Joint issues – conflicts of interest, the ASR hip and suggestions for managing surgical conflicts of interest.Jane Johnson &WendyRogers -2014 -BMC Medical Ethics 15 (1):63.detailsFinancial and nonfinancial conflicts of interest in medicine and surgery are troubling because they have the capacity to skew decision making in ways that might be detrimental to patient care and well-being. The recent case of the Articular Surface Replacement (ASR) hip provides a vivid illustration of the harmful effects of conflicts of interest in surgery.
Innovative surgery: the ethical challenges.Jane Johnson &WendyRogers -2012 -Journal of Medical Ethics 38 (1):9-12.detailsInnovative surgery raises four kinds of ethical challenges: potential harms to patients; compromised informed consent; unfair allocation of healthcare resources; and conflicts of interest. Lack of adequate data on innovations and lack of regulatory oversight contribute to these ethical challenges. In this paper these issues and the extent to which problems may be resolved by better evidence-gathering and more comprehensive regulation are explored. It is suggested that some ethical issues will be more resistant to resolution than others, owing to special (...) features of both surgery and innovation. (shrink)
A Migrant Ethic of Care? Negotiating Care and Caring among Migrant Workers in London's Low-Pay Economy.Jane Wills,Jon May,Joanna Herbert,Yara Evans,Cathy McIlwaine &Kavita Datta -2010 -Feminist Review 94 (1):93-116.detailsA care deficit is clearly evident in global cities such as London and is attributable to an ageing population, the increased employment of native-born women, prevalent gender ideologies that continue to exempt men from much reproductive work, as well as the failure of the state to provide viable alternatives. However, while it is now acknowledged that migrant women, and to a lesser extent, migrant men, step in to provide care in cities such as London, there is less research on how (...) this shapes the nature, politics and ethics of care. Drawing upon empirical research with low-paid migrant workers employed as domiciliary care providers in London, this paper explores the emergence of a distinct migrant ethic of care that is critically shaped by the caring work that migrant women and men perform. (shrink)
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Ethical and regulatory implications of the COVID-19 pandemic for the medical devices industry and its representatives.Guy Maddern,Bernadette Richards,Robyn Clay-Williams,Katrina Hutchison,Quinn Grundy,Jane Johnson,WendyRogers &Brette Blakely -2022 -BMC Medical Ethics 23 (1):1-7.detailsThe development and deployment of medical devices, along with most areas of healthcare, has been significantly impacted by the COVID-19 pandemic. This has had variable ethical implications, two of which we will focus on here. First, medical device regulations have been rapidly amended to expedite approvals of devices ranging from face masks to ventilators. Although some regulators have issued cessation dates, there is inadequate discussion of triggers for exiting these crisis standards, and evidence that this may not be feasible. Given (...) the relatively low evidence standards currently required for regulatory approval of devices, this further indefinite reduction in standards raises serious ethical issues. Second, the pandemic has disrupted the usual operations of device representatives in hospitals, providing an opportunity to examine and refine this potentially ethically problematic practice. In this paper we explain and critically analyse the ethical implications of these two pandemic-related impacts on medical devices and propose suggestions for their management. These include an endpoint for pandemic-related adjustments to device regulation or a mechanism for continued refinement over time, together with a review of device research conducted under crisis conditions, support for the removal and replacement of emergency approved devices, and a review of device representative credentialling. (shrink)
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Working with Children in End-of-Life Decision Making.Joanne Whitty-Rogers,Marion Alex,Cathy MacDonald,Donna Pierrynowski Gallant &Wendy Austin -2009 -Nursing Ethics 16 (6):743-758.detailsTraditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning (...) children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families. (shrink)
Buddhisms and Deconstructions.Jane Augustine,Zong-qi Cai,Simon Glynn,Gad Horowitz,Roger Jackson,E. H. Jarow,Steven W. Laycock,David R. Loy,Ian Mabbett,Frank W. Stevenson,Youru Wang &Ellen Y. Zhang -2006 - Rowman & Littlefield Publishers.detailsBuddhisms and Deconstructions considers the connection between Buddhism and Derridean deconstruction, focusing on the work of Robert Magliola. Fourteen distinguished contributors discuss deconstruction and various Buddhisms—Indian, Tibetan, and Chinese —followed by an afterword in which Magliola responds directly to his critics.
