Academic literature on the topic 'Intractable pain Treatment Moral and ethical aspects'

This discussion article examines narrative positioning related to pain management for people who use substances at the end of life. We explore how dominant narrative genres associated with biomedicine, such as ‘restitution’ and narratives common within the context of drug services such as ‘recovery’ can hinder effective pain management within this population. We argue that these discourses can marginalise the ethical self-identity of patients who use substances at the end of life. It can also trouble health and social care professionals in supporting patients and generating counter-narratives that challenge those often associated with substance use. Stigma is a common experience for this population with stereotyping as ‘junkies’ and associated with criminality. They are positioned as drug-seeking, and this requires more surveillance at the end of life when opioid therapy is potentially more available and authorised. This can make it challenging to generate ‘companion’ stories that are positive and maintain moral adequacy. Dominant biomedical narrative genres often prevent the recognition of the fractured stories that people using substances can often present with. This can lead to narrative silencing and to the under treatment of pain. The person’s self-identity is invested in narratives of recovery, and opioid use symbolises their addicted past because for practitioners, this population is at clinical risk with the potential for drug seeking behaviours. Whilst not requiring formal ethical review this discussion paper was constructed in accordance with good scientific practice with the work of other researchers respected and cited appropriately.

Only within the past decade or so have medical ethicists, healthcare policy analysts, and politicians devoted significant time and energy to the myriad issues and problems facing the elderly. Careful consideration has revealed multiple concerns over the treatment of the elderly by families, healthcare providers, government agencies, and facility administrators and staff. One particularly troublesome area of concern involves nursing home placement and care. Dramatic stories sometimes rise to the level of national attention and scrutiny. We hear and read accounts of elder abuse by nursing home staff, indifference by nursing home administrators, disagreements over whether to initiate or withdraw a particular life-sustaining treatment, pain management protocols, physician-assisted suicide, and the issuing and honoring of DNR orders. But then these stories, as well as the ethical and policy debates they engender, are soon forgotten by the general public. Stories often not heard at all involve the everyday, mundane problems and dilemmas faced by nursing home residents. These problems include roommate selection, waiting lists, privacy surrounding grooming and sexual relations, scheduling of meals and sleeping, confidentiality of medical conditions, freedom to walk around the facility or take trips outside the facility, and use of mechanical and chemical restraints. In one sense, these issues are more problematic and more intractable than those represented in dramatic but fleeting news accounts. What is gradually becoming obvious to many is that the problems faced by the elderly in long-term care—whether these problems are remarkable or mundane, rare or frequent—deserve sustained, careful attention.

IntroductionA recent court decision in Germany defined assisted suicide as a basic human right. Consequently, the discussion regarding PAD needs to be extended to people who are in forensic/secure psychiatric hospitals or prisons, sometimes without any prospects of release. Several studies have shown that long-term hospitalization and detention are associated with feelings of hopelessness, depression and suicidal ideations. Moreover, the resources for adequate therapy are often rare. This results in complex moral challenges for mental health care.ObjectivesTo review current practices in countries that allow PAD and to discuss ethical conflicts.MethodsLiterature review; international comparison of current regulations.ResultsA majority of the literature on PAD in detention refers to prisoners with terminal medical conditions. Single case reports of PAD-requests of mentally disordered offenders aroused great public interest. The resulting ethical conflicts are similar to those issues regarding PAD and mental disorder in general. However, in secure treatment settings and detention additional aspects such as adverse living conditions and inadequate access to mental health care need to be taken into account.ConclusionsIf unbearable pain is not a precondition for assisted suicide, then mentally disordered and healthy offenders have a right to request PAD, provided they have medical decision-making capacity. Considering the common insufficient mental health care for people in detention, policy and law makers need to ensure that access to PAD will not replace therapy. Professionals involved in PAD evaluations need support by specific guidelines.DisclosureNo significant relationships.

The recent renaissance in research on psychedelic-assisted psychotherapy is showing great promise for the treatment of many psychiatric conditions. Interestingly, therapeutic outcomes for patients undergoing these treatments are predicted by the occurrence of a mystical experience—an experience characterised in part by a sense of profound meaning. This has led to hypotheses that psychedelic-assisted psychotherapy is therapeutic because it enhances perception of meaning, and consequently leads to a meaning response (a therapeutic mechanism that has been well described in the philosophical literature on the placebo effect). The putative mechanism of action of psychedelics as meaning enhancers raises normative ethical questions as to whether it can be justified to pharmacologically increase the perception of meaning in order to heal patients. Using the perspectives of hedonistic moral theories, this paper argues that if psychedelics operate as meaning enhancers, psychedelic-assisted psychotherapy can be ethically justified. An anti-hedonistic objection is presented by applying Robert Nozick’s Experience Machine thought experiment to the case of psychedelic-assisted psychotherapy. However, it is argued that this objection falls short for two reasons. First, even if pleasure and pain are not the only consequences which have moral value they are not morally irrelevant, therefore, therapeutic meaning enhancement can still be justified in cases of extreme suffering. Second, it is possible that psychedelic states of consciousness do not represent a false reality, hence their therapeutic meaning enhancement is not problematic according to Nozick’s standards.

