know for sure. And this latter position is the one that Meillassoux attempts to transform from an agnostic, skeptical point into an ontological claim about the contingency of everything. Consider it this way. How does the correlationist defeat the idealist? The idealist holds that the existence of anything outside thought is impossible. The correlationist, by contrast, holds that something might exist outside the human-world correlate. But this “something might” has to be an absolute possibility. It cannot mean that “something outside thought might exist for thought ,” because that is what the idealist already says. No, the correlationist must mean that something might exist outside thought quite independently of thought. In other words, the correlationist says that idealism might be wrong, and this means it is absolutely true that idealism might be wrong. Thus, correlationism is no longer just a skeptical position. It holds that all the possibilities of the world are absolute possibilities. We have absolute knowledge that any of the possibilities about the existence or non-existence of things-in-themselves might be true, and this means that correlationism flips into Meillassoux’s own position: speculative materialism. As Meillassoux sees it, there are only two options here. Option A is to absolutize the human-world correlate, which is what the idealist does: there absolutely cannot be anything outside thought. Option B, by contrast, is to absolutize the facticity of the correlate: its character of simply being given to us, without any inherent necessity. The correlationist cannot have it both ways by saying: “there absolutely might be something outside thought, yet maybe this is absolutely impossible.” In other words, once we escape dogmatism we can only be idealists or speculative materialists, not correlationists. The human-world correlate is merely a fact, not an absolute necessity. But this facticity itself cannot be merely factical: it must be absolute. Here Meillassoux coins the French neologism factualité , which has been suitably translated into the English neologism “factiality.” (7, 122-3) Factialty means that for everything that exists, it is absolutely possible that it might be otherwise, not just that we cannot know whether or not it might be otherwise. Just as Kant transformed philosophy into a meditation on the categories governing human finitude, Meillassoux wishes to turn philosophy into a meditation on the necessary conditions of factiality, which he calls “figures”—a new technical term for him. (80) One such figure is that the law of non-contradiction must be true, and for an unusual reason. Since everything is proven to be contingent, nothing that exists can be contradictory, for whatever is contradictory has no opposite into which it might be transformed, and thus contingency would be impossible.3 Another such figure is that there must be something rather than nothing: for since contingency exists, something must exist in order to be contingent. It is a daring high-wire act, one that sacrifices realism to the correlational circle in order to rebuild it from out of its own ashes. Some might conclude that the lack of reason in things is a byproduct of the ignorance of finite humans, Meillassoux is making precisely the opposite point. For in fact, the doctrine of finitude usually leads directly to belief in a hidden reason. The fact that it lies beyond human comprehension merely increases our belief in this arbitrarily chosen concealed ground. By defending anew the concept of absolute knowledge Meillassoux evacuates the world of everything hidden. The reason for things having no reason is not that the reason is hidden, but that no reason exists. Thus, even while insisting on the necessity of non-contradiction, he rejects the other Leibnizian principle: sufficient reason. Everything simply is what it is, in purely immanent form, without deeply hidden causes. Or as Meillassoux puts it: “There is nothing beneath or beyond the manifest gratuitousness of the given—nothing but the limitless and lawless power of its destruction, emergence, or persistence” (63).The world is a “hyper-chaos”(64). But this is not the same thing as flux. For the chaos of the world is such that stability might occur just as easily as constant, turbulent change. Let’s now digress a bit, and return to the question of ancestrality, which Meillassoux transforms later in the book into “dia-chronicity.” Correlationism holds that all talk of a world outside the correlate is immediately recuperated by the correlate. The phrase “13.5 billion years ago” becomes “13.5 billion years ago for us ,” and the phrase “the universe following the extinction of humans” becomes “the universe following the extinction of humans for humans .” But notice that whether we talk about the world before or after humans, in both cases it is time that is used to challenge the correlate. Meillassoux has no interest in challenges that might be posed by space. For example, what about a vase in a lonely country house that topples to the floor and smashes when no one is there to watch it? Isn’t this also a challenge to correlationism, no less than the Big Bang or the heat death of the universe long after humans have vanished? In an eight-page supplement to the English translation of After Finitude ,4 possibly in response to my own 2007 review of the French original,5 Meillassoux bluntly denies that space is of any relevance to the question. Spatial distance is a merely harmless challenge to the human-world correlate. After all, even though no one is there in the lonely country house to witness the shattering of the vase, we can say that had there been an observer , that observer would have witnessed the toppling and destruction of the vase. For this event still occurs in a world in which the human-world correlate already exists, whereas the diachronicity of events both before and after the existence of humans makes it impossible to say that had there been an observer they would have witnessed the Big Bang occurring in such and such a fashion. However, it seems to me that Meillassoux merely asserts that the temporal simultaneity of our existence with that of the vase in the lonely country house is enough to render it harmless. It is true that the house does not exist prior to the correlate, but nonetheless it exists outside the correlate, and that is enough to make the same challenge. It is difficult to see why the “had there been an