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Addressing Within-Role Conflicts of Interest in Surgery.Wendy A.Rogers &Jane Johnson -2013 -Journal of Bioethical Inquiry 10 (2):219-225.detailsIn this paper we argue that surgeons face a particular kind of within-role conflict of interests, related to innovation. Within-role conflicts occur when the conflicting interests are both legitimate goals of professional activity. Innovation is an integral part of surgical practice but can create within-role conflicts of interest when innovation compromises patient care in various ways, such as by extending indications for innovative procedures or by failures of informed consent. The standard remedies for conflicts of interest are transparency and recusal, (...) which are unlikely to address this conflict, in part because of unconscious bias. Alternative systemic measures may be more effective, but these require changes in the culture of surgery and accurate identification of surgical innovation. (shrink)
The Right Thing to Do.JaneRogers -2014 -Narrative Inquiry in Bioethics 4 (3):208-210.detailsIn lieu of an abstract, here is a brief excerpt of the content:The Right Thing to DoJane RogersIn stark contrast to getting my graduate degree in bioethics in which I discovered that I am inclined to favor an ethics based on my religious beliefs, in nursing school I learned that I had to take my religion out of nursing care. As a bioethics student, I read in my textbook, Bioethics: A Systematic Approach, that “… just because an action is rationally (...) allowed does not mean that everyone agrees one ought to act in that way.” Yet often in nursing I found that we nurses knew what was best for our patients, even if they did not. At least, we believed that we did. This general paternalistic belief spread into every area of the care we gave except for one, and that was religion. [End Page 208]As student nurses, we learned to separate our religion from our care to focus on the patient’s religion or spiritual needs. Our patients should never know of our religious beliefs or even if we had a lack of them. We needed to be completely neutral on all religious issues and focus solely on the patient’s preference. If our patients needed spiritual care, we would find someone to provide it and we would incorporate it into the nursing plan of care. Providing care of the whole patient including their religious needs was the definition of a good nurse. Certainly I wanted to be a good nurse, so I swore I would always include the spiritual needs of my patients as part of my care, while never expressing my own.As fate would have it, as a new nurse I found myself overwhelmed running around just trying to give medications, admit and discharge patients, start IV’s, insert catheters, note doctor’s orders and get my charting done. My time was engaged in trying to calm confused and combative patients, running to grab an emesis basin for a patient to throw up in or answering the phone, so thinking about religion or spiritual care for my patients most of the time amounted to “God help me and my patients get through this shift.” My goal of being a good nurse was starting to look dismal as I realized I had no idea if I could find the time or means and ways to incorporate religion into the care I gave, or if it even mattered if I did.Fortuitously for me, most of my patients never mentioned religion, although at times they did leave some nonverbal clues. I could see a rosary laying on a bedside table or a bible or prayer book next to them in bed. While I would make sure their religious item was always within reach, I remained respectful yet distant in religious matters, never offering any spiritual care or assistance. I was quite accepting of my first Mormon patient wearing the garment under the traditional hospital gown. I was appalled when an unconscious Jehovah Witness patient was nearly given blood. When a minister or priest came to visit, I’d excuse myself quickly so that the work of their God could do what I could not or should not do. Occasionally I was asked by family members to call in a minister or a priest or chaplain and I did that with a great feeling of satisfaction as I was surely providing the spiritual care they requested.Eventually however I did start to indulge in highly spontaneous and random acts of religion. These were always done secretly. The patient or family must never know. Thinking it would help I once covertly gave a patient a special rosary I had with Lourdes water in it thinking it might heal him. I waited to see a miracle. It never came. Despite the absence of that miracle I was still hopeful that perhaps my prayers or another rosary could heal or at least help some of my patients. After all, as a nurse I witnessed lots of healings that astounded me. People I never thought would get better sometimes did anyway.Although I was cognizant that some healing was the direct result of superb medical intervention and excellent nursing care, there were always... (shrink)
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Details Matter—Definitions and Context Can’t Be Glossed Over When Managing Innovation.Jane Johnson,Katrina Hutchison &Wendy A.Rogers -2019 -American Journal of Bioethics 19 (6):28-29.detailsVolume 19, Issue 6, June 2019, Page 28-29.