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 (the three Abrahamic religions) 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 (1949) Medical science under dictatorship. New England Journal of Medicine, 241, p39-47 DOI10.1056/NEJM194907142410201 [2] Lederberg J. (1967) 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 (1968) https://www.nature.com/articles/220429b0 [5] Giublini A Minerva F (2013) After-birth abortion: why should the baby live. J Med Ethics 39, 261- [6] Rachels J (1975) 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

Photo by Sandy Millar on Unsplash INTRODUCTION On November 25, 2019, the federal law H.R. 724 – the Preventing Animal Cruelty and Torture Act (PACT) prohibiting the intentional harm of “living non-human mammals, birds, reptiles, or amphibians” was signed.[1] This law was a notable step in extending protections, rights, and respect to animals. While many similar state laws existed, the passing of a federal law signaled a new shift in public tone. PACT is a declaration of growing societal sentiments that uphold the necessity to shield our fellow creatures from undue harm. Protecting animals from the harm of citizens is undoubtedly important, but PACT does nothing to protect animals from state-sanctioned harm, particularly in the form of research, which causes death and cruelty. It is time to extend and expand protections for animals used in research. BACKGROUND There is a long history of animal experimentation in the US, but no meaningful ethical protections of animals emerged until the 20th century. Proscription of human experimentation and dissection led to animals bearing the brunt of harm for scientific and medical progress. For instance, English physician William Harvey discovered the heart did not continuously produce blood but instead recirculated it; he made this discovery by dissecting and bleeding out living dogs without anesthesia.[2] Experiments like this were considered ethically tenable for hundreds of years. Philosophers like Immanuel Kant, Thomas Aquinas, and Rene Descartes held that humans have no primary moral obligations to animals and that one should be concerned about the treatment of an animal only because it could indicate how one would treat a human.[3] During the 20th century, as agriculture became more industrialized and government funding for animal research increased, the social demand for ethical regulations finally began to shift. In 1966, the Animal Welfare Act (Public Law 89-544) marked the first American federal legislation to protect laboratory animals, setting standards for use of animals in research.[4] ANALYSIS There has been progress in the field of animal research ethics since Harvey’s experiments, but much work remains. In the US alone, there are an estimated 20 million mice, fish, birds, and invertebrates used for animal research each year that are not regulated by the Animal Welfare Act.[5] Instead, the “3Rs Alternatives” approach (“reduce, replace, and refine”)[6] is one framework used to guide ethical treatment of animals not covered by federal protections. Unfortunately, unpacking the meaning and details of this approach only leads to ambiguity and minimal actionable guidance. For instance, an experimenter could reduce the number of animals used in research but subsequently increase the number of experiments conducted on the remaining animals. Replace could be used in the context of replacing one species with another. Refining is creating “any decrease in the severity of inhumane procedures applied to those animals, which still have to be used.”[7] The vague “any” implies that even a negligible minimization would be ethically acceptable.[8] An experimenter could technically follow each of the “3Rs” with minimal to no reduction in harm to the animals. One must also consider whether it is coherent to refer to guidelines as ethical when they inevitably produce pain, suffering, and death as consequences of research participation. Other ethical guides like Humane Endpoints for Laboratory Animals Used in Regulatory Testing[9] encourage researchers to euthanize animals that undergo intractable pain or distress. This is a fate that an estimated one million animals face yearly in the US.[10] However, to use the word “humane” in this context contradicts the traditional meaning and undermines the integrity of the word. Taking living creatures, forcing them to experience intractable pain and suffering for human benefit, and killing them is the antithesis of what it means to be humane. During one of my Animal Ethics classes as a graduate student, our cohort visited an animal research facility to help inform our opinions on animal research. We observed one of the euthanasia chambers for lab mice – an enclosed metal lab bench with a sign above describing methods for euthanasia if CO2 asphyxiation were to fail. The methods included decapitation, removal of vital organs, opening of the chest cavity, incision of major blood vessels, and cervical dislocation.[11] Behind us were rows and rows of see-through shoebox-sized containers housing five mice in each little box. Thousands of mice were packed together in this room for the sole purpose of breeding. If the mice were not the correct “type” for research, then they were “humanely” euthanized. “Humane,” in this context, has been deprived of its true meaning. One can acknowledge that animal research was historically necessary for scientific progress, but those that currently claim these practices are still required must show empirically and undoubtedly this is true. As of now, this is not a settled issue. In the scientific community, there is contention about whether current animal research is actually applicable to humans.[12] Many drug researchers even view animal testing as a tedious barrier to development as it may be wholly irrelevant to the drug or medical device being tested. Since 1962, the FDA has required preclinical testing in animals; it is time to question whether this is necessary or helpful for drug development. CONCLUSION The scientific community should stop viewing animal testing as an unavoidable evil in the search for medical and technological innovation. PACT should be amended and extended to all animals and the FDA should modify the requirement for preclinical animal testing of all drugs and medical devices. It is time to encourage the scientific community to find alternative research methods that do not sacrifice our fellow animals. We use animals as test subjects because, in some sense, they resemble humans. But, if they are indeed like humans, they should receive similar protections. Science builds a better world for humans, but perhaps it is time for science to be more inclusive and build a better world for all creatures. - [1] Theodore E. Deutch, “Text - H.R.724 - 116th Congress (2019-2020): Preventing Animal Cruelty and Torture Act,” legislation, November 25, 2019, 2019/2020, https://www.congress.gov/bill/116th-congress/house-bill/724/text. [2] Anita Guerrini, “Experiments, Causation, and the Uses of Vivisection in the First Half of the Seventeenth Century,” Journal of the History of Biology 46, no. 2 (2013): 227–54. [3] Bernard E. Rollin, “The Regulation of Animal Research and the Emergence of Animal Ethics: A Conceptual History,” Theoretical Medicine and Bioethics 27, no. 4 (September 28, 2006): 285–304, https://doi.org/10.1007/s11017-006-9007-8; Darian M Ibrahim, “A Return to Descartes: Property, Profit, and the Corporate Ownership of Animals,” LAW AND CONTEMPORARY PROBLEMS 70 (n.d.): 28. [4] Benjamin Adams and Jean Larson, “Legislative History of the Animal Welfare Act: Introduction | Animal Welfare Information Center| NAL | USDA,” accessed November 3, 2021, https://www.nal.usda.gov/awic/legislative-history-animal-welfare-act-introduction. [5] National Research Council (US) and Institute of Medicine (US) Committee on the Use of Laboratory Animals in Biomedical and Behavioral Research, Patterns of Animal Use, Use of Laboratory Animals in Biomedical and Behavioral Research (National Academies Press (US), 1988), https://www.ncbi.nlm.nih.gov/books/NBK218261/. [6] Robert C. Hubrecht and Elizabeth Carter, “The 3Rs and Humane Experimental Technique: Implementing Change,” Animals: An Open Access Journal from MDPI 9, no. 10 (September 30, 2019): 754, https://doi.org/10.3390/ani9100754. [7] Hubrecht and Carter. [8] Hubrecht and Carter. [9] William S. Stokes, “Humane Endpoints for Laboratory Animals Used in Regulatory Testing,” ILAR Journal 43, no. Suppl_1 (January 1, 2002): S31–38, https://doi.org/10.1093/ilar.43.Suppl_1.S31. [10] Stokes. [11] “Euthanasia of Research Animals,” accessed April 21, 2022, https://services-web.research.uci.edu/compliance/animalcare-use/research-policies-and-guidance/euthanasia.html. [12] Neal D. Barnard and Stephen R. Kaufman, “Animal Research Is Wasteful and Misleading,” Scientific American 276, no. 2 (1997): 80–82.

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.

