Journal articles on the topic 'Badness of death'

AbstractI aim to show that the common idea according to which we can assess how bad death is for the person who dies relies on numerous dubious premises. These premises are intuitive from the point of view of dominant views regarding the badness of death. However, unless these premises have been thoroughly justified, we cannot measure the badness of death for the person who dies. In this paper, I will make explicit assumptions that pertain to the alleged level of badness of death. The most important assumption I will address is the assignment of a quantitative value of zero to death, which leads to the conclusion that there are lives not worth living for the affected person. Such a view interprets the idea of a live worth living in quantitative terms. It is in conflict with actual evaluations of relevant people of their lives.

AbstractDesire satisfaction theories of well-being and deprivationism about the badness of death face similar problems: desire satisfaction theories have trouble locating the time when the satisfaction of a future or past-directed desire benefits a person; deprivationism has trouble locating a time when death is bad for a person. I argue that desire satisfaction theorists and deprivation theorists can address their respective timing problems by accepting fusionism, the view that some events benefit or harm individuals only at fusions of moments in time. Fusionism improves on existing solutions to the timing problem for deprivationism because it locates death’s badness at the same time as both the victim of death and death itself, and it accounts for all of the ways that death is bad for a person. Fusionism improves on existing solutions to the problem of temporally locating the benefit of future and past-directed desires because it respects several attractive principles, including the view that the intrinsic value of a time for someone is determined solely by states of affairs that obtain at that time and the view that intrinsically beneficial events benefit a person when they occur.

In ‘Abortion and deprivation: a reply to Marquis’, Anna Christensen contends that Don Marquis’ influential ‘future like ours’ argument for the immorality of abortion faces a significant challenge from the Epicurean claim that human beings cannot be harmed by their death. If deprivation requires a subject, then abortion cannot deprive a fetus of a future of value, as no individual exists to be deprived once death has occurred. However, the Epicurean account also implies that the wrongness of murder is also not grounded in the badness of death, which is strongly counterintuitive. There is an alternative: we can save our intuitions by adopting a more moderate Epicurean account such as that proposed by David Hershenov, who grounds the wrongness of killing in the prevention of the benefit of further good life rather than in the badness of death. Hershenov’s account, however, is equally applicable to Marquis’ argument: abortion similarly prevents a fetus from enjoying the benefit of a future like ours. Consequently, we conclude that Christensen’s criticism of Marquis’ argument fails to undermine his reasoning.

RésuméLa mort d'une personne peut-elle être intrinsèquement mauvaise pour la personne qui meurt? Et pourquoi est-il mal de tuer une autre personne? Je soutiens qu'une réponse adéquate à l'une ou l'autre de ces questions requiert d'apprécier l'importance morale de l'autonomie. J'examine ici la conception dominante de ce qui rend la mort mauvaise — la théorie de la dépossession —, ainsi que deux conceptions rivales de ce qui fait qu'il est mal de tuer — la théorie de la dépossession appliquée à l'acte de tuer, et la thèse des droits liminaux de Judith Thomson. Bien que mon objectif principal dans cet article soit d'établir l'importance de l' autonomie pour expliquer à lafois que la mort est mauvaise et qu'il est mal de tuer, je pense également qu'une réflexion sur ce qui rend la mort mauvaise nous apprend quelque chose au sujet des droits et de leur force, et qu'une réflexion sur les droits nous apprend quelque chose quant à ce qui fait que la mort et l'immortalité sont toutes deux de mauvaises choses.

AbstractEpicureans believe that death cannot harm the one who dies because they hold the existence condition, which states that a subject is able to be harmed only while they exist. I show that on one reading of this condition death can, in fact, make the deceased worse off because it is satisfied by the deprivation account of death’s badness. I argue that the most plausible Epicurean view holds the anti-modal existence condition, according to which no merely possible state of affairs can be good or bad relative to the subject who dies. I go on to show how this condition, as well as any other condition that denies the deprivation account, results in skepticism about practical reason. Thus, the Epicurean faces a dilemma. Either our practical reasoning is hopelessly mistaken or death can make us worse off. Given that our practical reasoning seems at least mildly reliable, we should conclude that death can make us worse off.

AbstractThe concept of a time-relative interest is introduced by Jeff McMahan to solve certain puzzles about the badness of death. Some people (e.g. McMahan and David DeGrazia) believe that this concept can also be used to show that abortion is permissible. In this paper, I first argue that if the Time-Relative Interest Account permits abortion, then it would also permit infanticide. I next reject the suggestion that the Time-Relative Interest Account can at least explain the permissibility of early abortion, even if it cannot explain the permissibility of late abortion. Given this, early and late abortions have to be justified on other grounds.