Traditional, modern or mixed? Perspectives on social, economic, and health impacts of evolving food retail in Thailand.Matthew Kelly,Sam-ang Seubsman,Cathy Banwell,Jane Dixon &Adrian Sleigh -2015 -Agriculture and Human Values 32 (3):445-460.detailsTransnational food retailers expanded to middle-income countries over recent decades responding to supply and demand. Control in new markets diffuses along three axes: socio-economic, geographic, and product category. We used a mixed method approach to study the progression of modern retail in Thailand on these three axes and consumer preferences for food retailing. In Thailand modern retail controls half the food sales but traditional fresh markets remain important. Quantitative questionnaires administered to members of a large national cohort study revealed around (...) half of respondents were primarily traditional shoppers and half either utilized modern and traditional formats equally or primarily shopped at supermarkets. Fresh foods were mainly purchased at traditional retail formats and dry packaged foods at supermarkets. Qualitative interviews found price and quality of produce and availability of culturally important products to be significant reasons for continued support of fresh markets. Our results show socio-economic and geographic diffusion is already advanced with most respondents having access to and utilizing modern retail. Control of the fresh food sector by transnationals faces barriers in Thailand and may remain elusive. The short to mid-term outcome may be a bifurcated food system with modern and traditional retail each retaining market share, but fresh markets longer term survival may require government assistance as supermarkets become more established. Fresh markets supply affordable, healthy foods, and livelihoods for poorer Thais and are repositories of Thai food culture and social networks. If they survive they will confer cultural, social, economic, and health benefits. (shrink)
Device representatives in hospitals: are commercial imperatives driving clinical decision-making?Quinn Grundy,Katrina Hutchison,Jane Johnson,Brette Blakely,Robyn Clay-Wlliams,Bernadette Richards &Wendy A.Rogers -2018 -Journal of Medical Ethics 44 (9):589-592.detailsDespite concerns about the relationships between health professionals and the medical device industry, the issue has received relatively little attention. Prevalence data are lacking; however, qualitative and survey research suggest device industry representatives, who are commonly present in clinical settings, play a key role in these relationships. Representatives, who are technical product specialists and not necessarily medically trained, may attend surgeries on a daily basis and be available to health professionals 24 hours a day, 7 days a week, to provide (...) advice. However, device representatives have a dual role: functioning as commissioned sales representatives at the same time as providing advice on approaches to treatment. This duality raises the concern that clinical decision-making may be unduly influenced by commercial imperatives. In this paper, we identify three key ethical concerns raised by the relationship between device representatives and health professionals: impacts on healthcare costs, the outsourcing of expertise and issues of accountability and informed consent. These ethical concerns can be addressed in part through clarifying the boundary between the support and sales aspects of the roles of device representatives and developing clear guidelines for device representatives providing support in clinical spaces. We suggest several policy options including hospital provision of expert support, formalising clinician conduct to eschew receipt of meals and payments from industry and establishing device registries. (shrink)
Emergency communication: the discursive challenges facing emergency clinicians and patients in hospital emergency departments.Jeannette McGregor,Maria Herke,Christian Matthiessen,Jane Stein-Parbury,Roger Dunston,Rick Iedema,Marie Manidis,Hermine Scheeres &Diana Slade -2008 -Discourse and Communication 2 (3):271-298.detailsEffective communication and interpersonal skills have long been recognized as fundamental to the delivery of quality health care. However, there is mounting evidence that the pressures of communication in high stress work areas such as hospital emergency departments present particular challenges to the delivery of quality care. A recent report on incident management in the Australian health care system cites the main cause of critical incidents, as being poor and inadequate communication between clinicians and patients. This article presents research that (...) describes and analyses spoken interactions between health care practitioners and patients in one ED of a large, public teaching hospital in Sydney, Australia. The research aimed to address the challenges and critical incidents caused by breakdowns in communication that occur