Photo by Adhy Savala on Unsplash ABSTRACT During a crisis, when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, crisis standards of care are invoked to distribute scarce hospital space, staff, and supplies. When transitioning between conventional standards of care and crisis standards, hospitals may have to manage resources under scarcity constraints in an intermediate phase defined as the contingency phase. While much attention has been paid to the ethics of crisis standard of care protocols, contingency measures were more widely implemented, though little exists within the literature on the ethics of contingency measures or a clearly explicated contingency standard of care. This paper addresses three ethical issues with the current contingency response to COVID-19: the lack of formalization, the risks of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care. INTRODUCTION When transitioning between conventional standards of care and crisis standards, or in situations where shortages do not immediately threaten care delivery, hospitals may have to manage scarce resources in an intermediate phase, known as the “contingency” phase.[1] While much attention has been paid to the ethics of crisis standards, less literature covers the ethics of contingency measures or a clearly explicated contingency standard of care. Many states and hospital systems do not have contingency standards of care to dictate allocation absent an event triggering crisis standards. Crisis standards of care, used when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, reflect ethical priorities relevant in times of shortage or other emergencies. These priorities include saving the most lives, the stewardship of scarce resources, and justice relating to equitable resource distribution.[2] Crisis standards of care delineate specialized allocation protocols and triage decision-making bodies at the institutional or state levels. Crisis standards of care require formal activation at the state level, and in the absence of clear triggers or governmental willingness to use them, hospitals may adopt informal strategies to manage allocation in the form of contingency measures. The contingency phase is defined by two simultaneous goals: prevent or stall crisis-level scarcity by managing limited resources and providing patient care that is functionally equivalent to usual care.[3] In other words, allocate scarce resources with no significant health consequences to patients. However, this is an unrealistic expectation: meeting a patient’s medical needs and allocating resources on the basis of scarcity instead of medical indications can be at odds, creating ethical tension. This paper addresses three ethical issues with the current contingency response stemming from this tension: the lack of formalization, the risk of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care. l. Lack of Formalization One shortcoming of current contingency measures is that they fail to meet the same level of procedural detail and clarity as crisis standards. The early COVID-19 surges in Italy and France demonstrated the pitfalls of bedside allocation in the absence of procedural guidance. The acute scarcity of critical care resources forced doctors in these countries to make allocation decisions at the bedside, which often resulted in de facto age-based allocation as well as experiences of moral distress and shame among providers.[4] In France, medical allocation guidelines and statistics were never released to the public, raising concerns over the role of transparency in implementing crisis standards and triage guidelines and causing the public to question the trustworthiness of provider triage.[5] Though many states in the US have crisis standards of care that can be implemented in the case of a large-scale triage event, these measures vary widely. A 2020 review of 31 crisis standards of care in the US found that only 18 contained strong “ethical grounding,” 28 used “evidence-based clinical processes and operations,” 21 included “ongoing community and provider engagement, education, and communication,” and 16 had “clear indicators, triggers, and lines of responsibility.”[6] The need for standardization, public transparency, and guidelines for crisis standards of care to prevent bedside allocation has been widely recognized. However, these issues remain unresolved by public policy or legislative efforts during the contingency period before (or after) crisis standards apply. A recent public health study that observed triage team members in a high-fidelity triage simulation highlighted the challenges of making equitable frontline allocation decisions.[7] In the simulation, participants nudged patient priority status up or down depending on what they subjectively identified as morally relevant factors. Through the simulation, participants reported difficulty separating implicit biases about patient characteristics from their clinical judgment. In the absence of formal institutional or regional guidelines for allocation during contingency-level shortages, there are few to no procedural safeguards against biased, ad hoc, and non-transparent rationing. Without formalized or standardized contingency allocation guidance, providers are left to make bedside allocation decisions that are susceptible to individual biases and patterns of unintended discrimination. An example of this susceptibility is seen when hospitals allow patients who no longer benefit from ICU resources to continue occupying ICU beds. This is based on a first-come-first-served (FCFS) approach to bed allocation. FCFS is often a default for patient intake, which led to disparities in care access during the early COVID-19 pandemic. Media reports of hospitals with “plenty of space” being unwilling to accept patients from overwhelmed, lower-income hospitals illustrate that the FCFS default advantages those who could show up first to a particular hospital: often privileged, well-funded healthcare systems that were inaccessible to low-income communities.[8] FCFS is blind to several morally relevant factors, including the likelihood of survival to discharge, reciprocity (i.e. prioritizing healthcare workers), and varying degrees of access to healthcare. Therefore, it inappropriately privileges those in proximity to healthcare systems or with social connections enabling greater initial access to care.[9] During crisis standards of care, excessive mortality that would result from FCFS is mitigated through formalized system-wide triage protocols based on current patient health status and potential benefit from resources. Crisis and contingency standards may provide liability coverage for providers who reallocate critical care beds away from those who no longer benefit during periods of scarcity. This liability coverage shifts bed allocation away from an FCFS model, but only if the policy is well-defined, clearly established, and known to providers. Without a formal system to guide the process or transition from the usual method of allocation to the contingency period, contingency decisions about who gets a scarce resource may continue to operate on an implicit FCFS basis, even when approaching crisis levels of scarcity. Additionally, these decisions will fall unsustainably on individual providers or transfer center workers, leading to moral distress on the frontlines when hospitals are already strained. Lessons from the crisis and contingency responses during COVID-19 can improve future contingency responses. There are multiple ways of achieving equity during contingency allocation, ranging from hospital-level to state-level policy changes. State-wide policies and interventions to facilitate resource-sharing can relieve some of the scarcity burdens that hospitals may face during the contingency period. For example, moving ICU patients to lower levels of care once they have sufficiently recovered is a challenge for doctors, who often call other hospitals to find open beds. In these situations, providers who do not move patients who no longer benefit from ICU beds unknowingly reinforce the FCFS system in which those who arrive first keep the scarce beds, while those who arrive later or wait for one are disadvantaged by having limited access to them. State-wide patient transfer centers, often facilitated by state public health departments, present an alternative by balancing patient needs and bed distribution more equitably and efficiently than individual physicians do, as demonstrated following COVID-19 surges in hospitalization.