In Hausa worldview, Peaceful living (Zaman Lafiya) is conceived as the chief goal of life. Zaman Lafiya is that which determines goodness or badness of actions and practices. Everything, including morality, life, death and the afterlife is construed as being good or bad with reference to Zaman Lafiya. So, for instance, no matter the gravity of one’s wrongful conducts, it is not justified to punish him, except when punishing him does contribute to the consolidation/realization/attainment of Zaman Lafiya. This paper investigates the Hausa culture and belief system, especially the aspect of punishment alongside the actions that are thought of as being grave to warrant evil punishment such as the death penalty. With the aid of some Hausa proverbs and the African notion of relationality, it would demonstrate how a conversation of metaphysical nature is sparked among such realities/constructs as morality, life, evil, death and the afterlife. It will also show how living an ethical life entails acting in a manner that consolidates communal or relational existence as framework for Zaman Lafiya.

Humane farming, that is, a husbandry system where animals do not suffer, either during their lives, or at the time of their killing, has been advertised as an ethical alternative to the horrors of factory farming. Although it could be argued that such a system does not currently exist, we ought to determine whether this is a morally desirable end to strive for. My objective is to assess one of the utilitarian arguments used in the debate about humane farming. In particular, I am interested in whether we have risk-related reasons to argue against the implementation of this practice. I will argue, against de Lazari-Radek and Singer, that considerations of moral risk should lead us to reject the practice of humane farming. In doing so, I will engage with arguments dealing with both the badness of animal death and the value of coming into existence.

Longevity is valuable. Most of us would agree that it’s bad to die when you could go on living, and death’s badness has to do with the value your life would have if it continued. Most of us would also agree that it’s bad if life expectancy in a country is low, it’s bad if there is high infant mortality and it’s bad if there is a wide mortality gap between different groups in a population. But how can we make such judgments more precise? How should we evaluate the harm of mortality in a population? Although philosophers have written a lot about the harm of death for individuals, very little work has been done on the harm of mortality for populations. In this article, I take the first steps towards developing a theory of the harm of population mortality. Even these first steps, I argue, lead to surprising results.

AbstractAdorno’s critical theory is distinguished by his affirming what I call the ‘Wrong Life Claim’ (WLC), the claim that everything in existence exhibits wrongness or badness. This claim is notoriously hard to justify. The WLC, as I describe it, appears to rest on two things: the first is a form of Hegelian social holism; the second is some experience of or fundamental orientation towards reality which can motivate an ‘inversion’ of said holism. In this paper, I will leave aside questions of whether Hegelian holism is itself justified, and instead focus my efforts on convincing already-convinced Hegelians of the plausibility of the WLC. My argument is that we can formulate a version of the WLC that stands a chance of convincing ‘the Hegelian’ by focusing on the Kierkegaardian heritage of Adorno’s ideas: specifically, by understanding Adornian ‘wrongness’ to be analogous to ‘despair’, a concept which Kierkegaard explores at length in The Sickness Unto Death.

Comparing the genuine meaning of the human nature explained in the book Zhōngyōng-Zhízhǐ written by Ǒuyì Zhìxù, one of the four greatest Buddhist monks in the Ming dynasty with that translated by Zhū Xī who compiled Neo-Confucianism in the South Song dynasty, this study looks into the genuine meaning of the human nature in the unique viewpoint of Ǒu yì Zhìxù different from that of Zhū Xī. In his book Zhōngyōng-Zhízhǐ, he divides the Seong (性: human nature) into Cheon (天: heaven) and Myeong (命: life) to explain that Seong is SunSuJinYeo (純粹眞如: pure truth) of BulSaengBulMyeol (不生不滅: There is neither birth nor death) and JapBakJoAk (雜駁粗惡: Human nature is roughly mixed) of Saeng MyeolHwanMang (生滅幻妄: Birth and death of everything are all vain), which all means that the human nature can basically become not only the nature of pure reason of Gunja (君子: a Confucian standard person) but also the nature of Soin (小人: a person who is petty and crafty) harassed by passions. This is a part of his thoughts presenting the inner essence of human that a person can be good and bad as well; and implying that the object of discipline may be somewhere around such inner essence of human. On the other hand, Zhū Xī understands the Cheon as the pure truth and explains that the Myeong is given. He says that the Cheon consists of mainly ‘Yin-Yang and Five Elements’, which has Yi (理) and Gi (氣). It is noticeable that he appreciates: such Gi forms a body of JiWoo-Hyeon BulCho (智愚 賢不肖: mixed of wisdom, stupidity, goodness and badness) and such Yi is the essential source of human nature forming Deok (德: virtue) of GeonSun-OSang (健順 五常: Yin-Yang based virtues), which is the nature of InEuiYeJiShin (仁義禮智信: benevolence, righteousness, propriety, wisdom and sincerity). Like this, he refers to Yi-Gi and YiYeok BuYeo (理亦賦焉: Yi is also given) to explain about the Cheon, so that he thinks that the Myeong of Cheon-Myeong is a kind of step given by the heaven, which is the step right before the human nature is given. Such human nature given by the heaven comes with such characters as JiWoo- HyeonBulCho based on each person’s GiJilPumSu (氣質稟受: characters and personalities) requiring everybody to be educated. That is, education is aimed at the recovery of the essential nature of human.

