Journal articles on the topic 'Hastings Center report'

En la sección final de un artículo dedicado a la ética de la investigación internacional, publicado en el número de julio/agosto del Hastings Center Report, Alex London y Kevin Zollman postulan la necesidad de que las responsabilidades de investigación<br />internacional en el campo de la medicina y la salud se asienten en un marco normativo más amplio, de justicia social, distributiva y rectificadora. De la misma manera, durante los últimos años y en toda una serie de publicaciones Thomas Pogge ha venido reclamando la necesidad de un enfoque basado en los derechos humanos en el ámbito de la investigación internacional

How aggressively should we pursue life-sustaining treatment of the demented patient? This question becomes increasingly important as our population ages and medical technology offers ever more life-prolongation. In Life's Dominion, Ronald Dworkin addresses the issue in the context of an Alzheimer patient who had previously declared the desire to avoid life-sustaining intervention. Dworkin argues for the primacy of what he calls precedent autonomy: “A competent person's right to autonomy requires that his past decisions about how he is to be treated if he becomes demented be respected even if they contradict the desires he has at a later point.” In 1995, the Hastings Center Report carried thoughtful rebuttals by Daniel Callahan and Rebecca Dresser. Much of Callahan's article is devoted to patients who never executed an advance directive, but he states unequivocally that such directives can be overridden, basing much of his argument on the writings of Sanford Kadish. Together, Dresser, Callahan, and Kadish define a clear position opposed to precedent autonomy.

Institutional ethics committees remain largely absent from the literature on error reduction and patient safety. This paper attempts to fill the gap. Healthcare professionals are on the front lines in the defense against medical error, but the changes that are needed to reduce medical errors and enhance patient safety are cultural and systemic in nature. As noted in the Hastings Centers recent report, Promoting Patient Safety, the occurrence of medical error involves a complex web of multiple factors. Human misstep is certainly one such factor, but not the only one. In this paper, I build on the Hasting Centers report on patient safety (HCR) in arguing that institutional ethics committees ought to play an integral role in the transformation of a culture of blame to a culture of safety in healthcare delivery.

Berdyaev, N. A. (1951). The kingdom of the spirit and the kingdom of Caesar. Paris: Umca-Press. Recovered from: https://vtoraya-literatura.com/pdf/berdyaev_tsarstvo_dukha_i_tsastvo_kesarya_1951__ocr.pdf. Berlinger, N., & Solomon, M. Z. (2018). Becoming Good Citizens of Aging Societies. Hastings center report, Vol. 48(3), 2–9. Bostrom, N. (2003). Are You Living in a Simulation? Philosophical Quarterly, Vol. 53(211), 243–255. Bostrom, N. (2016). Development of values. Artificial Intelligence: Stages. Threats. Strategies. Moscow: Publishing House "Mann, Ivanov and Ferber". Recovered from: https://element.ru/bookclub/chapters/433044/Iskusstvennyy_intellekt_Glava_iz_knigi. Goryachkovskaya, A. N. (2014). Philosophy of transhumanism: on the surrogates of being, the abduction of identity and euthanasia of humanity. Bulletin of V. N. Karazin Kharkiv National University. Series: Theory of Culture and Philosophy of Science, Vol. 1092, Issue 50. Recovered from: http://periodicals.karazin.ua/thcphs/issue/view/209. Gould, C. C. (2018). Solidarity and the problem of structural injustice in healthcare. Bioethics, Vol. 32(9), 541–552. Guerrini, C., Lewellyn, M., Majumder, M. et al. (2019). Donors, authors, and owners: how is genomic citizen science addressing interests in research outputs? BMC Medical Ethics, Vol. 20, Issue 1, Article number 84. Habermas, J. (2002). The future of human nature. Towards liberal eugenics. Moskva: Ves' Mir. Haker, H. (2019). Habermas and the Question of Bioethics. European journal for Philosophy of Religion, Issue 4, 61–86. Heidegger, M. (1967). Being And Time. Max Niemeyer loading facility