[10] These centers aid not only in allocating open tertiary care beds, but also in identifying open beds at lower levels of care and assisting physicians with transferring out patients who can be safely downgraded and no longer benefit from tertiary care resources. However, the simplest solution is to encourage the creation of ethics guidance or protocols for contingency allocation at the hospital level. In hospitals, institutional ethics guidance can help providers navigate difficult decisions and conversations with patients. When providers face time-sensitive allocation decisions, like the allocation of open ICU beds, the guidance would be a useful tool for making transparent, principled, and ethically justified allocation decisions in real-time to mitigate the risk of ad hoc or implicit rationing. ll. Unsuited for Prolonged Resource Shortages Secondly, neither contingency nor crisis standards are currently designed to respond to prolonged strains on the healthcare system. Since the start of the pandemic, a prolonged period of staffing shortages began and is projected to persist.[11] However, both crisis and contingency standards assume that the system will eventually return to conventional standards of care. For example, as a contingency or crisis standard, many hospitals deferred elective surgeries to preserve limited resources for emergency and life-saving procedures. Massachusetts, for instance, issued a public health emergency order that required hospitals to defer 50 percent of all non-essential and non-urgent (elective) surgeries. This order demonstrates the use of this contingency measure in response to prolonged staffing and bed shortages.[12] However, the deferral of elective procedures can result in adverse long-term community health consequences. Medical conditions typically addressed through elective surgery, such as joint replacement surgeries for osteoarthritis patients, may worsen if delayed. This can result in greater numbers of acute emergencies, the need for more complex surgical procedures later, increased reliance on pain medications, and longer recovery times.[13] Without a greater understanding of long-term complications in community health, existing contingency strategies, such as the deferral of elective surgeries, may be unsuitable for prolonged shortages. This becomes a greater threat to patient safety when contingency measures inappropriately take the place of crisis standards, risking the long-term implementation of emergency measures designed for temporary use. Although some state emergency planning documents identify indicators and triggers for activating contingency and crisis operations,[14] this transition is not always clear in action. For example, New York did not implement crisis standards of care during the early COVID-19 pandemic despite being one of the hardest-hit cities in the US.[15] Other states, including California, Texas, and Florida, did not activate crisis standards of care, leaving hospitals to implement informal contingency measures that ultimately required allocation strategies very similar or identical to many crisis standards of care protocols.[16] Due to the hesitance to activate crisis standards, ad hoc contingency measures and bedside decision-making prevailed over formal triage protocols. If contingency measures are not set forth in objective documents and are inappropriately used in the place of crisis standards, these short-term measures may result in an unfair or non-transparent distribution of scarce resources. When shortages in space, staff, or supplies jeopardize the ability to provide necessary care for critically ill patients under a conventional standard of care, failures to activate crisis standards risk the inappropriate use of ad hoc contingency measures in their place. With clear contingency standards of care, the duration of an ad hoc approach could be limited. Crisis standards are defined and activated at the regional or state-wide level, but outside of hospital-specific resource limitations, there are generally no standardized indications or triggers for transitioning into and out of contingency measures. Leaving contingency needs to individual hospitals may seem beneficial but defining the contingency period at the hospital level and the crisis period at the state or regional level blurs the line about when it is appropriate for decision makers to activate crisis standards, risking delayed activation or failure to activate them at all. Therefore, it is important that state policies implement automatic triggers for activation that clearly delineate between contingency and crisis responses.[17] Automatic triggers based on validated metrics like remaining available resources can inform the appropriate decision makers about when they must activate crisis standards. These triggers should be transparent to the public, validated, and updated over time with evolving data. These automatic triggers would prevent confusion, inconsistent guidelines, and inequitable contingency allocation at the hands of distressed providers when crisis standards are needed. Defining when to begin crisis standards could help limit the length of the contingency period. This would protect against the inappropriate application of contingency measures to crisis-level scarcity and prolonged shortages that they could not sustainably ameliorate. lll. Potential to Exacerbate Health Disparities Inconsistencies in contingency allocation open the door to disparities in care and unequal distribution of scarcity burdens among different communities based on their location or health needs. This is a concern because it is unclear whether contingency measures can meet their goal of achieving functionally equivalent patient outcomes when resource allocation must be balanced with patient-centered care.[18] The care under contingency standards is meant to be functionally equivalent to regular care. The definition assumes (or may wrongly suggest) that any contingency strategy in place to avoid critical scarcity has no significant impact on patient outcomes. While functional equivalence is attainable, there is currently little research into which contingency measures achieve functionally equivalent outcomes and which patient groups may be disproportionately affected by harmful resource allocation strategies. Although the transition from contingency standards to crisis standards is defined by the inability to provide functionally equivalent care, the difference in practice may merely be a distinction between visible, immediate sacrifices to patient well-being during crises and less-obvious, long-term decrements in community health due to protracted contingency care alterations. Two common contingency measures are cause for concern over disparate patient outcomes and the attainability of functional equivalence. First, restricting emergency room visits by the patient’s degree of need has worrying consequences. In late 2021 and early 2022, hospitals in Massachusetts faced widespread staffing shortages, leading to an emergency order that restricted emergency visits to emergency needs.[19] While this order is a reasonable method of allocating limited staff in the emergency department during severe shortages, it is doubtful that the outcomes of this restriction were equivalent to usual care. Health issues that are soon-to-be emergencies are filtered out until they worsen, resulting in patients overflowing to urgent care clinics or presenting to ERs with more severe forms of sicknesses later on. Given the empirical evidence demonstrating ER treatment and admission disparities that disadvantage Black and Hispanic patients, such a measure would only exacerbate these disparities by further limiting access to needed care.[20] Second, altered staffing ratios, which stretch a limited number of providers to meet patient needs during a staffing shortage, are another concerning yet common contingency measure. Staffing allocation is often viewed similarly to the allocation of space and medical equipment, such that contingency alterations to staffing operations may not seem like they significantly jeopardize patient care quality and outwardly appear functionally equivalent.[21] However, lower ratios of qualified nurses are associated with poor outcomes such as higher inpatient mortality[22] and lower survival rates of in-hospital cardiac arrest for Black patients.