Resum: En aquest article es presenta l’estudi de la figura del comte Arnau, heroi llegendari sorgit a les terres de la Catalunya Vella el drama del qual ha travessat els segles i ha estat difós per mitjà d’una balada i uns textos llegendaris de caràcter oral. El senyor poderós i malvat, sacríleg sense escrúpols i amic del diable, apareix a la seva esposa després de mort, sorgit de l’infern, com una ànima en pena que recorre la terra muntat en un cavall de flames. La balada, en forma de diàleg entre la dama i l’espectre del comte, ens reconta la causa de la seva condemna: «per soldades mal pagades», perquè no pagà els jornals que havia promès als seus treballadors. Per mitjà de la història llegendària del comte Arnau, el poble qüestionava la legitimitat d’un senyor incapaç de complir les seves promeses. En migrar a l’illa de Mallorca, el mite es consolida en un personatge històricament identificat que concentra les malvestats del comte llegendari, desapareix qualsevol al·lusió al tema dels jornals mal pagats, però persisteix en la denúncia d’un comte malvat i dèspota. Paraules clau: llegenda, comte Arnau, comte Mal, ànima en pena, legitimitat del senyor. Abstract: This article presents the study of the figure of Conde Arnau, the legendary hero from the Old Catalunya lands, whose history has passed through the centuries and has spreaded through a ballad and legendary spoken texts. The powerful and bad master, without scruples and friend of the devil, appears to his wife after death. He comes out of hell, like a spirit in pain, wandering the land on a horse of flames. The ballad was composed in form of a dialogue between the lady and the spirit of the Conde. Through the legendary history of the Conde Arnau, the villagers questioned the legitimity of the Master, who was unable tu fulfelt his promises. In inmigrated to the island of Mallorca, the legend is consolidated in one identified historical character, which was concentrated in this legendary conde badness. Key words: legendary history, Conde Arnau, Conde Mal, spirit in pain, legímity of the Master.

Basically, Islamic legal thought is very demanding a person's understanding of the Qur'an and alhadith, in the hope of formation of the application in line with the rules of Shari'a. Therefore, an in-depth understanding of an Islamic legal thought is necessary. Among the understanding is what is called the fiqh alawlawiyyat. Fiqh priority or fiqh in the priority scale balance is intended is a complex understanding of the study of Islamic law in a more proportional, with the intent and purpose for a mukallaf able to provide value for a practice in accordance with the views of Islamic Shari'a,because the majority of Muslims are considered not able to put the values ​​of worship and practice in accordance with the guidance of the Shari'a, then there is confusion that is happening to the Muslims. Confusion in determining this priority scale will be very dangerous if it continues to be left, then efforts to stem danger and clarify the problem need to be realized.Islamic Shari'ah has placed certain values ​​and stages for each act in accordance with its influence in the soul and life.as Islam also sets a certain level for things that are prohibited in accordance with its harm and badness for humans.The tendency to put forward something that is sunnah from the obligatory or overriding the more important of something important, it would discredit the value and purpose of the Shari'a.

Rasulullah saw. had informed muslims about the occurrences that will befall mankind on their way to the end of time, including the evil disasters that will hit the earth, kill, and destroy the human being. As a muslim, there is no word except that we believe in the occurrences and phases of the journey towards the end of the time. This study aimed to explain one of the occurrences of the journey towards the end of time that befall the world and mankind today, which is one of the deadly infectious outbreaks so-called coronavirus or covid-19, which has destroyed many people, imprisoned people in cities and countries, and caused various disasters and havocs as the result of the outbreak. The research method used was library research which was through a literature review related to the research. The results showed that the information of the journey towards the end of time would appear one by one in the range of human life, how they live, so thus Allah swt. shows them the meaning of the age they lived in. The worse human life is, the more Allah swt. show the badness of that era to the point where it is rampant engulfing the world and mankind, even though among those times are pious people, whether in an Islamic country or groups. Muslims are encouraged to follow the Shari'a when an epidemic strikes a country, namely: 1) not entering a country affected by disaster; 2) close the container where the water is; 3) pray a lot and recite; and 4) living in the city of Medina; stay indoors. Finally, the effects of the plague at the end of time are: 1) the number of sudden deaths; and 2) humans are isolated.

Abstract In this paper, I investigate backward-looking accounts of death's badness. I begin by reviewing deprivationism—the standard, forward-looking account of death's badness. On deprivationism, death is bad for its victims when it deprives them of a good future. This account famously faces two problems—Lucretius’s symmetry problem and the preemption problem. This motivates turning to backward-looking accounts of death's badness on which death is bad for its victim (in a respect) when it involves a decline from a good life. I distinguish three different backward-looking accounts of death's badness in terms of decline, and I argue for the attractiveness of one in particular. I conclude by considering how the backward-looking consideration of decline might factor into our overall account of death's badness.

AbstractThis article argues that Epictetus employs the terms orexis and hormê in the same manner as the older Stoics. It then shows, on the basis of this claim, that the older Stoics recognized a distinction between dispositional and occurrent forms of motivation. On this account of Stoic theory, intentional action is in each instance the product of two forms of cognition: a value ascription that attributes goodness or badness to some object, conceiving of its possession as beneficial or harmful to the agent, together with a situational judgment about appropriate action. The resulting interpretation suggests that the Stoic theory of motivation as a whole — and not merely the Stoic analysis of the pathê — has the basic shape of a practical syllogism, with more psychological depth than commentators have recognized.