observer” maneuver succeeds in the case of a vase in the countryside in April 2011 but fails in the case of the Big Bang. This is not just a matter of nitpicking Meillassoux’s argumentative style: the fact that he bases his argument on time has at least two important consequences for his position. For in the first place, even though Meillassoux insists that the laws of nature are absolutely contingent, this turns out to be true only in a temporal sense. That is to say, it is a paradoxical feature of Meillassoux’s philosophy that he does allow for the existence of laws of nature, and simply believes that they can change at any moment without reason. Within any given moment, laws of nature do exist. He never suggests that different parts of the universe can have different laws at the same time, nor does he have any interest in the laws of part/whole composition that take place within any given instant. Could it be the case that rather than being made of gold atoms, a small chunk of gold could be made of silver atoms, cotton, horses, or that this same small piece of gold could be made of gigantic vaults filled with even more gold? These are not topics that draw Meillassoux’s attention, since he is focused solely on how the laws of nature might change or endure from one moment to the next . Another implication for Meillassoux’s system is that his concept of things-in-themselves turns out to be to be inadequate. For when he proves that things-in-themselves can exist without humans, this turns out to be true only in a temporal sense as well. Namely, things-in-themselves existed ten billion years ago, and they will continue to exist after all humans have succeeded in exterminating themselves. However, being able to exist before our births and after our deaths is just one small part of what it means to be a thing-in-itself. The more important part is that even if a thing is sitting on a table right now, in front of me, even if I stroke it lovingly or press my face up against it directly, I am still dealing only with a phenomenal version of the thing; the thing-in-itself continues to withdraw from all access. Yet no such thing is acknowledged by Meillassoux. For him finitude is a disaster, and absolute knowledge is in fact possible. Meillassoux’s thing-in-itself exists in independence only of the human lifespan , not of human knowledge. The fifth pillar of Meillassoux’s argument is his use of Cantor’s transfinite mathematics to show that even if the laws of nature are contingent, they need not be unstable, and thus we cannot use the apparent stability of nature to disprove his metaphysics of absolute contingency. What Cantor showed is that there are different sizes of infinity, and that all these infinities cannot be totalized in a single infinite number of infinities. Meillassoux sees this as crucial, since it allows him to discredit any “probabilistic” argument against his theory. The probabilistic argument (as defended quite clearly by Jean-René Vernes)6 would say this: given that the laws of nature seem so stable, it it is extremely improbable that there is no hidden reason for their remaining so stable. As Meillassoux sees it, probability is of value only when we can index an accessible total of cases. These can even be infinite: for example, there are an infinite number of points where a rope can break when stretched tight, but this does not stop us from calculating probabilities for various sections of the rope to break. By contrast, there is no way to sum up the number of possible laws of nature. For here there is no way to totalize; we cannot stand outside of nature and calculate the possible number of laws so as to determine the probabilities that any one of them might change. Therefore, although we can speak of probability when dealing with intraworldly events such as elections, horse races, and coin-flips, we cannot use the words “probable” or “improbable” when describing alterations at the level of nature as a whole. Rather than commenting on the validity of this argument and its use of Cantor, let me simply note that it once again creates a dualistic ontology. We already saw that Meillassoux treats time differently from space. In analogous fashion, he now treats the level of world differently from that of intraworldly events. The emergence of worlds is purely contingent and virtual and governed by no probability at all, while events within the world necessarily follow laws (even if these laws can change at any moment without reason), and thus their probabilities can be calculated. It is a strategy deeply reminiscent of Badiou’s (2005) own dualism between the normal “state of the situation” and the rare and intermittent “event.” The sixth and final pillar of Meillassoux’s book can be dealt with briefly, since we have already touched on it elsewhere. It comes at the very beginning of the book, when Meillassoux says that we must revive the distinction between primary and secondary qualities, and that the primary qualities are the ones that can be mathematized. He admits that he has not yet published a proof of this idea, though in fact it is already known as one of his primary doctrines. And here we encounter the familiar problem with Meillassoux’s inadequate conception of things-in-themselves. “Primary qualities” refers to those qualities that a thing has independently of its relations with us or anything else. But if the primary qualities can be mathematized, this means that they are not entirely independent of us, since our knowledge can get right to the bottom of them. The mathematized qualities of things are independent of us only in Meillassoux’s sense that they will still have those qualities even when all humans are dead. But to repeat, autonomy from the human lifespan is not the same as autonomy from human access. Here once more Meillassoux is concerned only with independence from the human-world correlate across time, not in any given instant. 