[23] These examples highlight the strong potential for contingency measures to amplify social health disparities, particularly when adopted over a prolonged time frame. Lowered standards of care in crisis allocation disproportionately impact racial and ethnic minorities.[24] For example, crisis standards of care used clinical scoring systems that were not developed or validated for crisis triage to prioritize access to life-saving treatments during the COVID-19 pandemic. This practice actively gives rise to racial health disparities and discrimination against disabled patients.[25] Not only were the standards inequitable in practice, but they varied widely from state to state and sometimes even from hospital to hospital, creating disparities across and within geographic regions.[26] If contingency measures are similarly implemented across hospitals or hospital departments without standardization or advance planning to ensure equitable outcomes, it is likely that the burden of a lower standard of care will fall primarily on disadvantaged patient groups and racial minorities. However, standardization alone may be insufficient. Other factors like varying levels of details on patients’ charts between hospitals could produce unfair outcomes if used to determine patient admission or transfer priority, even if the criteria for admissions and transfers are consistent. Thus, ongoing monitoring for unintended patterns of disparity must accompany standardization to ensure that blind spots in the allocation process are identified and corrected. Bioethics has long been preoccupied with the micro-allocation of limited resources within hospitals instead of confronting the structural inequities that underlie broader scarcity and patient needs. The traditional dilemma of allocating limited hospital resources among a certain number of patients overlooks questions about how other resources have already been allocated, which patients were present at the hospital in the first place, where hospitals have (and have not) been built, and whether previous allocation strategies created bias in the broader distribution of resources. Therefore, to achieve fairness, bioethicists must pay attention to aspects of the broader distribution of resources, such as social determinants of health and the allocation of preventative resources at the public health level. One strategy for measuring and addressing these disparities is the Area Deprivation Index (ADI). The ADI quantifies the effects of race, class, and socioeconomic background by geographic region for use in public health research and the prioritization of resources.[27] It has shown promise in identifying geographic regions in need of targeted community health efforts for diabetes management based on electronic patient health records.[28] The ADI and similar tools would be useful in proactively deciding how to allocate public health resources when hospitals are strained. Moreover, through using population health and resource data, public health organizations may forecast contingency shortages allowing for the adoption of early measures to mitigate health disparities that might otherwise be amplified from hospital-level contingency allocation decisions. CONCLUSION Meeting community health needs during periods of contingency scarcity, both before and after crisis standards of care apply, will require contingency standards of care rather than a bedside ad hoc distribution of scarce resources. While it is not inherently ethically unjustifiable for hospitals to adopt measures that may lower the standard of care during contingency standards, the necessity of these measures requires that bioethicists consider how equity, transparency, and the overall aim of functional equivalence can best be achieved under conditions of scarcity. The long-term health consequences of existing contingency measures, the potential for ad hoc and inconsistent allocation of scarce resources, and the need for consensus about when it becomes appropriate to make the formal transition to crisis standards of care demand further consideration. Because contingency measures will likely amplify existing disparities as crisis standards have, hospital-level management of scarcity is inadequate. Public health measures should be adopted in parallel to anticipate and manage health needs at the community or state level when resources are strained. - [1] Altevogt, B. M., Stroud, C., Hanson, S. L., Hanfling, D., & Gostin, L. O. (2009). Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. The National Academies Press. https://doi.org/10.17226/12749 [2] Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine, 382(21), 2049–2055. https://doi.org/10.1056/NEJMsb2005114 [3] Alfandre, D., Sharpe, V. A., Geppert, C., Foglia, M. B., Berkowitz, K., Chanko, B., & Schonfeld, T. (2021). Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures. The American Journal of Bioethics, 21(8), 4–16. https://doi.org/10.1080/15265161.2021.1925778 [4] Rosenbaum, L. (2020). Facing Covid-19 in Italy—Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. New England Journal of Medicine, 382(20), 1873–1875. https://doi.org/10.1056/NEJMp2005492 [5] Orfali, K. (2020). What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France. Journal of Bioethical Inquiry, 17(4), 675–679. https://doi.org/10.1007/s11673-020-10059-y [6] Romney, D., Fox, H., Carlson, S., Bachmann, D., O’Mathuna, D., & Kman, N. (2020). Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents. Disaster Medicine and Public Health Preparedness, 14(5), 677–683. https://doi.org/10.1017/dmp.2020.101 [7] Butler, C. R., Webster, L. B., Diekema, D. S., Gray, M. M., Sakata, V. L., Tonelli, M. R., & Vranas, K. C. (2022). Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Network Open, 5(4), e227639. https://doi.org/10.1001/jamanetworkopen.2022.7639 [8] Dwyer, J. (2020, May 14). One Hospital Was Besieged by the Virus. Nearby Was ‘Plenty of Space.’—The New York Times. The New York Times. https://www.nytimes.com/2020/05/14/nyregion/coronavirus-ny-hospitals.html [9] Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. Lancet (London, England), 373(9661), 423–431. https://doi.org/10.1016/S0140-6736(09)60137-9 [10] Mitchell, S. H., Rigler, J., & Baum, K. (2022). Regional Transfer Coordination and Hospital Load Balancing During COVID-19 Surges. JAMA Health Forum, 3(2), e215048. https://doi.org/10.1001/jamahealthforum.2021.5048 [11] ASPE. (2022, May 3). Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce: Challenges and Policy Responses. ASPE. https://aspe.hhs.gov/reports/covid-19-health-care-workforce [12] Executive Office of Health and Human Services. (2021). Baker-Polito Administration Provides COVID-19 Update on Mask Advisory, Hospital Support | Mass.gov. https://www.mass.gov/news/baker-polito-administration-provides-covid-19-update-on-mask-advisory-hospital-support [13] The Lancet Rheumatology. (2021). Too long to wait: The impact of COVID-19 on elective surgery. The Lancet Rheumatology, 3(2), e83. https://doi.org/10.1016/S2665-9913(21)00001-1 [14] For an example of transition planning between crisis and contingency standards, see Minnesota Department of Health. (2021). Ethical Framework for Transitions Between Conventional, Contingency, and Crisis Conditions in Pervasive or Catastrophic Public Health Events with Medical Surge Implications (Minnesota Crisis Standards of Care). https://www.health.state.mn.us/communities/ep/surge/crisis/framework_transitions.pdf [15] Powell, T., & Chuang, E. (2020). COVID in NYC: What We Could Do Better. The American Journal of Bioethics, 20(7), 62–66. https://doi.org/10.1080/15265161.2020.1764146 [16] Persoff, J., & Wynia, M. K. (2021). Ethically Navigating the Murky Waters of “Contingency Standards of Care.” The American Journal of Bioethics, 21(8), 20–21. https://doi.org/10.1080/15265161.2021.1939810 [17] Board on Health Sciences Policy & Institute of Medicine. (2013). Indicators and Triggers. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK202381/ [18] Frith, L., Draper, H., Fovargue, S., Baines, P., Redhead, C., & Chiumento, A. (2021). Neither ‘Crisis Light’ nor ‘Business as Usual’: Considering the Distinctive Ethical Issues Raised by the Contingency and Reset Phases of a Pandemic. The American Journal of Bioethics, 21(8), 34–37. https://doi.org/10.1080/15265161.2021.1940363 [19] Rosseau, M. (2022, January 14). New emergency orders issued to help understaffed Mass. Hospitals. Boston.Com. https://www.boston.com/news/coronavirus/2022/01/14/new-emergency-orders-issued-to-help-understaffed-mass-hospitals/ [20] Zhang, X., Carabello, M., Hill, T., Bell, S. A., Stephenson, R., & Mahajan, P. (2020). Trends of Racial/Ethnic Differences in Emergency Department Care Outcomes Among Adults in the United States From 2005 to 2016. Frontiers in Medicine, 7. https://www.frontiersin.org/articles/10.3389/fmed.2020.00300 [21] Hick, J. L., Hanfling, D., & Wynia, M. (2022). Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19. The Joint Commission Journal on Quality and Patient Safety. https://doi.org/10.1016/j.jcjq.2022.02.003 [22] Musy, S. N., Endrich, O., Leichtle, A. B., Griffiths, P., Nakas, C. T., & Simon, M. (2021). The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study. International Journal of Nursing Studies, 120, 103950. https://doi.org/10.1016/j.ijnurstu.2021.103950 [23] Brooks Carthon, M., Brom, H., McHugh, M., Sloane, D. M., Berg, R., Merchant, R., Girotra, S., & Aiken, L. H. (2021). Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests. Medical Care, 59(2), 169–176. https://doi.org/10.1097/MLR.0000000000001464 [24] Annas, G. J., & Crosby, S. S. (2021). Standard Racism: Trying to Use “Crisis Standards of Care” in the COVID-19 Pandemic. The American Journal of Bioethics, 21(8), 1–3. https://doi.org/10.1080/15265161.2021.1941424 [25] Wynia, M. K., & Sottile, P. D. (2020). Ethical Triage Demands a Better Triage Survivability Score. The American Journal of Bioethics, 20(7), 75–77. https://doi.org/10.1080/15265161.2020.1779412 [26] Fink, S. (2020). Ethical Dilemmas in Covid-19 Medical Care: Is a Problematic Triage Protocol Better or Worse than No Protocol at All? The American Journal of Bioethics, 20(7), 1–5. https://doi.org/10.1080/15265161.2020.1788663 [27] Knighton, A. J., Savitz, L., Belnap, T., Stephenson, B., & VanDerslice, J. (2016). Introduction of an Area Deprivation Index Measuring Patient Socioeconomic Status in an Integrated Health System: Implications for Population Health. EGEMS (Washington, DC), 4(3), 1238. https://doi.org/10.13063/2327-9214.1238 [28] Kurani, S. S., Lampman, M. A., Funni, S. A., Giblon, R. E., Inselman, J. W., Shah, N. D., Allen, S., Rushlow, D., & McCoy, R. G. (2021). Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. 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“People live here, they die here so they must leave traces.” (Read 140) “Whatever colonialism was and is, it has made this place unsettling and unsettled.” (Gibson, Badland 2) Introduction What does it mean for [a] country to be haunted? In much theoretical work in film and Cultural Studies since the 1990s, the Australian continent, more often than not, bears traces of long suppressed traumas which inevitably resurface to haunt the present (Gelder and Jacobs; Gibson; Read; Collins and Davis). Felicity Collins and Therese Davis illuminate the ways Australian cinema acts as a public sphere, or “vernacular modernity,” for rethinking settler/indigenous relations. Their term “backtracking” serves as a mode of “collective mourning” in numerous films of the last decade which render unspoken colonial violence meaningful in contemporary Australia, and account for the “aftershocks” of the Mabo decision that overturned the founding fiction of terra nullius (7). Ray Lawrence’s 2006 film Jindabyne is another after-Mabo film in this sense; its focus on conflict within settler/indigenous relations in a small local town in the alpine region explores a traumatised ecology and drowned country. More than this, in our paper’s investigation of country and its attendant politics, Jindabyne country is the space of excessive haunting and resurfacing - engaging in the hard work of what Gibson (Transformations) has termed “historical backfill”, imaginative speculations “that make manifest an urge to account for the disconnected fragments” of country. Based on an adaptation by Beatrix Christian of the Raymond Carver story, So Much Water, So Close to Home, Jindabyne centres on the ethical dilemma produced when a group of fishermen find the floating, murdered body of a beautiful indigenous woman on a weekend trip, but decide to stay on and continue fishing. In Jindabyne, “'country' […] is made to do much discursive work” (Gorman-Murray). In this paper, we use the word as a metonym for the nation, where macro-political issues are played out and fought over. But we also use ‘country’ to signal the ‘wilderness’ alpine areas that appear in Jindabyne, where country is “a notion encompassing nature and human obligation that white Australia has learned slowly from indigenous Australia” (Gibson, Badland 178). This meaning enables a slippage between ‘land’ and ‘country’. Our discussion of country draws heavily on concepts from Ross Gibson’s theorisation of badlands. Gibson claims that originally, ‘badland’ was a term used by Europeans in North America when they came across “a tract of country that would not succumb to colonial ambition” (Badland 14). Using Collins and Davis’s “vernacular modernity” as a starting point, a film such as Jindabyne invites us to work through the productive possibilities of postcolonial haunting; to move from backtracking (going over old ground) to imaginative backfill (where holes and gaps in the ground are refilled in unconventional and creative returns to the past). Jindabyne (as place and filmic space) signifies “the special place that the Australian Alps occupy for so many Australians”, and the film engages in the discursive work of promoting “shared understanding” and the possibility of both Aboriginal and non-Aboriginal being “in country” (Baird, Egloff and Lebehan 35). We argue specifically that Jindabyne is a product of “aftermath culture” (Gibson Transformations); a culture living within the ongoing effects of the past, where various levels of filmic haunting make manifest multiple levels of habitation, in turn the product of numerous historical and physical aftermaths. Colonial history, environmental change, expanding wire towers and overflowing dams all lend meaning in the film to personal dilemmas, communal conflict and horrific recent crimes. The discovery of a murdered indigenous woman in water high in the mountains lays bare the fragility of a relocated community founded in the drowning of the town of old Jindabyne which created Lake Jindabyne. Beatrix Christian (in Trbic 61), the film’s writer, explains “everybody in the story is haunted by something. […] There is this group of haunted people, and then you have the serial killer who emerges in his season to create havoc.” “What’s in this compulsion to know the negative space?” asks Gibson (Badland 14). It’s the desire to better know and more deeply understand where we live. And haunting gives us cause to investigate further. Drowned, Murderous Country Jindabyne rewrites “the iconic wilderness of Australia’s High Country” (McHugh online) and replaces it with “a vast, historical crime scene” (Gibson, Badland 2). Along with nearby Adaminaby, the township of Old Jindabyne was drowned and its inhabitants relocated to the new town in the 1960s as part of the Snowy Mountains Hydro-electric Scheme. When Jindabyne was made in 2006 the scheme no longer represented an uncontested example of Western technological progress ‘taming’ the vast mountainous country. Early on in the film a teacher shows a short documentary about the town’s history in which Old Jindabyne locals lament the houses that will soon be sacrificed to the Snowy River’s torrents. These sentiments sit in opposition to Manning Clark’s grand vision of the scheme as “an inspiration to all who dream dreams about Australia” (McHugh online). With a 100,000-strong workforce, mostly migrated from war-ravaged Europe, the post-war Snowy project took 25 years and was completed in 1974. Such was this engineering feat that 121 workmen “died for the dream, of turning the rivers back through the mountains, to irrigate the dry inland” (McHugh online). Jindabyne re-presents this romantic narrative of progress as nothing less than an environmental crime. The high-tension wires scar the ‘pristine’ high country and the lake haunts every aspect of the characters’ interactions, hinting at the high country’s intractability that will “not succumb to colonial ambition” (Gibson, Badland 14). Describing his critical excavation of places