“For there is nothing either good or bad, but thinking makes it so” (Hamlet, Act 2 Sc.II) The theme for this issue of M/C Journal was inspired, not just by the melancholic Prince Hamlet of Denmark, but by the proceedings of the 8th annual Postgraduate Work-in-Progress Conference at The University of Queensland, September 2004. Despite the usefulness of the connections and disparities produced by delegate meditation and analysis of the conference theme, ‘bad ideas?’, this issue of M/C Journal was envisioned as a corollary to those proceedings, not a summary. Thus, the ‘bad’ issue of M/C Journal both talks to and moves from many of the issues that inspired the conference proceedings. That which is unique, original, and different is most often interpreted in relation to what is accepted, normal, and traditional. The work of any researcher in the ever-broadening field of that nebulous thing, the Humanities, is to think about received ideas in surprising and unfamiliar ways, to challenge what is simply thought of as bad or good, to complicate essentialist categories, and to question passively-accepted thinking. Things that may have seemed indissolubly bad may in fact be revealed as good precisely because they are dissolute, troubling, and inevitably disruptive to accepted norms, including your own. The reverse is also true. Anything is possible. Our authors, in unravelling the implications, assumptions and authority of ‘bad’, have taken up the theme in diverse and unexpected ways. From the ethical consequences of teaching students to create computer viruses to the complexities of the gay parenting debate, the authors of this issue contest simplistic assumptions of ethical action and highlight the ambivalence, complexity, and rewards that are entailed in questioning moral norms. Tony Sampson kicks off this issue with a thoughtful article that examines the fraught trajectory of the computer virus debate. Sampson examines to what extent paranoia and fear of the computer virus as unequivocally bad has constrained research in the field, research that may actually prove to have positive consequences in the fight against the malevolent affects of viruses. The perceived incursion of ‘ethical norms’ short circuits innovation as it feeds moral outrage. Kirsten Seale examines the ‘bad’-ness of Iain Sinclair’s 2004 novel _Dining on Stones _ in her article “Iain Sinclair’s Excremental Narratives”. An examination of panopticism, publishing, and consumption, Seale investigates how Sinclair’s ‘difficult’ writing courts interpretation as ‘bad writing’—resistant, deviant, and perverse. Searle also notes that far from crumbling under the moral weigh of badness, Sinclair delights in perverse pleasure, and takes up a certain power in being outside the norm. In this case, being ‘bad’ is definitely a ‘good’ thing. Elanna Herbert Lowes’s article “Transgressive Women, Transworld Women: The Once ‘bad’ Can Make ‘Good’ Narratives” is a self-reflexive critical essay that charts the difficulties of producing a creative PhD thesis within the field of Communications. An investigation of transworld identity, historiographic metafiction, creative writing, postmodernism, and narrative voice. Damien Riggs, in “Who Wants to Be a ‘Good Parent’?” addresses the timely and provocative issue of gay parenting. Riggs argues that the media promotes a ‘heteronormative’ understanding of parenting practice. Riggs deftly engages with the moral complexities of defining good and bad parenting and the ways in which these ethical categories are transferred, or blocked, by subject interpolation into categories of sexuality. Also concerned with the oppressions of morality, subjectivity, and sexuality, Jacqueline Mikulsky’s article “Silencing (Homo)Sexualities in School … A Very Bad Idea” argues that by remaining silent on the topic of sexualities other than heterosexuality within the school environment, school staff members contribute to a climate of heterosexism within the classroom. Debra Ferreday contributes a provocative exploration of virtual community and hate speech in her article, “Bad Communities”. While her essay may raise more questions that it can answer in the limited space, Ferreday usefully draws our attention to some of the assumptions that circulate around the creation of online communities. She notes the existence of sites, such as God Hates Fags, that complicate a conventional interpretation of ‘community’ as an inherently and universally positive term. Carra Leah Hood engages directly with this issue’s Shakespearean epigraph in “Schools of Thought: Consensus unto Death”. Hood aligns an analysis of social hierarchy in Hamlet, to a investigation of intellectual exchange in contemporary society. As in Shakespeare’s play, Hood finds contemporary ascriptions of worth are also often distorted by the implications of social standing. What may be received as a good idea from one individual, may be rejected as bad from another; authority is all too often resident in the hierarchy, rather than in the value of the opinion itself. Citation reference for this article MLA Style Cardell, Kylie, and Jason Emmett. "Bad." M/C Journal 8.1 (2005). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0502/01-editorial.php>. APA Style Cardell, K., and J. Emmett. (Feb. 2005) "Bad," M/C Journal, 8(1). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0502/01-editorial.php>.