2. L’Inexistence divine In 1997, the same year in which he turned thirty years old, Meillassoux earned his doctorate at the École normale supériuere with a brazen dissertation entitled L’Inexistence divine ( The Divine Inexistence ). The work was substantially revised in 2003. But even then, with typical fastidiousness, Meillassoux decided that the work was not yet ready for press. It has now been scrapped in favor of some future, multi-volume work bearing the same title. While writing my book on Meillassoux for Edinburgh University Press, I was permitted to translate excerpts from this unpublished work for use as an appendix in my own book; in total, the appendix contains approximately twenty percent of Meillassoux’s 2003 manuscript, the first time any of it will be published in any language. Nonetheless, a portion of the argument was already tested in the article “Spectral Dilemma,” published in English in the journal Collapse (2008: 261-75). There the philosophical motives for the virtual God are already made clear. What troubles us most are early deaths, brutal deaths, deaths of especial injustice– the sorts of deaths in which the brutal twentieth century was so abundant. And here, neither the atheist nor the believer can help us. The atheist can offer nothing but a sad and cynical resignation when reflecting on the victims of these terrible crimes. The believer does little better, being unable to explain how God could have allowed such things to happen, due to the famous intractability of the problem of evil. The solution offered to this dilemma by Meillassoux is bold, and all the more so given that he emerges from such a deeply Leftist, materialist, and unreligious background. His solution is that God does not yet exist, and therefore is not blameworthy for these catastrophes. Given that everything is contingent in Meillassoux’s philosophy, this God and divine justice might never exist, but they can at least exist as an object of hope. Let’s begin by jumping to the end of L’Inexistence divine , where the alternatives are laid out so nicely. There are four basic attitudes that humans can have towards God, Meillassoux says. First, we can believe in God because he exists. This is the classical theist attitude, rejected for the simple reason that it would be amoral and blasphemous to believe in a God who allows children to be eaten by dogs, to use Dostoevsky’s example. Second, we can disbelieve in God because he does not exist: the classical atheist attitude. But this leads to sadness, cynicism, and a sneering contempt for the greatness of human capacity. The third option, rather more complex, is to disbelieve in God because he does exist: in other words, to exist in rebellion against God as the one who must be blamed for the evils of the earth. The examples here might range from Lucifer himself, to the more human figure of Captain Ahab in Melville’s Moby-Dick , to Werner Herzog’s even more recent catchphrase, “Every man for himself, and God against all.” That leaves only the fourth option: believing in God because he does not exist. Meillassoux closes his book by saying that the fourth option has now been tried (namely, in the course of his own book), and that now that all four have been specified, we must choose. The first reaction to this theory of the inexistent God will be laughter. Few readers will ever be literally convinced by it, and probably none will immediately be convinced by it. But if we ask ourselves why we laugh, the answer is because it sounds so improbable that an inexistent God might suddenly emerge and resurrect the dead. It obviously sounds more like a gullible theology than a rigorous piece of philosophical work. Yet two things need to be kept in mind. First, Meillassoux’s theories are hardly more unlikely than those of great philosophers of the past such as Plato, Plotinus, Avicenna, Malebranche, Spinoza, Leibniz, Nietzsche, or Whitehead. We read the great philosophers not because their systems are plausible in commonsense terms that can be measured by the laws of probability. Instead, we read them precisely because they shatter the existing framework of common sense and open up new window on the universe. Second, and even more importantly, Meillassoux has already rejected probability as a valid measuring stick in philosophy. Or rather, he accepts probability in the intra-worldly realm (where it is linked with potentiality), and rejects it at the level of the world itself (where potentiality is replaced with what he calls virtuality). The virtual God can appear at any moment for no reason at all, just as any other new configuration of laws of nature can appear: in a manner that the laws of probability cannot calculate. Responding to those who might ridicule the idea of a sudden emergence of God and a resurrection of the dead, Meillassoux cites Pascal, who asserts that the resurrection of the dead would be far less incredible than the fact that we were born in the first place. This shifts philosophy onto new ground. Rather than concerning ourselves with what is likely to happen in the world as we know it, we focus instead on the most important things that could happen. For this reason, the expected objection that a virtual God is no more likely to appear than a virtual unicorn or a virtual flying spaghetti monster misses the point. Unicorns and spaghetti monsters could also appear, just like any other non-contradictory thing. But these would just be novel bizarre entities among others, not the heralds of completely new worlds. For Meillassoux, the emergence of matter, life, and thought have been the three truly amazing advents of the world so far, each of them dependent on the advent(s) preceding them. As he sees it, there can be no greater intraworldly entity than the human beings who already exist, since nothing in the world is better than the absolute knowledge of which humans alone are capable. This means that the next great advent must be something that perfects human beings rather than superseding them. And this can only be the world of justice, in which the dead are resurrected and their horrible deaths partially cancelled (Meillassoux never considers the possibility of a God who would literally erase the pre-divine past so that it never happened at all). The only immortality worth having is an immortality of this life, not an existence in some ill-defined afterworld. Human existence, he holds, must always be governed by a “symbol” that gives us the “immanent and comprehensible inscription of values in a world.” And just as cosmic history made the three great contingent leaps of matter, life, and thought, with a leap to justice as the only one still to come, a similar structure occurs within human culture and its symbols, which consist so far of the cosmological, naturalistic, and historical symbols, with a “factial” symbol still to come. We can review each of these symbols briefly. The cosmological symbol refers to the ancient dualism between the terrestrial and celestial spheres. Here below everything is