in Tübinge. Recovered from: https://taradajko.org/get/books/sein_und_zeit.pdf. Kakkori, L. (2018). Postmodern as Secularization in Philosophy of Education. Educational Philosophy and Theory, Vol. 50(14), Special issue: SI, 1639–1640. Kroker, A., & Cook, D. (1986). The Postmodern Scene. Excremental Culture and Hyper-Aesthetics. Montreal: New World Perspectives. Kurzweil, R. (2012). How to create a mind: the secret of human thought revealed. New York: Penguin Books. Lipovetsky, G. (2015). Time Against Time, or The Hypermodern Society. In D. Rudrum and N. Stavris (Ed.), Supplanting the Postmodern. An Anthology of Writings on the Arts and Culture of the Early 21st Century (p. 191–208). New York; London; New Delhi; Sydney: Bloomsbury Academic. Lobanov, V.A (2020). Transhumanism in the interpretation of V. A. Lobanov. Samizdat Magazine. Recovered from: http://samlib.ru/l/lobanow_w_a/samlibrullobanow_w_amsworddocshtml-2.shtml. Meliakova, Y., Kovalenko, I., Zhdanenko, S., & Kalnytskyi, E. (2020). Performance in the Postmodern Culture and Law. Amazonia Investiga, 9(27), 340–348. https://amazoniainvestiga.info/index.php/amazonia/article/view/1247 Melyakova, Yu. V. (2018). Being of law and being in law: from performative to performance. Bulletin of the National University "Yaroslav the Wise Law Academy of Ukraine". Series: Philosophy, Vol. 1(36), 90–113. Odorcak, J. (2019). Exorganic Posthumanism and Brain-Computer Interface Technologies (BCI). Postmodern openings, Vol. 10(4), 193-208. Pavlov, A. V. (2019). Images of modernity in the 21st century: hypermodernism. Philosophical Journal, Vol. 12(2), 20–33. Piarce, D. (2015). The Hedonistic Imperative. eBook. Recovered from: https://ubq124.wordpress.com/2019/12/22/the-hedonistic-imperative-pdf. Polyakova, O. V. (2017). Commodification of the dead body: ethical and legal aspects. Bulletin of the RSUH. Series "Psychology. Pedagogy. Education", Vol. 2(8), 118–128. Recovered from: http://cyberleninka.ru/article/n/kommodifikatsiya-mertvogo-tela-etiko-pravovye-aspekty Popova, O. V. (2016). Man, its price and value: to the problem of body commodification in scientific knowledge. Epistemology and philosophy of science, Vol. 49(3), 140-157. Recovered from: http://cyberleninka.ru/article/n/chelovek-ego-tsena-i-tsennost-k-probleme-kommodifikatsii-tela-v-nauchnom-poznanii. Popova, O. V., Tishchenko, P. D., & Shevchenko, S. Yu. (2018). Neuroethics and biopolitics of biotechnology for cognitive improvement of human improvement. Philosophy questions, Vol. 7, 96–108. Russian Transhumanist Movement (2020). About the possibilities of self-upgrade and life extension. Recovered from: http://transhumanism-russia.ru/content/view/629/94/ Sandu, A., Vlad, L. (2018). Beyond Technological Singularity – the Posthuman Condition. Postmodern openings, Vol. 9(1), 91-102. Sartre, J.P. (1989). Existentialism is humanism. In: Twilight of the Gods. Moscow: Politizdat, 319-344. Strandbrink, P. (2018). Nostalgia and Shrinkage: Philosophy and culture under post-postmodern conditions. Educational Philosophy and Theory, Vol. 50(14), 1407–1408. Twenge, J. M. (2006). Generation Me: Why Today’s Young Americans Are More Confident, Assertive, Entitled – and More Miserable Than Ever Before. New York: ATRIA paperback. Retrieved from http://www.amazon.co.uk/Generation-Americans-Confident-Assertive-Entitled/dp/1476755566. Twenge, J. M. (2017). iGen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood. New York: ATRIA books. Retrieved from http://www.amazon.com/iGen-Super-Connected-Rebellious-Happy-Adulthood/dp/1501151983. United Nations (1997). Universal Declaration on the Human Genome and Human Rights. Recovered from http://www.un.org/ru/documents/decl_conv/declarations/human_genome.shtml United Nations (2005). Universal Declaration on Bioethics and Human Rights. Recovered from: http://www.un.org/ru/documents/decl_conv/declarations/bioethics_and_hr.shtml Yong, L. (2019). Moral Ambivalence: Relativism or Pluralism? Acta analytica-international periodical for Philosophy in the analytical tradition, Vol. 34(4), 473–491. Zinovyev, A. (2006). Global Human. Booksonline. Recovered from: http://booksonline.com.ua/view.php?book=97560 (in Russian).