Facial expression emotion recognition is an intuitive reflection of a person’s mental state, which contains rich emotional information, and is one of the most important forms of interpersonal communication. It can be used in various fields, including psychology. As a celebrity in ancient China, Zeng Guofan’s wisdom involves facial emotion recognition techniques. His book Bing Jian summarizes eight methods on how to identify people, especially how to choose the right one, which means “look at the eyes and nose for evil and righteousness, the lips for truth and falsehood; the temperament for success and fame, the spirit for wealth and fortune; the fingers and claws for ideas, the hamstrings for setback; if you want to know his consecution, you can focus on what he has said.” It is said that a person’s personality, mind, goodness, and badness can be showed by his face. However, due to the complexity and variability of human facial expression emotion features, traditional facial expression emotion recognition technology has the disadvantages of insufficient feature extraction and susceptibility to external environmental influences. Therefore, this article proposes a novel feature fusion dual-channel expression recognition algorithm based on machine learning theory and philosophical thinking. Specifically, the feature extracted using convolutional neural network (CNN) ignores the problem of subtle changes in facial expressions. The first path of the proposed algorithm takes the Gabor feature of the ROI area as input. In order to make full use of the detailed features of the active facial expression emotion area, first segment the active facial expression emotion area from the original face image, and use the Gabor transform to extract the emotion features of the area. Focus on the detailed description of the local area. The second path proposes an efficient channel attention network based on depth separable convolution to improve linear bottleneck structure, reduce network complexity, and prevent overfitting by designing an efficient attention module that combines the depth of the feature map with spatial information. It focuses more on extracting important features, improves emotion recognition accuracy, and outperforms the competition on the FER2013 dataset.

AbstractHaving chosen the topic of active contribution to social life, one of the most important aspects facilitating deeper social integration, we present the results of a three-staged sociological discourse analysis of media messages related to migrants and migration. In our study, we consistently used a number of methods — a quantitative and qualitative content analysis, semantic analysis, discourse positions’ analysis, critical discourse analysis, and an in-depth analysis of focus group interviews. The combination of them all helped us reveal specific details of media image constructing as well as requests for information on migrants’ life strategies. We took into account media discourse in fifteen top Ukrainian media over the span of time between 2015 and 2018, focusing on the differences between media discursive strategies based on the form of ownership (state/private), audiovisual type (printed/TV/Internet) and the degree of trustworthiness/popularity of the media among Ukrainians, the actors that had the advantage of being quoted in the media and the groups of migrants being displayed to practice certain active or passive life strategies. The messages with implicit meanings regarding the active migrants’ life strategy were less present in the state-controlled top media and the most trusted/popular top media. Similarly, the messages with implicit meanings regarding both the active and passive migrants’ life strategies featured less frequently in the top printed media. In the context of understanding ‘goodness’ as equivalent to ‘activity’, we found that in the top Ukrainian media there were two ‘good’ categories of migrants: first, internal migrants in Ukraine and, second, migrants from Ukraine (Ukrainian emigrants). However, it turned out that the first place regarding the presence of implications about ‘passivity’ (i.e., ‘badness’) went again to internal migrants in Ukraine. The opinions held by Ukrainians about what the media should have shown were clearly in favor of what migrants were offered by their destination society (thus, in favor of ‘passive’ media image), and all that the Ukrainians would like to see and hear included both favorable and unfavorable objective social life conditions.

