Institutional identity; sacramental potential: Catholic healthcare at century's end.

Government and market forces have fundamentally transformed the religious healthcare sector. Religious healthcare organizations are struggling to define their identities and determine what it is that makes them different and what implications the differences have for the delivery of social services and for public life. In response to these questions, the defenders of traditional Catholic healthcare make a variety of responses that first defend the continued relevance of the major institutions of Catholic healthcare, especially its hospitals, and second, specify reforms to make these institutions even more relevant to the new healthcare system. This essay argues that these defenses are inadequate to that challenge and that the reforms proposed are too timid. Catholic healthcare needs a better theoretical account of its mission and more creative institutional adaptations.     

Sedation and care at the end of life

This special issue of Theoretical Medicine and Bioethics takes up the question of palliative sedation as a source of potential concern or controversy among Christian clinicians and thinkers. Christianity affirms a duty to relieve unnecessary suffering yet also proscribes euthanasia. Accordingly, the question arises as to whether it is ever morally permissible to render dying patients unconscious in order to relieve their suffering. If so, under what conditions? Is this practice genuinely morally distinguishable from euthanasia? Can one ever aim directly at making a dying person unconscious, or is it only permissible to tolerate unconsciousness as an unintended side effect of treating specific symptoms? What role does the rule of double effect play in making such decisions? Does spiritual or psychological suffering ever justify sedation to unconsciousness? What are the theological and spiritual aspects of such care? This introduction describes how the authors in this special issue wrestle with such questions and shows how each essay relates to the author’s individual position on palliative sedation, as developed in greater detail within his contribution.     

Nutrition and hydration: an analysis of the recent papal statement in the light of the Roman Catholic bioethical tradition.

This article discusses the unexpectedly firm stance professed by John Paul II on the provision of artificial nutrition and hydration to patients who are in a persistent vegetative state, and it implications on previously held standards of judging medical treatments. The traditional ordinary/extraordinary care distinction is assessed in light of complexities of the recent allocution as well as its impact on Catholic individuals and in Catholic health care facilities. Shannon concludes that the papal allocution infers that the average Catholic patient is incapable of making proper judgments about their own care. Shannon sees the preservation of life at all costs as at least highly troubling, if not as a radical move against the Catholic medical ethics tradition.     

The right to die at the end of your life

The Missouri case of Nancy Cruzan brings into sharp focus the medical ethics issue of the right to privacy. It also raises the need for definition of life ranging from cellular to personal. What is it about forced feeding that transforms it into an extraordinary means of nonfunctional treatment? There is the question of balancing benefit and cost (whether personal or financial). Currently we are confronted by the problem of balancing human rights violations against efforts to be “helpful” by the use of heroic medical measures, all of this against the background of ever-changing medical technology.     

Henry S. Perkins: A guide to psychosocial and spiritual care at the end of life

Theoretical Medicine and Bioethics -     

Palliative-care professionals' experiences of unusual spiritual phenomena at the end of life

Research literature has highlighted unusual phenomena occurring at the end of life. Palliative-care professionals often feel ill-prepared in managing these and in talking to patients and family members about them. This study aimed to explore the meanings and interpretations ascribed to these phenomena by palliative-care professionals. Eight participants were interviewed, and interpretative phenomenological analysis used to identify themes within their accounts. Four themes emerged from the analysis: (1) Who are we to say what's out there?: a connection with something beyond what can be seen; (2) It opened up conversations: the experience of talking about unusual experiences; (3) It knocked me sideways: managing the emotional impact of these experiences; and (4) The fact that she was so accepting made it easier: the value of acceptance in relation to unusual experiences. These findings are discussed within the context of existing literature and implications for palliative-care professionals are discussed.     

Care versus treatment at the end of life for profoundly disabled persons

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of consciousness becomes permanently impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population.     

Similarity-guided depth of retrieval: constraining at the front end.

Lee Brooks has done important work to show that categorization often reflects reliance on specific instances rather than on an abstract representation. His work on the advantages of using a diagnostic hypothesis to search medical stimuli has demonstrated how constraining what one looks for influences clinical reasoning. Similarly, cognitive control can be accomplished by constraining memory retrieval in ways that influence interpretation of a memory probe. Here, we report two experiments in which the similarity of study items constrained how test items were interrogated for an immediate memory test and thereby produced differences in the depth of retrieval. A novel procedure that tests foil memory was used to diagnose differences in similarity-guided retrieval depth.     

Mother versus stranger: a triadic situation of imitation at the end of the first year of life

This study presents two experiments investigating 8‐ and 12‐month‐old infants' imitative behaviour. Seventy‐two 8‐month‐olds and seventy‐two 12‐month‐olds were observed in a triadic situation which included their mother and a stranger. Depending on the condition, either the mother or the stranger acted as the demonstrator and either stayed close or withdrew after the demonstration, during the response period. In addition to imitative acts, visual exploration and smiles addressed, respectively, to each partner were computed. Results showed that at both ages, neither the familiarity nor the position of the partner has an effect on the number of target gestures that are imitated. At 12 months, infants looked and smiled more at the stranger when he demonstrated target actions but no difference was found when the mother acted as demonstrator. Moreover, 12‐month‐old infants looked more at the demonstrating partner immediately after their first imitation. At 8 months, infants paid more attention to the stranger in all conditions except when the mother performed the target actions and moved away, a pattern that suggests a referencing to the mother. Results from the gaze and smile variables suggest that with age different motivations (social contact, exploration of objects) induce imitation. Copyright © 2003 John Wiley & Sons, Ltd.