conflict, corruption, and decay; but in the heavens nothing is perishable, all movement is circular, and everything is arranged in mutual harmony. This symbol is ended by modern physics when Galileo discovers such blemishes as sunspots and craters on the moon, and when Newton integrates both celestial and terrestrial movement into a single gravitational law. Next comes the naturalistic or romantic symbol, in which perfection comes not from the sky but from nature itself. The world is filled with pretty flowers (Meillassoux claims that the ancients never discussed the beauty of flowers until Plotinus in the third century) and with living creatures naturally moved by pity, at least until society corrupts them. This symbol collapses in the face of reality as we know it, since pity is no more common than war, corruption, and violence. This brings us to the historical symbol, which only now is passing away. Bad things may happen, but history has an inner logic of its own, such that everything works out in the end. The ultimate form of the historical symbol is the economic symbol, whether in a Marxist or neo-liberal form. Just as the Marxist holds that the inner economic logic of the capitalists will inexorably lead them to self-destruction, the neo-liberal assumes that the sum total of individual selfish actions will lead, in the long run, to the greatest possible good. We worship the economy and let it guide history for us, just as the ancients worshipped celestial bodies and held them to be free from blemish. The final remaining symbol is the factial symbol, which Meillassoux hopes will now emerge. Factiality, we recall, is his term for the absolute contingency of everything that exists. Once we have grasped this absolute contingency, we are free to expect the dramatic advent of the coming fourth World: the world of justice, inaugurated by a virtual God and even mediated by a messianic human figure. There is the added feature, however, that this messiah must abandon all claims to special status once the messianic realm of justice is achieved. The messianic figure will then be no more special than any person on the street, since a reign of human equality will have arisen. Although this focus on human being might seem like a return to standard humanism, Meillassoux holds that human pre-eminence has never truly been maintained. Previously, humans have been treated as special only because they contemplate the Good, because they resemble their omnipotent creator, or because they happen to be the temporary victors in a cruel Darwinian death-match between millions of living species. For Meillassoux, by contrast, humans have value because they know the eternal. But it is not the eternal that is important, since this merely represents the blind, anonymous contingency of each thing. What is important is not knowledge of the eternal , but knowledge of the eternal. We should not admire Prometheus for stealing fire from the gods; Prometheus is simply as bad as all the gods, no matter how much he increased our power. Feuerbach and Marx were wrong to say that God is a projection of the human essence, since for Meillassoux the usual concept of God represents the degradation of the human essence. If the traditional God was allowed to inflict plagues and tsunamis on the human race, the Promethean human of the twentieth century simply assumes the right to inflict death camps and atomic fireballs instead. In this respect, we have simply begun to imitate the degradation of humanity that was formerly invested in an omnipotent and arbitrary God. In response to charges that absolute contingency might lead to political quietism, Meillassoux counters that the World of justice would mean nothing unless we had already hoped for it beforehand. A World of justice that came along at random would merely be an improved third World of thought: indeed, a perfect one. But it would have satisfied no craving, and would therefore have no redemptive power. For this reason, we must actively hope for the fourth World of justice for such a fourth World ever to arise. Not only justice, but beauty is dependent on such hope: for Meillassoux, who is here somewhat dependent on Kant, beauty means an accord between our human symbolization and the actual world, which could never be present in a World of the blessed any more than justice could. And just as a messianic figure is needed to incarnate our hope and then abandon power once the World of justice is realized, it is the figure of the child whose fragile contingency shows us a dignity and a demand for justice beyond all power. 3. Meillassoux Radicalized or Reversed Given the promising reception of Meillassoux’s first book, it would not be groundless to engage in early speculation about what it might take to earn him a place in the history of philosophy. Maybe this will never happen—who knows?—but quite possibly it will: his lucid argumentative methods and sheer philosophical imagination at least make him a good candidate to be read well into the future, especially following further elaboration in print of his mature system. Philosophy is often practiced as thought it were nothing more than the amassing of “knockdown arguments.” But this is no more insightful than saying that good architecture is the amassing of steal beams. It is true that poorly constructed building cannot stand for long, but sound construction is merely the first, indispensable step in building. In fact, I am inclined to say that what really makes a philosopher important is not being right, but being wrong . I mean this in a very specific sense. I once heard the interesting remark about twentieth century culture that “you have to remember that the sixties really happened in the seventies.” That is to say, it was in the 1970’s rather than the more honored 1960’s that civil rights, free love, long hair, and the rock and roll drug culture really took root. With respect to the history of philosophy, we might just as easily say: “you have to remember that Plato really happened in Aristotle,” that “Kant really happened in Hegel” or “Hume really happened in Kant,” or that “Husserl’s phenomenology first achieved its truth in Heidegger.” One becomes an important philosopher not by being right, but by attracting rebellious admirers who tell you that you are wrong , even as their own careers silently orbit around your own. To recruit faithful disciples may be comforting and flattering, but the greatest thinkers have generally had