between health practitioners and patients and by refining and extending knowledge of discourse structures, to identify ways in which health care practitioners can enhance their communicative practices thereby improving the quality of the patient journey through the ED. The research used a qualitative ethnographic approach combined with discourse analysis of audio-recorded interactions. Some key findings from the analysis of data are outlined including how the absence of information about processes, the pressure of time within the ED, divergent goals of clinicians and patients, the delivery of diagnoses and professional roles impact on patient experiences. Finally, the article presents an in-depth linguistic analysis on interpersonal and experiential patterns in the discursive practices of patients, nurses and doctors. (shrink)
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Integrating Evolution and Development: From Theory to Practice.Roger Sansom &Robert N. Brandon (eds.) -2007 - MIT Press.detailsEmbryos, cells, genes, and organisms : reflections on the history of evolutionary developmental biology / Manfred D. Laubichler andJane Maienschein The organismic systems approach : streamlining the naturalistic agenda / Werner Callebaut, Gerd B. Müller, and Stuart A. Newman Complex traits : genetics, development, and evolution / H. Frederik Nijhout Functional and developmental constraints on life-cycle evolution : an attempt on the architecture of constraints / Gerhard Schlosser Legacies of adaptive development / Roger Sansom Evo-devo meets the mind (...) : toward a developmental evolutionary psychology / Paul E. Griffiths Reproducing entrenchments to scaffold culture : the central role of development in cultural evolution / William C. Wimsatt and James R. Griesemer. (shrink)
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Exploring Models for an International Legal Agreement on the Global Antimicrobial Commons: Lessons from Climate Agreements.SusanRogers Van Katwyk,Alberto Giubilini,Claas Kirchhelle,Isaac Weldon,Mark Harrison,Angela McLean,Julian Savulescu &Steven J. Hoffman -2023 -Health Care Analysis 31 (1):25-46.detailsAn international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change—both are common pool resource challenges that require massive, long-term political commitments—the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current governance structures for (...) AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support. (shrink)
Making Use of Existing International Legal Mechanisms to Manage the Global Antimicrobial Commons: Identifying Legal Hooks and Institutional Mandates.SusanRogers Van Katwyk,Isaac Weldon,Alberto Giubilini,Claas Kirchhelle,Mark Harrison,Angela McLean,Julian Savulescu &Steven J. Hoffman -2023 -Health Care Analysis 31 (1):9-24.detailsAntimicrobial resistance (AMR) is an urgent threat to global public health and development. Mitigating this threat requires substantial short-term action on key AMR priorities. While international legal agreements are the strongest mechanism for ensuring collaboration among countries, negotiating new international agreements can be a slow process. In the second article in this special issue, we consider whether harnessing existing international legal agreements offers an opportunity to increase collective action on AMR goals in the short-term. We highlight ten AMR priorities and (...) several strategies for achieving these goals using existing “legal hooks” that draw on elements of international environmental, trade and health laws governing related matters that could be used as they exist or revised to include AMR. We also consider the institutional mandates of international authorities to highlight areas where additional steps could be taken on AMR without constitutional changes. Overall, we identify 37 possible mechanisms to strengthen AMR governance using the International Health Regulations, the Agreement on the Application of Sanitary and Phytosanitary Measures, the Agreement on Trade-Related Aspects of Intellectual Property Rights, the Agreement on Technical Barriers to Trade, the International Convention on the Harmonized Commodity Description and Coding System, and the Basel, Rotterdam, and Stockholm conventions. Although we identify many shorter-term opportunities for addressing AMR using existing legal hooks, none of these options are capable of comprehensively addressing all global governance challenges related to AMR, such that they should be pursued simultaneously with longer-term approaches including a dedicated international legal agreement on AMR. (shrink)