The importance and power of the biomedical approach to health and illness cannot be under-estimated. It has underpinned Western understandings of medical science and technology; it has informed health systems and the training of medical personnel; and arguably it has become articulated in patients' experience of illness and treatment. The roots of this model are traced to the valorization of rational thought in the Enlightenment which, according to Lupton, was accompanied by the increasing professionalisation of medicine through university training of doctors and control over their licences to practice. Further, she argues the discovery of bacterial causes of scourges like tuberculosis, cholera and typhoid in the nineteenth century further increased the power and status of the profession to the extent that excellence in medicine became more closely associated with rigorous scientific knowledge than empathic bedside manner (84). The emerging doctrine of specific aetiology that evolved into biomedicine had replaced the older philosophical understanding of health as a state of equilibrium and disease as a lack of harmony between people and their environment (Dubos, 5-6; Morgan, Calnan and Manning 15). The patient's interpretation of illness and symptoms became reconfigured by the doctor as an identifiable disease state that can be investigated and (usually) treated, pharmacologically or surgically. Engel acknowledged the power of the biomedical model but labelled it reductionistic and dualistic. He said that it reduced illness to chemistry and physics and separated bodies from minds while conceptualising bodies as machines (131). Biochemical or biophysical abnormality becomes the criterion for diagnosis of the disease and the treatment of illness. The authoritative, objective, and scientific approach to medicine that constructs illness as not more than, but also no less than, a biochemical/physical effect of disease, in turn, constructs medical care as interventionist, scientific and empirical, but above all as the privileged domain of the physician. The same approach that defines the role of the physician ascribes a complementary but dependent role for the patient. The ill, after all, are expected to seek and then undergo treatment. Within such a paradigm, Parsons proposed an influential and much quoted set of institutionalised social expectations associated with the "sick role" to distinguish people who are ill from those who are well. Briefly, according to his theory, the sick person has some social privileges but also some social obligations: exemption from other normal social roles depending on the nature and seriousness of the illness; not responsible for the illness; should be motivated to get well; and should seek and co-operate with the treatment offered (436-37). Parsons' functionalism with its assumption of a homogeneous social structure and value system has attracted considerable criticism. At the very least, he did not differentiate between different medical conditions and their social and cultural implications. But, that said, his "sick role" or modified versions of it remains tied up with the biomedical framework of its context. Meanings of Illness or Minds, Emotions and Social Processes Ideas about illness (and wellness for that matter) are culturally dependent. Illness as the opposite of wellness, as non-health, is an impaired sense of well-being and in that sense at least, requires some self-diagnosis before treatment is sought. Individuals make judgements about their health against prevailing implicit standards of what it is to feel well (Eisenberg and Kleinman 13). As the cultural norms of illness change over time, what it means to be sick and what the "sick role" entails changes too (Christopoulos 93). The discursive label of illness, especially if the disease has specific moral connotations surrounding it, can have considerable consequences for the patient and their social identity to the extent that the "clinical label becomes a master status, one that swamps all other identities and compresses the identity of the person into a narrow and constricting mould" (George and Davis, 266) and circumscribes their sick role. Morris sees biomedicine as cultural discourse, specifically as a modernist narrative which is being challenged increasingly by "powerful alternative narratives that view human illness not as the malfunction of a biophysical mechanism but as the unique experience of a meaning-making and embodied cultural being" (7). Arthur Frank, Thomas Couser, Anne Hawkins and others have demonstrated how control of current understandings of illness is indeed moving away from medical practitioners and towards the patients themselves as they challenge the restriction and passivity of their sick role. The work of these researchers charts changing representations of illness as patients who choose to publish their narratives attempt to find meaning in their experience of illness. The narratives these people tell are often at odds with the biomedical accounts of their illness, or at least they are telling a different type of story - one that involves their reaction to and their experience of serious