to experience refutation at the hands of their most talented heirs. For this reason, I would propose that we size up the magnitude of living thinkers not by deciding how many times they are right and wrong, but by asking instead: who would take the trouble to refute this author? For this reason I do not ask: “Is Meillassoux right?”, since I do not believe in the virtual God myself, nor am I convinced by any important aspect of Meillassoux’s philosophy. Instead, I ask if there are interesting ways to overturn him. Only by being overturned, by no longer remaining a contemporary, does one become a classic. Let’s begin with a simple model of refutation, which can be refined further at a later date once the basic point is established. One kind of refutation simply consists in saying: “This author is a complete idiot.” The refuter now walks away in celebration, and no link between the present and the future is built; all is reduced to rubble. But this sort of mediocre triumphalism is generally practiced by those who achieve little of their own, and is not especially interesting. Much more interesting is the sort of refutation that does not take its target to be a complete idiot. I would like to suggest that there are just two basic ways in which this can be done: radicalization and reversal . It has not escaped my notice that this is a fairly good match for the Deleuzian distinction between irony and humor. Whereas irony critiques and adopts the opposite principle of what it attacks, humor accepts what it confronts but pushes it into highly exaggerated form. The ironist is like the worker who sows chaos by rebeling and contradicting the boss, while the humorist is like the worker who follows orders to an absurdly literal degree, with equally chaotic results. Let’s start with a few examples. In Aristotle’s treatment of Plato, and Heidegger’s of Husserl, we find reversal. Plato’s eidei are transformed by Aristotle into mere secondary substances, and the individual worldly things despised by Plato become what is primary. For Husserl what is primary is whatever is present to consciousness, while for Heidegger this is precisely what is secondary, since the primary stuff of the world withdraws from any form of presence at all. As for radicalization, it is most easily found in the transformation of Kant by German Idealism: “Kant was right to wall off the things-in-themselves from human access, and simply should have realized that the thought of the Ding an sich is also a thought, and thereby the noumena are just special cases of the phenomena,” with much following from this discovery. It would also be easy to read Spinoza as a radicalizer of Descartes, and Berkeley and Hume as radicalized versions of Locke. Perhaps the distinction is now sufficiently clear. Admiring refutations are not those that say “Professor X is an idiot,” which is merely the flip side of the eager disciple’s fruitless “Professor X got everything right.” Instead, it will be some variant of one of the following two options: “Professor X is important, but got it backwards,” or “Professor X is important, but didn’t push things far enough.” In the history of philosophy these two latter cases have often been painful in purely human terms: Aristotle expresses sadness at refuting Plato, Kant is openly annoyed at Fichte, and Husserl feels betrayed and used by Heidegger. Rude handling from later figures almost seems to be the sine qua non of being a great philosopher. Now, it has already been claimed that Meillassoux is an emerging philosopher of the first importance, and by no less a figure than Alain Badiou: “It would be no exaggeration to say that Quentin Meillassoux has opened up a new path in the history of philosophy…” (Preface, vii). But rather than taking Badiou’s word for it, or rejecting his word, we might experiment by asking how Meillassoux could be radicalized or reversed. Are there interesting ways of doing this that might launch whole new schools of philosophy, unexpected or even condemned by Meillassoux himself? While no one can see the future, the present is poor when it is not riddled with virtual futures. The relation between philosophers and their predecessors and successors is always somewhat complicated, of course. But generally there is one central divergence at stake, which might be taken as the key to all the others. On this basis we could say that new thinkers primarily radicalize or primarily reverse the main ideas of their chief philosophical forerunner. There may be specific historical conditions and perhaps even personality traits connected with these two types, but this question can be left aside for now. More important for us is that radicalizers will generally be followed by reversers, and vice versa. Consider the textbook example of a reversal in the history of philosophy: Kant’s Copernican Revolution, which inverts the so-called dogmatic tradition that addresses the world itself, and makes the world revolve instead around the conditions by which it is known. While it is not completely impossible that Kant’s successors might have re-reversed this principle back into a new and stronger dogmatic realism, conditions were premature for such a move. Anyone doing this too early would likely have been an angry anti-Kantian reactionary rather than an original thinker in command of a genuinely new realist principle. The far more likely outcome is the one that actually happened: Kant’s reversal of his predecessors was viewed as incomplete, or as retaining lamentable bits of the traditional view, which despite his admirable breakthrough he was unable to shake off. This was the view of German Idealism, anyway. In similar fashion, Spinoza could also be viewed as a radicalizer of Descartes, who is equally accused of preserving various Scholastic dogmas in an otherwise radical project of philosophical reversal. The point is this: reversals in the history of thought tend to be followed soon thereafter by radicalizations of those reversals. The same may hold true in reverse: radicalizations might generally be followed by reversals, given that it is not always possible to be more radical than the radicals have already been. Consider the case of Husserl, who radicalizes Brentano’s early vagueness about what lies beyond immanent objectivity, and Twardowski’s assertion that there must be an external object lying outside the intentional content, by collapsing everything into the intentional sphere: there is no difference between the