Brian Stoffell

Dr Gillian Craig (1) has argued that palliative medicine services have tended to adopt a policy of sedation without hydration, which under certain circumstances may be medically inappropriate, causative of death and distressing to family and friends. We welcome this opportunity to defend, with an important modification, the approach we proposed without substantive background argument in our original article (2). We maintain that slowing and eventual cessation of oral intake is a normal part of a natural dying process, that artificial hydration and alimentation (AHA) are not justified unless thirst or hunger are present and cannot be relieved by other means, but food and fluids for (natural) oral consumption should never be 'withdrawn'. The intention of this practice is not to alter the timing of an inevitable death, and sedation is not used, as has been alleged, to mask the effects of dehydration or starvation. The artificial provision of hydration and alimentation is now widely accepted as medical treatment. We believe that arguments that it is not have led to confusion as to whether or not non-provision or withdrawal of AHA constitutes a cause of death in law. Arguments that it is such a cause appear to be tenuously based on an extraordinary/ordinary categorisation of treatments by Kelly (3) which has subsequently been interpreted as prescriptive in a way quite inconsistent with the Catholic moral theological tradition from which the distinction is derived. The focus of ethical discourse on decisions at the end of life should be shifted to an analysis of care, needs, proportionality of medical interventions, and processes of communication

My principal claim is that Hobbes neither argues for, nor is committed to, psychological egoism. I construct a reading on which a non-egoistic theory of character supports his political theory; his mechanistic psychology and account of self-preservation are neutral with respect to the character of men in civil life. I deny there are compelling reasons to treat Hobbesian individuals as predisposed to egoism, and conclude Hobbes has ample room within his psychology for civic virtues. ;Contrary to Gauthier, who argues Hobbes is committed to psychological egoism by details of his mechanistic psychology, I contend the mechanistic basis is what disallows any ascription of egoism. But I follow neither McNeilly, who believes Hobbes' materialism irrelevant, nor Gert, who believes the materialism destructive of any motivational theory. Disagreeing with all three, I argue for a positive and constructive relation between Hobbes' materialism and his psychology. In particular, I claim one aspect of his materialism--the account of endeavour or conatus--constitutes a general theory of dispositions, one implication of which is that human dispositions are not fixed in any way necessary to creating egoists. So Hobbes' materialism actually provides the best reason for thinking Hobbesian individuals are not egoists. ;There are more accessible reasons for the same conclusion, deriving from Hobbes' descriptions of the best kind of men. I conclude Hobbes was impressed by older chivalric and martial virtues, despite being a strong proponent of a more civilian code. ;My method here assumes a particular, historical, point of view; I consider what Hobbes says about character in the social context of the Jacobean and Caroline Aristocracy. I argue he discusses traits for which there is no obvious egoistic interpretation, and consider why he was so exercised by the social impact of motives connected with power, honour, and worth. Unlike Macpherson, I do not think Hobbes' analysis unwittingly suffused with details from early English capitalism. Following Keith Thomas, I suggest his conception of pitfalls in the path of civility was based rather on aristocratic character

I cannot be certain what people have in mind when they wish to expose medical students to ethics, but if what I have said so far is sound, then they ought not to mean moral philosophy alone. The moral life of medicine and the moral life in general have certainly given rise to rules of thumb, guidelines and principles which summarise our sentiments about interactions within that life. However, the substance of that life is human vulnerability and our responses to it. This is not to say that the theories found in moral philosophy are not a rich terrain for intellectual ingenuity, they are, but there is no reason whatever to believe that their study sharpens moral sensitivity.Sensitivity to human vulnerability is the dimension which medical ethics education should seek to explore. One reason is that medical practice is at the hard edge of moral practice, and the character of the practitioners is one of our major concerns as consumers of health care.My conclusion is easy enough to state. Many have started the business of medical ethics on the assumption that moral philosophy has an applied correlate. This has proven to be a chimera. Let's have the courage to admit that a promising research project has petered out and start to look for a more plausible one. Perhaps we could start by looking for good narratives of suffering, of living under adversity, and of caring for the suffering