Paradoxes of populism during the pandemic.Rogers Brubaker -2021 -Thesis Eleven 164 (1):73-87.detailsPopulist protests against Coronavirus-related restrictions in the US appear paradoxical in three respects. Populism is generally hostile to expertise, yet it has flourished at a moment when expertise has seemed more indispensable than ever. Populism thrives on crisis and indeed often depends on fabricating a sense of crisis, yet it has accused mainstream politicians and media of overblowing and even inventing the Corona crisis. Populism, finally, is ordinarily protectionist, yet it has turned anti-protectionist during the pandemic and challenged the allegedly (...) overprotective restrictions of the nanny-state. I address each apparent paradox in turn before speculating in conclusion about how populist distrust of expertise, antipathy to government regulation, and skepticism toward elite overprotectiveness may come together – in the context of intersecting medical, economic, political, and epistemic crises – in a potent and potentially dangerous mix. (shrink)
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Evidence based medicine and justice: a framework for looking at the impact of EBM upon vulnerable or disadvantaged groups.W. A.Rogers -2004 -Journal of Medical Ethics 30 (2):141-145.detailsThis article examines the implicit promises of fairness in evidence based medicine , namely to avoid discrimination through objective processes, and to distribute effective treatments fairly. The relationship between EBM and vulnerable groups is examined. Several aspects of EBM are explored: the way evidence is created , and the way evidence is applied in clinical care and health policy. This analysis suggests that EBM turns our attention away from social and cultural factors that influence health and focuses on a narrow (...) biomedical and individualistic model of health. Those with the greatest burden of ill health are left disenfranchised, as there is little research that is relevant to them, there is poor access to treatments, and attention is diverted away from activities that might have a much greater impact on their health. (shrink)
Knowing How to Feel: Racism, Resilience, and Affective Resistance.TaylorRogers -2021 -Hypatia 36 (4):725-747.detailsThis article explores the affective dimension of resilient epistemological systems. Specifically, I argue that responsible epistemic practice requires affective engagement with nondominant experiences. To begin, I outline Kristie Dotson's account of epistemological resilience whereby an epistemological system remains stable despite counterevidence or attempts to alter it. Then, I develop an account of affective numbness. As I argue, affective numbness can promote epistemological resilience in at least two ways. First, it can reinforce harmful stereotypes even after these stereotypes have been rationally (...) demystified. To illustrate, I examine the stereotype of Black criminality as it relates to false confessions. Second, it can encourage “epistemic appropriation”, which I demonstrate by examining the appropriation of “intersectionality” and #MeToo by white culture. Finally, I conclude that resisting harmful resilience requires affective resistance, or efforts that target numbness via different kinds of affective engagement. I consider Kantian “disinterestedness” as a candidate. (shrink)
Why populism?Rogers Brubaker -2017 -Theory and Society 46 (5):357-385.detailsIt is a commonplace to observe that we have been living through an extraordinary pan-European and trans-Atlantic populist moment. But do the heterogeneous phenomena lumped under the rubric “populist” in fact belong together? Or is “populism” just a journalistic cliché and political epithet? In the first part of the article, I defend the use of “populism” as an analytic category and the characterization of the last few years as a “populist moment,” and I propose an account of populism as a (...) discursive and stylistic repertoire. In the second part, I specify the structural trends and the conjunctural convergence of a series of crises that jointly explain the clustering in space and time that constitutes the populist moment. The question in my title is thus twofold: it is a question about populism as a term or concept and a question about populism as a phenomenon in the world. The article addresses both the conceptual and the explanatory question, limiting the scope of the explanatory argument to the pan-European and trans-Atlantic populist conjuncture of the last few years. (shrink)
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Estranged Kinship: Empathy and Animal Desire in Merleau-Ponty.Chandler D.Rogers -2024 -Research in Phenomenology 54 (2):213-227.detailsMerleau-Ponty suggests in his Nature lectures that myth provides the best way into thinking the relation of strange kinship between humanity and animality. He goes on to refigure Husserl’s paradigm of the two hands touching to extend beyond merely human-to-human relations, invoking in the process the myth of Narcissus. By carefully examining Merleau-Ponty’s late refiguration of that paradigm, alongside the revised conception of narcissism that it helps him to develop, we find that while human-animal empathy is made possible by a (...) ground of intercorporeal kinship, human-animal estrangement makes possible the emergence of an ethical relation to other animals, contingent upon the sublimation of animal desire. Holding human-animal kinship and estrangement in tension reveals a nascent ideal present implicitly in the early stages of childhood development: a vision of the possibility of interspecies harmony, rooted in the bodily reciprocity that drives the process of self-maturation. (shrink)