Berlin in my consciousness and the actual Berlin that is home to millions of people. It is difficult to see how one could be even more radical than Husserl’s idealist turn here. And thus the road is paved to Heidegger’s reversal of classical phenomenology, in which the key point is what lies deeper than any presence to consciousness: the Sein whose power and obscurity cannot be made exhaustively present, but only sends itself in historical epochs. In similar fashion we might also read Leibniz as a reverser of Spinoza’s radicalization, retrieving a strong sense of individual substance and a certain validity of what the Scholastics had said. Returning to Meillassoux, we might ask which kind of philosopher he is: a radicalizer or a reverser? At present, Meillassoux looks to me like a radicalizer (though for now his future remains shrouded in mist). He takes the correlationist tradition, which allows us to speak only of the relation between human and world, and tries to raise it into an even more extreme claim about the absolute contingency of everything. But whereas German Idealism did this by trying to collapse the distinction between thought and world entirely into the “thought” side, Meillassoux does it by trying to shift the non-absolute contingency of the thought-world correlate from epistemology to ontology. It is no longer a question of the inability of human knowledge to know what lies outside the correlate, but the inability of reality itself to be rooted in any definite laws. Furthermore, if we look at the various features of Meillassoux’s philosophy identified earlier tonight, all but one are already so radical that there is no obvious way to push them further. The one exception would be his claim that the world as a whole can change for no reason at any moment, coupled with the inconsistent claim that within a given world there are laws of nature that everything must follow. If gravitational attraction between all masses is a current law in our world, then for Meillassoux there can be no exceptions to this law for as long as it remains in force. A toppled vase will fall to the floor every time for sure,unless there is a cosmic change by which the laws of nature as a whole have altered. (This is reminiscent of the late medieval distinction between the absolute and ordained power of God, according to which God has the power to set or change the laws of nature, but not to contravene those laws locally once they are set.) On this point, to radicalize Meillassoux would simply be to say: there are no laws of nature even in the local sense. Everything that happens, even in the world here and now, is purely contingent and not governed by even a trace of law. And while this would be a more consistent development of Meillassoux’s thoughts on contingency, it is difficult to see how it could lead to a new philosophy. Instead, the admiring successors of Meillassoux are more likely to reverse one of his already sufficiently radical points. At least four candidates come to mind: *First, we have seen that Meillassoux thinks correlationism is challenged by a time before or after consciousness, but not by a space lying outside it. Perhaps this could be reversed into saying that spatial exteriority is the really crucial point. The arguments on this point are perhaps the least convincing in After Finitude (and do not even occur in the original French edition), and therefore it might be a candidate for the “blind spot” of which no philosopher is ever free. *Second, Meillassoux uses Cantor to claim that the contingency of laws of nature would not entail that they are unstable. A successor of Meillassoux might claim that it does make them unstable, and celebrate this fact. This person would then have to explain why common sense seems to encounter a relatively stable world despite its truly rampant instability. Whereas Meillassoux’s problem is to show how stability might exist despite contingency, this successor’s problem would be slightly different: to show why actual, full-blown instability might have the appearance of stability. *Third, Meillassoux claims that the primary qualities of things are those that can be mathematized. He might be reversed by a successor who says the opposite: the mathematizable qualities are the secondary ones, and the primary ones are those that elude symbolic formulation. While this is a perfectly valid possible objection to Meillassoux, it is one that is made in advance by some of his predecessors and is still made by some of his peers, making it less interesting for futurology than some of his other points. *Fourth and finally, whereas Meillassoux claims that God does not exist but might exist in the future, a successor might argue even more bizarrely that God has always existed but might vanish in the future. Let’s arbitrarily select the first of these possibilities, and imagine briefly where it might lead, if pursued in the future by admiring detractors. Meillassoux comes from the circle of Badiou, and some of Badiou’s most ardent admirers are found in Latin America. So, let’s imagine that towards mid-century some ingenious reversers of Meillassoux emerge in that portion of the Spanish-speaking world. Just for fun, let’s call them Castro and Chávez. And in order to avoid any confusion with the present-day politicians of those names, we will stipulate that Meillassoux’s great successors are both women. The philosopher Castro (we will suppose she comes from Peru) reverses Meillassoux’s argument that the ancestral or diachronic are what most threaten the human-world correlate. Instead, she claims that the diachronic does not threaten the correlate at all, and that we must instead look at space as what ruins the correlate and demands a strange new realism. What would such a philosophy look like? In order to determine this, we might ask what price Meillassoux pays for doing it the opposite way. As I see it, he pays in two separate ways. One is that laws of nature for him are contingent over time . The laws of nature apply to the universe as a whole at any given moment, and would be changed globally if they are ever changed at all. The second price he pays is that Meillassoux has no mereology , or theory of parts and wholes. Everything for him is on the level of the given, or immanent in experience, with the sole proviso that the laws governing this immanence might change without notice at any given moment. In reversing Meillassoux, Castro makes the following claims in the preface