haunted, out-of-balance or simply badlands, Gibson explains: Rummaging in Australia's aftermath cultures, I try to re-dress the disintegration in our story-systems, in our traditional knowledge caches, our landscapes and ecologies […] recuperate scenes and collections […] torn by landgrabbing, let's say, or by accidents, or exploitation that ignores rituals of preservation and restoration (Transformations). Tourism is now the predominant focus of Lake Jindabyne and the surrounding areas but in the film, as in history, the area does not “succumb to the temptations of pictorialism” (McFarlane 10), that is, it cannot be framed solely by the picture postcard qualities that resort towns often engender and promote. Jindabyne’s sense of menace signals the transformation of the landscape that has taken place – from ‘untouched’ to country town, and from drowned old town to the relocated, damned and electrified new one. Soon after the opening of the film, a moment of fishing offers a reminder that a town once existed beneath the waters of the eerily still Lake Jindabyne. Hooking a rusty old alarm clock out of the lake, Stuart explains to Tom, his suitably puzzled young son: underneath the water is the town where all the old men sit in rocking chairs and there’s houses and shops. […] There was a night […] I heard this noise — boing, boing, boing. And it was a bell coming from under the water. ‘Cause the old church is still down there and sometimes when the water’s really low, you can see the tip of the spire. Jindabyne’s lake thus functions as “a revelation of horrors past” (Gibson Badland 2). It’s not the first time this man-made lake is filmically positioned as a place where “violence begins to seem natural” (Gibson, Badland 13). Cate Shortland’s Somersault (2004) also uses Lake Jindabyne and its surrounds to create a bleak and menacing ambience that heightens young Heidi’s sense of alienation (Simpson, ‘Reconfiguring rusticity’). In Somersault, the male-dominated Jindabyne is far from welcoming for the emotionally vulnerable out-of-towner, who is threatened by her friend’s father beside the Lake, then menaced again by boys she meets at a local pub. These scenes undermine the alpine region’s touristic image, inundated in the summer with tourists coming to fish and water ski, and likewise, with snow skiers in the winter. Even away from the Lake, there is no fleeing its spectre. “The high-tension wires marching down the hillside from the hydro-station” hum to such an extent that in one scene, “reminiscent of Picnic at Hanging Rock (Peter Weir, 1975)”, a member of the fishing party is spooked (Ryan 52). This violence wrought upon the landscape contextualises the murder of the young indigenous woman, Susan, by Greg, an electrician who after murdering Susan, seems to hover in the background of several scenes of the film. Close to the opening of Jindabyne, through binoculars from his rocky ridge, Greg spots Susan’s lone car coursing along the plain; he chases her in his vehicle, and forces her to stop. Before (we are lead to assume) he drags her from the vehicle and murders her, he rants madly through her window, “It all comes down from the power station, the electricity!” That the murder/murderer is connected with the hydro-electric project is emphasised by the location scout in the film’s pre-production: We had one location in the scene where Greg dumps the body in some water and Ray [Lawrence] had his heart set on filming that next to some huge pipelines on a dam near Talbingo but Snowy Hydro didn’t […] like that negative content […] in association with their facility and […] said ‘no’ they wouldn’t let us do it.” (Jindabyne DVD extras) “Tales of murder and itinerancy in wild country are as old as the story of Cain in the killing fields of Eden” (Badlands 14). In Jindabyne we never really get to meet Greg but he is a familiar figure in Australian film and culture. Like many before him, he is the lone Road Warrior, a ubiquitous white male presence roaming the de-populated country where the road constantly produces acts of (accidental and intentional) violence (Simpson, ‘Antipodean Automobility’). And after a litany of murders in recent films such as Wolf Creek (Greg McLean, 2005) and Gone (Ringan Ledwidge, 2007) the “violence begins to seem natural” (Gibson Transformations 13) in the isolating landscape. The murderer in Jindabyne, unlike those who have migrated here as adults (the Irish Stuart and his American wife, Claire), is autochthonous in a landscape familiar with a trauma that cannot remain hidden or submerged. Contested High Country The unsinkability of Susan’s body, now an ‘indigenous murdered body’, holds further metaphorical value for resurfacing as a necessary component of aftermath culture. Such movement is not always intelligible within non-indigenous relations to country, though the men’s initial response to the body frames its drifting in terms of ascension: they question whether they have “broken her journey by tying her up”. The film reconfigures terra nullius as the ultimate badland, one that can never truly suppress continuing forms of physical, spiritual, historical and cultural engagement with country, and the alpine areas of Jindabyne and the Snowy River in particular. Lennon (14) points to “the legacy of biased recording and analysis” that “constitutes a threat to the cultural significance of Aboriginal heritage in alpine areas” (15). This significance is central to the film, prompting Lawrence to state that “mountains in any country have a spiritual quality about them […] in Aboriginal culture the highest point in the landscape is the most significant and this is the highest point of our country” (in Cordaiy 40). So whilst the Jindabyne area is contested country, it is the surfacing, upward mobility and unsinkable quality of Aboriginal memory that Brewster argues “is unsettling the past in post-invasion Australia” (in Lambert, Balayi 7). As the agent of backfill, the indigenous body (Susan) unsettles Jindabyne country by offering both evidence of immediate violence and reigniting the memory of it, before the film can find even the smallest possibility of its characters being ‘in country’. Claire illustrates her understanding of this in a conversation with her young son, as she attempts to contact the dead girls’ family. “When a bad thing happens,” she says, “we all have to do a good thing, no matter how small, alright? Otherwise the bad things, they just pile up and up and up.” Her persistent yet clumsy enactment of the cross-cultural go-between illuminates the ways “the small town community move through the terms of recent debate: shame and denial, repressed grief and paternalism” (Ryan 53). It is the movement of backfill within the aftermath: The movement of a foreign non-Aboriginal woman into Aboriginal space intertextually re-animates the processes of ‘settlement’, resolution and environmental assimilation for its still ‘unsettled’ white protagonists. […] Claire attempts an apology to the woman’s family and the Aboriginal community – in an Australia before Kevin Rudd where official apologies for the travesties of Australian/colonial history had not been forthcoming […] her movement towards reconciliation here is reflective of the ‘moral failure’ of a disconnection from Aboriginal history. (Lambert, Diasporas) The shift from dead white girl in Carver’s story to young Aboriginal woman speaks of a political focus on the ‘significance’ of the alpine region at a given moment in time. The corpse functions “as the trigger for crisis and panic in an Australia after native title, the stolen generation and the war-on-terror” (Lambert, Diasporas). The process of reconnecting with country and history must confront its ghosts if the community is to move forward. Gibson (Transformations) argues that “if we continue to close our imaginations to the aberrations and insufficiencies in our historical records. […] It’s likely we won’t dwell in the joy till we get real about the darkness.” In the post-colonial, multicultural but still divided geographies and cultures of Jindabyne, “genocidal displacement” comes face to face with the “irreconciled relation” to land “that refuses to remain half-seen […] a measure of non-indigenous failure to move from being on the land to being in country” (Ryan 52), evidenced by water harvesting in the Snowy Mountains Scheme, and the more recent crises in water and land management. Aftermath Country