Feminism and public health ethics.W. A.Rogers -2006 -Journal of Medical Ethics 32 (6):351-354.detailsThis paper sketches an account of public health ethics drawing upon established scholarship in feminist ethics. Health inequities are one of the central problems in public health ethics; a feminist approach leads us to examine not only the connections between gender, disadvantage, and health, but also the distribution of power in the processes of public health, from policy making through to programme delivery. The complexity of public health demands investigation using multiple perspectives and an attention to detail that is capable (...) of identifying the health issues that are important to women, and investigating ways to address these issues. Finally, a feminist account of public health ethics embraces rather than avoids the inescapable political dimensions of public health. (shrink)
Being Consistently Biocentric: On the (Im)possibility of Spinozist Animal Ethics.Chandler D.Rogers -2021 -Journal for Critical Animal Studies 18 (1):52-72.detailsSpinoza’s attitude toward nonhuman animals is uncharacteristically cruel. This essay elaborates upon this ostensible idiosyncrasy in reference to Hasana Sharp’s commendable desire to revitalize a basis for animal ethics from within the bounds of his system. Despite our favoring an ethics beginning from animal affect, this essay argues that an animal ethic adequate to the demands of our historical moment cannot be developed from within the confines of strict adherence to Spinoza’s system—and this is not yet to speak of a (...) more robust animal ethics which would advocate actual care and compassion for the animals themselves. We argue that on the assumption of Spinoza’s ontological biocentrism, in the presence of Spinozist determinism and the absence of an axiological biocentrism, an anthropocentric axiology necessarily follows. Any Spinozist animal ethic must fall back, therefore, upon appeals to the maximization of human pleasure and power; hence Spinoza’s ruthless injunction to “use (the animals) at our pleasure.” These are the very ontological and ethical assumptions which have incited human self-exaltation in the modern period, in pursuit of power and pleasure even despite the destructive long-term consequences for all the living. We suggest that an adequate animal ethic would require either an abandonment of Spinoza’s ontological biocentrism or the adoption of an axiological biocentrism. (shrink)
Abandoning happiness for life: Mourning and futurity in Maja Borg’s Future My Love.Anna BackmanRogers -2016 -European Journal of Women's Studies 23 (4):353-364.detailsWhy do we labour so hard to sustain relationships that are fundamentally harmful to our wellbeing? That is the question which lies at the heart of Maja Borg’s poetic and alternatively distributed documentary film, Future My Love. The detrimental bonds on which the film focuses are those that maintain our connection to an economic system that has thrown us into an acute state of crisis and the stillborn emotions that keep us hopefully attached to a romantic partnership that we have (...) already outgrown; this elision imbricates and implicates the personal in the political. Through a prism of painful and, at times, unbearable emotion, and by blurring the boundaries between the public and the private, the real and the fictional, this film urges us to imagine ourselves into a future in which it might be possible to live otherwise; but this requires us to abandon the future we have already imagined and, as the film evinces through archival imagery from the 1950s or golden age of capitalism, imaged ourselves into. By drawing on the work of Lauren Berlant and Sara Ahmed on the cultural politics of emotion, Judith Butler’s work on the act of mourning, and the writing of Eva Illouz, Luce Irigaray and Alain Badiou on love in the age of late capitalism, this article contends that Future My Love pleads with us to abandon, in Ahmed’s words, ‘happiness for life’, to forsake an ideology that is invested in a highly specific notion of what it means to flourish and to thrive, to mourn and name our losses, and to think about the future creatively and without cynicism. (shrink)
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Bioethics in Europe.ArthurRogers -1995 - Council of Europe Press. Edited by Denis Durand de Bousingen.detailsIn a clear, accessible journalistic style, generously illustrated with examples, the two authors report on the variety of responses found in each country & on ...