Photo by Diana Polekhina on Unsplash ABSTRACT With the increasing legalization of MAiD across the world, the question of whether psychiatric patients with refractory mental illness should have access to this health service is a topic of ethical debate. Even so, with present-day autonomy encouragement, and the right to die, a psychiatric diagnosis should never automatically preclude a patient from making decisions about their treatment, including the use of MAiD. INTRODUCTION Likely, no matter where we live in the world, we have similar wants: to be healthy, to be happy, to be in a community, to make our own decisions about our lives. The first and last of these wants are the primary concerns of medicine. Diseases are treated, suffering is alleviated, chronic illnesses are managed – to the extent possible. Along the way, patient autonomy is encouraged. Perhaps the greatest manifestation of this autonomy is evidenced in the increasing availability of Physician-Assisted Suicide or Medical Aid-in-Dying (MAiD). With important nuances, the criteria that patients must meet to participate in MAiD are generally similar: a patient must be over the age of 18, able to state a voluntary desire to end their own life, and two independent physicians must verify their decision-making capacity. Yet, clinical criteria for accessing this option differ. In U.S. jurisdictions where MAiD is legal, patients must have a terminal illness with a 6-month prognosis.[1] In Holland and Belgium, the presence of “intractable pain” is sufficient.[2] With the increasing legalization of MAiD across the world, the question of whether psychiatric patients suffering from refractory mental illness should have access to this means of relieving suffering is under continual debate. The ethical implications of denying autonomous decision-making to psychiatric patients at the end of life will be discussed – along with suggestions for clinical practice. l. Medical Aid-in-Dying and the Psychiatric Patient There are three main arguments against allowing a patient with psychiatric suffering to pursue MAiD. The first is that patients with severe mental illness may have impaired decision-making capacity. This impaired capacity generally encompasses the following four criteria: the ability to express a choice, the ability to understand the information presented, the ability to appreciate the “medical consequences of the situation,” and the ability to engage with different choices of treatment.[3] These criteria are impaired to varying degrees across the spectrum of mental illnesses. For instance, about 50 percent of patients with schizophrenia hospitalized for an acute episode displayed at least one element of impaired capacity, compared with 20-25 percent of those admitted with an acute depressive episode. In contrast, depression treated on an outpatient basis may not be associated with any impairment in capacity.[4] The second argument against allowing a patient with psychiatric suffering to pursue MAiD is that suicidality itself can manifest as a common symptom of psychiatric disorders (including major depressive disorder). In this context, a patient with severe mental illness who has requested MAiD, following appropriate treatment, may in fact no longer wish to die. The fear of wrongly fulfilling a MAiD request in this context alienates the notion of liberally applying MAiD to the psychiatric population. A literature review found that between 8 percent and 47 percent of patients in the Netherlands and Oregon who requested MAiD presented with depression, while 2-17 percent of those who pursued MAiD to completion had “depressive symptoms.” In the Netherlands, patients with depression were significantly less likely to be granted euthanasia/MAiD requests.[5] Providers are rightfully afraid of making a mistake that will cost a life. Kious and Battin phrase the dilemma simply: “When is it worse that someone die, whether from suicide or with physician assistance, who could have been helped, and when is it worse that someone whose suffering could only be alleviated by death continue to suffer?”[6] It is doubtful that this question will ever have a sufficient answer. The third argument, that Calkins and Swetz fervently pose, claims that “allowing the psychiatrically ill to participate in [MAiD] will compromise the patient-clinician relationship and the relationship of medicine with the public as a whole… fundamentally alter[ing] the clinician’s role as healer and trusted advisor.”[7] This argument stems from western medicine’s bias of preserving life at whatever cost, the idea being that any deviation from this goal constitutes an abandonment of the patient. Calkins and Swetz’s suggestion that all patients with severe, persistent mental illness who might request MAiD do so inappropriately vastly overestimate the capacity of current psychotropic pharmacology to alleviate pain and suffering. There remain patients who have diligently run the gamut of available treatment options and remain debilitated by their disease. Allowing for participation in MAiD can instead be a testament to the strength of a patient-clinician relationship: that this patient, after presenting the topic of MAiD to their “healer and trusted advisor,” is met with a provider who willingly and carefully listens to their reasons for requesting this option, rather than rejecting the notion out of hand. If deemed appropriate, and after careful fulfillment of the remaining MAiD criteria, the relationship can then shift towards an end-of-life alliance – therapeutic in and of itself, one in which the goal is not further treatment but a peaceful end. However, attitudes about the appropriateness of MAiD for patients with severe mental illness differ, even among psychiatrists. In a survey of 457 psychiatrists in Switzerland – one of the few countries in which MAiD can be granted “on the basis of a primary psychiatric diagnosis,” 29.3 percent of respondents indicated some degree of support for the availability of MAiD to patients with severe and persistent mental illness – an acceptance rate that parallels that of medical providers.[8] Among a profession dedicated to preserving life, there remains much (reasonable) caution about hastening its end. ll. The Psychiatric Advance Directive The ambiguity over whether patients with psychiatric illnesses should be allowed to make their own treatment decisions is not limited to the end of life. For patients with predominantly medical conditions who no longer have the capacity to make decisions about their care (for instance, patients with advanced dementia), clinicians can defer to previously stated wishes as expressed in an advance directive or per the discretion of a healthcare proxy. This deferred decision-making is sometimes referred to as substituted judgment.