to her stunning debut book of 2045, The Cosmos and its Neighborhoods , rapidly translated from Spanish into all the languages of the world: Despite his brilliant analysis of the contingency of laws of nature over time, Meillassoux gets two important assumptions wrong. First, he allows for only one set of contingent laws to govern nature as a whole. Second, he allows laws to govern only the world that is immanent in experience, and thereby fails to explore the contingency among part-whole relations. In this book I will argue, first, that the laws of nature vary in any given instant between one region of the universe and the next; and second, that the world is made up of layers of parts and wholes that are also contingent with respect to one another. Those are the words of Castro. This may sound like a hopeless free-for-all of chaos, yet the book somehow succeeds in drawing some compelling deductions about how laws must vary from one place or level in the world to the next. Trapped in the limited horizon of 2011, and not yet inspired by the heavily balkanized political and technological situation of 2050 that somehow lends additional credence to Castro’s vision, we can only vaguely grasp what such a philosophy might look like. After this reversal of Meillassoux by Castro, the usual pattern leads us to expect a radicalization by Chávez, a young Argentine student of Castro. How could the already strange theories of Castro be radicalized? Perhaps as follows, in a disturbing new book entitled The Implosion of the Neighborhoods , which argues as follows: Castro was right to shift the Meillassouxian framework of contingency from time to space. However, in this respect she retained a surprisingly traditional opposition between the two. In this book I will show that time and space collapse into one another. This may sound too much like the discredited four-dimensional block universe of twentieth century physics and philosophy. However, the four-dimensional universe is a model biased in favor of space, merely adding an extra dimension to the commonsense spatial continuum while stipulating that the serial passage of time is an illusion. In this book I will argue instead for a one-dimensional space-time modeled after our experience of time, in which there is no simultaneous co-existence at all between different parts of the universe, or ‘neighborhoods’ as my esteemed teacher Castro has called them. Instead, the various portions of the universe link to one another by succession rather than by coexistence. Buenos Aires, New York, and Amsterdam do not exist simultaneously in the same landscape, but one after the other in the mind of some observer, and this observer can only be an observer much larger than any human. Against Meillassoux’s notion of a virtual God that does not exist now but might exist in the future, I will argue for an actual God that surveys the universe in sequence, thereby generating the illusion of spatial diversity and even the illusion of individual minds located within that diversity. Once this divine observer dies, the universe as a whole must perish. Again, these ideas are so bizarre that we of 2011 can barely comprehend them, just as Aristotle would have had a difficult time grasping the theories of Descartes. We could then perhaps imagine a further reversal of this theory, emanating from the intellectually resurgent Philippines of the twenty-second century. The Filipino School might argue that the universe is already dead, given the collapse of its spatial richness into the serial observations of a flimsy and mortal God. The virtual universe does not yet exist, but might exist in fully spatial form in the future, and this would require the death of God and the resulting liberation of God’s succession of images as independent, spatially situated realities. With a bit of sharpening, we might be able to make all of these imaginary thinkers more intuitively clear. Along with the history of philosophy, there might arise a new discipline generating imaginary futures for philosophy. The richness of Meillassoux’s system comes not from the fact that he is plausibly right about so many things, but because his philosophy offers such a treasury of bold statements ripe for being radicalized or reversed. He is a rich target for many still-unborn intellectual heirs, and this is what gives him the chance to be an important figure. NOTES 1. Quentin Meillassoux, After Finitude . Trans. R Brassier. (London: Continuum, 2008.) Page 5. The word “correlationism” does not appear in his doctoral thesis. As Meillassoux informed me in an email of February 8, 2011, he first coined this term in 2003 or 2004, while editing for publication a lecture he had given at the École normale supérieure on a day devoted to the theme of “Philosophy and Mathematics,” an event including Alain Badiou as one of the participants. 2. Graham Harman, Quentin Meillassoux: Philosophy in the Making . (Edinburgh: Edinburgh University Press, forthcoming 2011). 3. In an email of December 6, 2010, Meillassoux clarifies that in After Finitude he only deduces the impossibility of a “universal contradiction,” not of a determinate contradiction. In the same email he suggests that he can also prove the latter, though the proof is somewhat lengthier than the one found in After Finitude . 4. After Finitude (18-26), in the passage falling between the two sets of triple asterisks. These pages were sent by Meillassoux to translator Ray Brassier (in French) during the translation process, and do not appear in the original French version of the book. 5. Graham Harman, “Quentin Meillassoux: A New French Philosopher.” Philosophy Today 51.1 (2007): Pages 104-117. The passage where I raise the question of space can be found in the first column of page 107. 6. Vernes is first cited on p. 95 of After Finitude . See Jean-René Vernes, Critique de la raison aléatoire, ou Descartes contra Kant . (Paris: Aubier, 1982).  . (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this (...) paper argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

Medical aid in dying (MAiD), despite being legal in many jurisdictions, remains controversial ethically. Existing surveys of physicians’ perceptions of MAiD tend to focus on the legal or moral permissibility of MAiD in general. Using a novel sampling strategy, we surveyed physicians likely to have engaged in MAiD-related activities in Colorado to assess their attitudes toward contemporary ethical issues in MAiD.