illness rather than just its onset, diagnosis, treatment and prognosis. These stories are sometimes triumphal accounts of overcoming illness, designed to inspire others in similar situations; sometimes dark, emotional accounts of overwhelming adversity and suffering. In providing such introspections of the meaning of illness for the patient's life (and even anticipations of death too), these texts re-negotiate the sick role. They are empowering accounts because they disrupt the sense of the sick role as a passive and silent state (Frank 3). The stories can be found in full length autobiographical accounts of encounters with serious illness like those discussed by Frank, Couser, and also Hawkins, but they are evident across a range of the mass media as well. Women's magazines are a particularly rich source where illness experiences of celebrities and ordinary folk are mixed in with other gossip, scandal, features and advice (Bonner and McKay 2000). Reality television shows (for example, those set in hospitals) also occasionally feature patients' experiences and their quest for meaning for their illness. While the internet offers unprecedented access to detailed medical information, dedicated sites also provide spaces for patients to tell their stories and chat rooms give the opportunity for patient-patient access and interaction in the absence of doctors. These electronic "virtual" communities provide new interactive forums for those with chronic conditions to discuss their fears, their needs and their activities (Patsos; Hardey). The texts produced by these media constitute a different version of the sick role and augment the meanings of illness by providing alternative or at least parallel resources to conventional medical interaction for those who are ill, their carers or those with vicarious interest. As Foucault demonstrated, medical knowledge, its associated "clinical gaze" and the representation of illness always need to be seen in its socio-historical context. The understanding of this "provides a perspective which is able to show, as does the cross-cultural perspective offered by anthropology, that the conventions of western biomedicine are no more 'scientific' or 'objective' than medical systems in other cultures or in other times" (Lupton 15). This type of approach does not necessarily call into question the medical definitions of disease, but points out the limitations of biomedicine without due attention to more cultural approaches. In that sense, the proliferation of patients' stories should be seen as a reaction to (rather than a rejection of) biomedicine and its modernist perspective that situates illness more in the professional domain of the doctor than in the experiential domain of the patient. Indeed, as Morris notes, "modernist biomedicine with its dualistic and reductive language of disease mechanisms now co-exists uneasily with a new concern (irreducible to mechanisms) for the role played in illness by minds, emotions, and social processes" (7). References Bonner, F., & S.McKay. "Challenges, Determination and Triumphs: Inspirational Discourse in Women's Magazine Health Stories." Continuum: Journal of Media and Cultural Studies 14.2 (2000): 133-144. Christopoulos, Katerina. "The Sick Role in Literature and Society." Journal of the American Medical Association 285.1 (3 January 2001): 93. Couser, G. Thomas. Recovering Bodies: Illness, Disability, and Life Writing. Madison: University of Wisconsin Press, 1997. Dubos, René. "Mirage of Health". Health and Disease. Ed. Nick Black. Milton Keynes: Open University Press, 1984. 4-9. Eisenberg, Leon, and Arthur Kleinman. "Clinical Social Science." The Relevance of Social Science for Medicine. Ed. Leon Eisenberg and Arthur Kleinman. Dordrecht: Reidel, 1981. 1-23. Engel, George. "The Need for a New Medical Model: A Challenge for Biomedicine." Science 196.4268 (8 April 1977): 129-36. Foucault, Michel. The Birth of the Clinic : An Archaeology of Medical Perception. Trans. A.M. Sheridan Smith. London: Tavistock, 1973. Frank, Arthur. "Reclaiming an Orphan Genre: The First-Person Narrative of Illness." Literature and Medicine 13.1 (Spring 1994): 1-21. George, Janet, and Alan David. States of Health: Health and Illness in Australia 3rd ed. South Melbourne: Addison Wesley Longman, 1998. Hardey, Michael. "Doctor in the House: The Internet as a Source of Lay Knowledge and the Challenge to Expertise." Sociology of Health and Illness 21.6 (1999): 820-835. Hawkins, Anne. Reconstructing Illness: Studies in Pathography. West Layfayette: Purdue University Press, 1993. Lupton, Deborah. Medicine as Culture: Illness, Disease and the Body in Western Societies. London: Sage, 1994. Morgan, Myfanwy, Michael Calnan, and Nick Manning. Sociological Approaches to Health and Medicine. London: Routledge, 1985. Morris, David. "How to Speak Postmodern: Medicine, Illness, and Cultural Change." The Hastings Center Report 30.6 (2000): 7-11. Parsons, Talcott. The Social System. Glencoe, Ill.: Free Press, 1951. Patsos, Mary. "The Internet and Medicine: Building a Community for Patients with Rare Diseases." Journal of the American Medical Association 285.6 (14 February 2001): 805.