[9] As a correlate, patients suffering from mental illness can complete a Psychiatric Advance Directive (PAD) to indicate what treatments they would or would not want should they lose decisional capacity. These are often informed by prior, traumatic hospitalizations (for instance, a patient may request not to undergo involuntary electroconvulsive shock therapy, or receive specific antipsychotics, or may decline all psychiatric management). Yet, in contrast to advance directives guiding medical treatment, PADs are frequently (and legally) overridden if they violate “accepted clinical standards.”[10] At their discretion, physicians can override any part or all of a patient’s PAD if it violates what they deem to be acceptable care. Rather than a “let-the-patient-decide” law, the actual influence of PADs on clinical management is often minimal – shrinking its effect to a “let the doctor decide whether the patient gets to decide” law.[11] For example, Pennsylvania’s PAD statute (Act 194) specifies three instances in which physicians can override a patient’s directive. First, a physician maintains the right to involuntarily admit a patient under civil commitment law. Second, a physician may override any part of a patient’s PAD so long as they make “every reasonable effort” to have the patient transferred to a provider willing to adhere to the patient’s request. Third, the act protects any physician who violates a patient’s PAD request from “criminal or civil liability or discipline[e] for unprofessional conduct” who is deemed to have acted in “good faith” based on accepted clinical guidelines.[12] In Pennsylvania’s fairly standard PAD legislation, the physician is virtually untouchable. North Carolina’s “Advance Instruction for Mental Health Treatment” documentation explicitly communicates its limitations to the patient: the opening paragraph states, “Your instructions may be overridden if you are being held in accordance with civil commitment law.”[13] Of course, neither is it sustainable to adhere to all PAD requests. Consider the case of Hargrave v. Vermont. The Second Circuit Court of Appeals upheld the durable power of attorney (DPOA) of Nancy Hargrave (a patient with schizophrenia who was civilly committed) to refuse treatment. As Applebaum notes, “If large numbers of patients were to complete advance directives such as Nancy Hargrave’s, declining all medication, hospitals might well begin to fill with patients whom they could neither treat nor discharge.”[14] Notably, this case is an exception rather than the rule. Broad legislation emulating Hargrave will not act towards the betterment of all patients with severe mental illness. But, in the conversation on the applicability of MAiD for psychiatric patients, it is worth noting how frequently and readily these patients’ wishes are overlooked, even when they have been expressed and properly documented in a state of decisional capacity (as must be the case when completing a Psychiatric Advance Directive). lll. The Way Forward While those with mental illness deserve both fierce protection and robust mental health treatment, they also have a right to define what quality of life is acceptable. When determining the point at which treatment of a psychiatric illness becomes futile – and thus the option of pursuing MAiD more readily permissible – the concept of “qualitative futility” is particularly generative. Focus turns towards a patient’s first-person experience of illness and an understanding of their “subjective view about the quality of an outcome.”[15] This perspective shifts away from the statistical probability that a certain treatment will succeed and instead incorporates the lived reality of a patient’s illness narrative. For example, in the World Health Organization’s published report on the treatment of cancer pain, the phrase “total pain” identifies the physical and non-physical components of suffering, including “the noxious physical stimulus and also psychological, spiritual, social, and financial factors.”[16] For severely ill patients with treatment-refractory mental illness, an understanding of “qualitative futility” and “total pain” could be the most humane way to approach who should and should not qualify for MAiD. In one take on how patients with mental illness have the right to define what consists of an acceptable quality of life, Kious and Battin posit that if a patient’s decision to pursue MAiD is voluntary and if the patient possesses decision-making capacity, their request should be granted “irrespective of whether their underlying medical diagnosis is physical or mental, terminal or nonterminal.”[17] While this option should, of course, be withheld from patients suffering from an acute exacerbation in which the patient may not achieve decisional capacity, it is nevertheless true that psychiatric illness, even in severe cases, is often episodic, undergoing periods of remission when a patient may be symptom-free.[18] During these periods of lucidity, the patient’s perception of quality of life should be examined with great care. Another option offered by Kious and Battin to identify psychiatric patients who may be appropriately pursuing MAiD is to create two “metric[s] for suffering” – one for physical and one for mental illnesses. For psychiatric patients who wish to end their lives, this establishes a threshold above which suffering becomes “unbearable,” opening the door for a legitimate conversation about MAiD between patient and physician (should the patient request it). Suffering below this threshold would remain grounds for involuntary admission to an inpatient facility.[19] The question remains: how do we gauge severe enough suffering to die and suffering that is not? In exploring this question, Zhong et al.’s understanding that a person with mental illness pursuing MAiD must be evaluated differently proves valuable. The authors suggest that rather than focusing on “point capacity” (the ability to make a specific decision), an evaluation of “global capacity” should instead be conducted - a style of evaluation that is interested in “fully contextualiz[ing]” the patient’s choice to pursue MAiD. This requires asking not only about medical and psychiatric history but also family and relationship history, trauma history, education and employment history, and includes a rigorous collection of collateral information from family and friends who can confirm the patient’s wishes.