Death and dying are natural phenomena embedded within complex political, cultural and social systems. Nurses often practice at the forefront of this process and have a fundamental role in caring for both patients and those close to them during the process of dying and following death. While nursing has a rich tradition in advancing the palliative and end‐of‐life care movement, new modes of care for patients with serious and irremediable medical conditions arise when assisted death is legalized in a (...) particular jurisdiction. In early 2015, the Supreme Court of Canada released its landmark decision Carter v. Canada (Attorney General) (‘Carter’), which legalized physician‐assisted suicide in particular clinical situations. The new law provided the broad national framework for Medical Assistance in Dying (MAiD) in Canada but, once the law was passed, provincial and territorial governments and health professional regulatory bodies each had to undertake a process of developing policies, procedures and processes to guide MAiD‐related practice specific to their jurisdiction. In this paper, we begin to examine the political ramifications and professional tensions arising from MAiD for nurses and nursing, focusing specifically upon the impacts for registered nurses. We identify how variations in the provincial and territorial literature and regulatory guidelines across Canada have given rise to role confusion and uncertainty among some registered nurses and how this may potentially impact patient care. We then continue to highlight the need for greater political activism among nurses to foster greater clarity in nursing roles in MAiD and to advocate for improved supports for patients and those close to them. (shrink)

Substantial efforts have recently been made to reform the physician-patient relationship, particularly toward replacing the `silent world of doctor and patient' with informed patient participation in medical decision-making. This 'new ethos of patient autonomy' has especially insisted on the routine provision of informed consent for all medical interventions. Stronly supported by most bioethicists and the law, as well as more popular writings and expectations, it still seems clear that informed consent has, at best, been received in a lukewarm (...) fashion by most clinicians, many simply rejecting what they commonly refer to as the `myth of informed consent'. The purpose of this book is to defuse this seemingly intractable controversy by offering an efficient and effective operational model of informed consent. This goal is pursued first by reviewing and evaluating, in detail, the agendas, arguments, and supporting materials of its proponents and detractors. A comprehensive review of empirical studies of informed consent is provided, as well as a detailed reflection on the common clinician experience with attempts at informed consent and the exercise of autonomy by patients. In the end, informed consent is recast as a management tool for pursuing clinically and ethically important goods and values that any clinician should see as meriting pursuit. Concurrently, the model incorporates a flexible, anticipatory approach that recognizes that no static, generic ritual can legitimately pursue the quite variable goods and values that may be at stake with different patients in different situations. Finally, efficiency of provision is addressed by not pursuing the unattainable and ancillary. Throughout, the traditional principle of beneficence is appealed to toward articulating an operational model of informed consent as an intervention that is likely to change outcomes at the bedside for the better. (shrink)

According to the High Court in England and Wales, the primary purpose of legal interventions into the lives of vulnerable adults with mental capacity should be to allow the individuals concerned to regain their autonomy of decision making. However, recent cases of clinical decision making involving capacitous vulnerable adults have shown that, when it comes to medical law, medical ethics and clinical practice, vulnerability is typically conceived as opposed to autonomy. The first aim of this paper (...) is to detail the problems that arise when the courts and health care practitioners respond to the vulnerability of capacitous adults on the basis of such an opposition. It will be shown that not only does the common law approach to vulnerability fail to adequately capture the autonomy of capacitous vulnerable adults, the conception of vulnerability and autonomy in oppositional terms leads to objectionably paternalistic health care responses that undermine the autonomy of vulnerable patients as well as clinical and legal interventions that violate their autonomy. In response, the second aim of this paper is to show that the concepts of autonomy and vulnerability are necessarily entwined and, on that basis, the focus should be on promoting the autonomy of capacitous vulnerable adults where possible. In order to make this case, the paper explains the limitations of standard approaches to the autonomy of vulnerable adults and, in their place, offers a conception of legitimate, self-authorised autonomy that is fundamentally dependent on intersubjective practices of recognition. (shrink)