Haunted by historical, cultural and environmental change, Jindabyne constitutes a post-traumatic screen space. In aftermath culture, bodies and landscapes offer the “traces” (Gibson, Transformations) of “the social consequences” of a “heritage of catastrophe” that people “suffer, witness, or even perpetrate” so that “the legacy of trauma is bequeathed” (Walker i). The youth of Jindabyne are charged with traumatic heritage. The young Susan’s body predictably bears the semiotic weight of colonial atrocity and non-indigenous environmental development. Evidence of witnesses, perpetrators and sufferers is still being revealed after the corpse is taken to the town morgue, where Claire (in a culturally improper viewing) is horrified by Susan’s marks from being secured in the water by Stuart and the other men. Other young characters are likewise haunted by a past that is environmental and tragically personal. Claire and Stuart’s young son, Tom (left by his mother for a period in early infancy and the witness of his parents strained marital relations), has an intense fear of drowning. This personal/historical fear is played with by his seven year old friend, Caylin-Calandria, who expresses her own grief from the death of her young mother environmentally - by escaping into the surrounding nature at night, by dabbling in the dark arts and sacrificing small animals. The two characters “have a lot to believe in and a lot of things to express – belief in zombies and ghosts, ritual death, drowning” (Cordaiy 42). As Boris Trbic (64) observes of the film’s characters, “communal and familial harmony is closely related to their intense perceptions of the natural world and their often distorted understanding of the ways their partners, friends and children cope with the grieving process.” Hence the legacy of trauma in Jindabyne is not limited to the young but pervades a community that must deal with unresolved ecologies no longer concealed by watery artifice. Backfilling works through unsettled aspects of country by moving, however unsteadily, toward healing and reconciliation. Within the aftermath of colonialism, 9/11 and the final years of the Howard era, Jindabyne uses race and place to foreground the “fallout” of an indigenous “condemnation to invisibility” and the “long years of neglect by the state” (Ryan 52). Claire’s unrelenting need to apologise to the indigenous family and Stuart’s final admission of impropriety are key gestures in the film’s “microcosm of reconciliation” (53), when “the notion of reconciliation, if it had occupied any substantial space in the public imagination, was largely gone” (Rundell 44). Likewise, the invisibility of Aboriginal significance has specificity in the Jindabyne area – indigeneity is absent from narratives recounting the Snowy Mountains Scheme which “recruited some 60,000 Europeans,” providing “a basis for Australia’s postwar multicultural society” (Lennon 15); both ‘schemes’ evidencing some of the “unrecognised implications” of colonialism for indigenous people (Curthoys 36). The fading of Aboriginal issues from public view and political discourse in the Howard era was serviced by the then governmental focus on “practical reconciliation” (Rundell 44), and post 9/11 by “the broad brushstrokes of western coalition and domestic political compliance” (Lambert, CMC 252), with its renewed focus on border control, and increased suspicion of non-Western, non-Anglo-European difference. Aftermath culture grapples with the country’s complicated multicultural and globalised self-understanding in and beyond Howard’s Australia and Jindabyne is one of a series of texts, along with “refugee plays” and Australian 9/11 novels, “that mobilised themselves against the Howard government” (Rundell 43-44). Although the film may well be seen as a “profoundly embarrassing” display of left-liberal “emotional politics” (44-45), it is precisely these politics that foreground aftermath: local neglect and invisibility, terror without and within, suspect American leadership and shaky Australian-American relations, the return of history through marked bodies and landscapes. Aftermath country is simultaneously local and global – both the disappearance and the ‘problem’ of Aboriginality post-Mabo and post-9/11 are backfilled by the traces and fragments of a hidden country that rises to the surface. Conclusion What can be made of this place now? What can we know about its piecemeal ecology, its choppy geomorphics and scarified townscapes? […] What can we make of the documents that have been generated in response to this country? (Gibson, Transformations). Amidst the apologies and potentialities of settler-indigenous recognition, the murdering electrician Gregory is left to roam the haunted alpine wilderness in Jindabyne. His allegorical presence in the landscape means there is work to be done before this badland can truly become something more. Gibson (Badland 178) suggests country gets “called bad […] partly because the law needs the outlaw for reassuring citizens that the unruly and the unknown can be named and contained even if they cannot be annihilated.” In Jindabyne the movement from backtracking to backfilling (as a speculative and fragmental approach to the bodies and landscapes of aftermath culture) undermines the institutional framing of country that still seeks to conceal shared historical, environmental and global trauma. The haunting of Jindabyne country undoes the ‘official’ production of outlaw/negative space and its discursively good double by realising the complexity of resurfacing – electricity is everywhere and the land is “uncanny” not in the least because “the town of Jindabyne itself is the living double of the drowned original” (Ryan 53). The imaginative backfill of Jindabyne reorients a confused, purgatorial Australia toward the “small light of home” (53) – the hope of one day being “in country,” and as Gibson (Badland 3) suggests, the “remembering,” that is “something good we can do in response to the bad in our lands.” References Baird, Warwick, Brian Egloff and Rachel Lenehan. “Sharing the mountains: joint management of Australia’s alpine region with Aboriginal people.” historic environment 17.2 (2003): 32-36. Collins, Felicity and Therese Davis. Australian Cinema after Mabo. Cambridge: Cambridge UP, 2005. Cordaiy, Hunter. “Man, Woman and Death: Ray Lawrence on Jindabyne.” Metro 149 (2006): 38-42. Curthoys, Anne. “An Uneasy Conversation: The Multicultural and the Indigenous.” Race Colour and Identity in Australia and New Zealand. Ed. John Docker and Gerhard Fischer. Sydney, UNSW P, 2000. 21-36. Gelder, Ken and Jane M. Jacobs. Uncanny Australia: Sacredness an Identity in a Postcolonial Nation. Carlton: Melbourne UP, 1998. Gibson, Ross. Seven Versions of an Australian Badland. St Lucia: U of Queensland P, 2002. Gibson, Ross. “Places, Past, Disappearance.” Transformations 13 (2006). Aug. 11 2008 transformations.cqu.edu.au/journal/issue_13/article_01.shtml. Gorman-Murray, Andrew. “Country.” M/C Journal 11.5 (this issue). Kitson, Michael. “Carver Country: Adapting Raymond Carver in Australia.” Metro150 (2006): 54-60. Lambert, Anthony. “Movement within a Filmic terra nullius: Woman, Land and Identity in Australian Cinema.” Balayi, Culture, Law and Colonialism 1.2 (2001): 7-17. Lambert, Anthony. “White Aborigines: Women, Mimicry, Mobility and Space.” Diasporas of Australian Cinema. Eds. Catherine Simpson, Renata Murawska, and Anthony Lambert. UK: Intellectbooks, 2009. Forthcoming. Lambert, Anthony. “Mediating Crime, Mediating Culture.” Crime, Media, Culture 4.2 (2008): 237-255. Lennon, Jane. “The cultural significance of Australian alpine areas.” Historic environment 17.2 (2003): 14-17. McFarlane, Brian. “Locations and Relocations: Jindabyne & MacBeth.” Metro Magazine 150 (Spring 2006): 10-15. McHugh, Siobhan. The Snowy: The People Behind the Power. William Heinemann Australia, 1999. http://www.mchugh.org/books/snowy.html. Read, Peter. Haunted Earth. Sydney: UNSW Press, 2003. Rundle, Guy. “Goodbye to all that: The end of Australian left-liberalism and the revival of a radical politics.” Arena Magazine 88 (2007): 40-46. Ryan, Matthew. “On the treatment of non-indigenous belonging.” Arena Magazine 84 (2006): 52-53. Simpson, Catherine. “Reconfiguring Rusticity: feminizing Australian Cinema’s country towns’. Studies in Australasian Cinemas 2.1 (2008): forthcoming. 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