[20] An additional benefit of evaluating for “global capacity” should the choice of MAiD be followed to completion is the illumination, no matter how slight, that might be provided to relatives and friends. This prior justification for, and understanding of, the patient’s decision might dull the sharpness of loss for family and friends – healing insight that may be inaccessible in the case of unassisted suicide. While Kious and Battin express concern that it is “deeply unclear” how to measure the dimensions of suffering given that “we cannot wholly trust first-person reports,” these narratives nonetheless form the substrate of psychiatry and serve as the diagnostic tool of most gravitas available to providers of mental illness.[21] They must be trusted. Or, as the old medical adage goes, they can be trusted and confirmed. It is no accident that in the WHO’s “Cancer Pain Relief” manual, the first step of pain assessment is to “believe the patient’s complaint of pain.”[22] The lived experience of a patient with severe, refractory mental illness can challenge physician hesitation about the appropriateness of MAiD. In the previously cited study in which 29.3 percent of Swiss psychiatrists reported general support for the availability of MAiD in cases of refractory mental illness, the percentage curiously swelled when presented with three clinical vignettes (in each, the patient is stated to have decision-making capacity to “refuse further treatment”). In the case of a 37-year old female with a 26-year history of anorexia nervosa, ten prior hospitalizations, a weight of 52 pounds, general muscle weakness, and low bone density, who no longer wishes to undergo force-feeds, 35.4 percent of respondents indicated that they would support her choice of MAiD.[23] In the case of a 33-year old male with a 16-year history of schizophrenia, who has failed numerous trials of anti-psychotic regiments and electroconvulsive shock therapy, who has “never been free from positive or negative symptoms,” and whose persisting illness has left him severely isolated, 32.1 percent indicated that they would support his choice of MAiD. And in the case of a 40-year-old male with persistent suicidal ideation for 20 years, whose symptoms have been refractory to numerous trials of anti-depressants, anti-psychotics, mood stabilizers, combination therapy, psychotherapy, and electroconvulsive shock therapy, who plans to commit suicide “in the near future,” 31.4 percent of respondents indicated that they would support his choice of MAiD. With generous and nuanced attention to a patient’s “total pain,” following careful evaluation of their “global capacity,” and after a thorough review of all treatment trials and any available therapeutic options yet un-tried (assessing “psychiatric futility”), those who are suffering from severe, refractory mental illness should be granted similar access to MAiD as patients suffering from cancer, ALS, and other organic causes of disease. We cannot adequately police the “badness of suffering.”[24] CONCLUSION In summary, a psychiatric diagnosis should never automatically preclude a patient from making decisions about their treatment, including deciding to end one’s own life with the help of a licensed provider. Medical Aid-in-Dying is associated with a safe, certain, and painless death. In the circumstances where it would be applicable, it serves as a less fraught option than unassisted suicide. We owe anyone who is ceaselessly suffering that much. Or, at the very least, we owe this equally fraught topic an honest conversation. [1] Calkins, Bethany C., and Keith M. Swetz. “Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Imperative Over a Crisis.” The American Journal of Bioethics, vol. 19, no. 10, 2019, pp. 68–70, doi:10.1080/15265161.2019.1653398. [2] Montanari Vergallo, Gianluca et al. “Euthanasia and physician-assisted suicide for patients with depression: thought-provoking remarks.” Rivista di psichiatria vol. 55,2 (2020): 119-128. doi:10.1708/3333.33027 [3] Appelbaum, Paul S. “Assessment of Patients’ Competence to Consent to Treatment.” New England Journal of Medicine, vol. 357, no. 18, 2007, pp. 1834–40, doi:10.1056/nejmcp074045. [4] Appelbaum, Paul S. “Assessment of Patients’ Competence to Consent to Treatment,” 1834–40. [5] Levene, Ilana, and Michael Parker. “Prevalence of Depression in Granted and Refused Requests for Euthanasia and Assisted Suicide: A Systematic Review.” Journal of Medical Ethics vol. 37,4 (2011): 205-11. doi:10.1136/jme.2010.039057 [6] Levene, Ilana, and Michael Parker. “Prevalence of Depression in Granted and Refused Requests for Euthanasia ...” 205-11. [7] Calkins, Bethany C., and Keith M. Swetz. “Physician Aid-in-Dying and Suicide Prevention in Psychiatry,” 68–70. [8] Hodel, Martina A et al. “Attitudes Toward Assisted Suicide Requests in the Context of Severe and Persistent Mental Illness: A Survey of Psychiatrists in Switzerland.” Palliative & Supportive Care vol. 17,6 (2019): 621-627. doi:10.1017/S1478951519000233 [9] Appel, Jacob M. “Trial by Triad: Substituted Judgment, Mental Illness and the Right to Die.” Journal of Medical Ethics, 2021, pp. 1–4. doi:10.1136/medethics-2020-107154. [10] Swanson, Jeffrey W et al. “Superseding Psychiatric Advance Directives: Ethical and Legal Considerations.” The Journal of the American Academy of Psychiatry and the Law vol. 34,3 (2006): 385-94. [11] Swanson, Jeffrey W et al. “Superseding Psychiatric Advance Directives,” 385-94. [12] Ibid [13] “Advance Directive for Mental Health Treatment." NC Secretary of State. Web. 13 July 2021. <https://www.sosnc.gov/forms/by_title/_advance_healthcare_directives>. [14] Appelbaum, Paul S. “Law & Psychiatry: Psychiatric Advance Directives and the Treatment of Committed Patients.” Psychiatric Services (Washington, D.C.) vol. 55, no. 7, 2004, pp. 751–763. doi:10.1176/appi.ps.55.7.751 [15] Zhong, Rocksheng, et al. “Physician Aid-in-Dying for Individuals with Serious Mental Illness: Clarifying Decision-Making Capacity and Psychiatric Futility.” The American Journal of Bioethics, vol. 19, no. 10, 2019, pp. 61–63, doi:10.1080/15265161.2019.1654018. [16] World Health Organization. (‎1986)‎. Cancer Pain Relief. World Health Organization. https://apps.who.int/iris/handle/10665/43944 [17] Kious, Brent M., and Margaret (Peggy) Battin. “Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?” The American Journal of Bioethics, vol. 19, no. 10, 2019, pp. 29–39, doi:10.1080/15265161.2019.1653397. [18] Kious, Brent M., and Margaret (Peggy) Battin. “Physician Aid-in-Dying,” 29–39. [19] Ibid [20] Appelbaum, Paul S. “Law & Psychiatry,” 751–763. [21] Kious, Brent M., and Margaret (Peggy) Battin. “Physician Aid-in-Dying,” 29–39. [22] World Health Organization, Cancer Pain Relief. [23] Hodel, Martina A et al. “Attitudes Toward Assisted Suicide Requests,” 621-627. [24] Kious, Brent M., and Margaret (Peggy) Battin. “Physician Aid-in-Dying,” 29–39.