“Live free or die!” (New Hampshire State motto) Should individuals be free to make lifestyle decisions (such as what, when and how much to eat and how much physical activity to take), without undue interference from the state, even when their decisions may lead to negative consequences (obesity, heart disease, diabetes)? The UN Declaration of Human Rights enshrines the belief that “All human beings are born free and equal in dignity and rights”. The philosophy of Libertarianism (Locke) proposes that rights can be negative (e.g. the freedom to be free from outside interference) as well as positive (e.g. the right to certain benefits supplied by others). Robert Nozick, a proponent of Libertarianism, has argued that we have the right to make informed decisions about our lives without unnecessary interference. This entitlement requires that we exercise our rights only as far as they do not infringe the rights of others. The popular notion of the “Nanny State” (often used derogatively) is discussed, and the metaphor is extended to draw on the Super Nanny phenomenon, a reality television series that has been shown in numerous countries including the UK, the US, and Australia. It is argued in this paper that social marketing, when done well, can help create a “Super Nanny State” (implying positive connotations). In the “Nanny State” people are told what to do; in the “Super Nanny State” people are empowered to make healthier decisions. Social marketing applies commercial marketing principles to “sell” ideas (rather than goods or services) with the aim of improving the welfare of individuals and/or society. Where the common good may not be easily discerned, Donovan and Henley recommended using the UN Declaration of Human Rights as the baseline reference point. Social marketing is frequently used to persuade individuals to make healthier lifestyle decisions such as “eat less [saturated] fat”, “eat two fruits and five veg a day”, “find thirty minutes of physical activity a day”. Recent medical gains in immunisation, sanitation and treating infectious diseases mean that the health of a population can now be more improved by influencing lifestyle decisions than by treating illness (Rothschild). Social marketing activities worldwide are directed at influencing lifestyle decisions to prevent or minimise lifestyle diseases. “Globesity” is the new epidemic (Kline). Approximately one billion people globally are overweight or obese (compared to 850 million who are underweight); most worryingly, about 10% of children worldwide are now overweight or obese with rising incidence of type 2 diabetes in this population (Yach, Stuckler, and Brownwell). “Nanny state” is a term people often use derogatively to refer to government intervention (see Henley and Jackson). Knag (405) made a distinction between old-style, authoritarian “paternalism”, which chastised the individual using laws and sanctions, and a newer “maternalism” or “nanny state” which smothers the individual with “education and therapy (or rather, propaganda and regulation)”. Knag’s use of the term “Nanny State” still has pejorative connotations. In the “Nanny State”, governments are seen as using the tool of social marketing to tell people what they should and shouldn’t do, as if they were children being supervised by a nanny. At the extreme, people may be afraid that social marketing could be used by the State as a way to control the thoughts of the vulnerable, a view expressed some years ago by participants in a survey of attitudes towards social marketing (Laczniak, Lusch, and Murphy). More recently, the debate is more likely to focus on why social marketing often appears to be ineffective, rather than frighteningly effective (Hastings, Stead, and Macintosh). Another concern is the high level of fear being generated by much of the social marketing effort (Hastings and MacFadyen; Henley). It is as if nanny thinks she must scream at her children all the time to warn them that they will die if they don’t listen to her. However, by extension, I am suggesting that the “Super Nanny State” metaphor could have positive associations, with an authoritative (rather than authoritarian) parenting figure, one who explains appropriate sanctions (laws and regulations) but who is also capable of informing, inspiring and empowering. Still, the Libertarian ethical viewpoint would question whether governments, through social marketers, have the right to try to influence people’s lifestyle decisions such as what and how much to eat, how much to exercise, etc. In the rise of the “Nanny State”, Holt argued that governments are extending the range of their regulatory powers, restricting free markets and intruding into areas of personal responsibility, all under the guise of acting for the public’s good. A number of arguments, discussed below, can be proposed to justify interference by the State in the lifestyle decisions of individuals. The Economic Argument One argument that is often quoted to justify interference by the State is that the economic costs of allowing unsafe/unhealthy behaviours have to be borne by the community. It has been estimated in the US that medical costs relating to diabetes (which is associated directly with obesity) increased from $44 billion to $92 billion in five years (Yach, et al). The economic argument can be useful for persuading governments to invest in prevention but is not sufficient as a fundamental justification for interference. If we say that we want people to eat more healthily because their health costs will be burdensome to the community, we imply that we would not ask them to do so if their health costs were not burdensome, even if they were dying prematurely as a result. The studies relating to the economic costs of obesity have not been as extensive as those relating to the economic costs of tobacco (Yach, et al), where some have argued that prematurely dying of smoking-related diseases is less costly to the State than the costs incurred in living to old age (Barendregt, et al). This conclusion has been disputed (Rasmussen et al), but even if true, would not provide sufficient justification to cease tobacco control efforts. Similarly, I think people would expect social marketing efforts relating to nutrition and physical activity to continue even if an economic analysis showed that people dying prematurely from obesity-related illnesses were costing the State less overall in health care costs than people living an additional twenty years. The Consumer Protection Argument Some degree of interference by the State is desirable and often necessary because people are not entirely self-reliant in every circumstance (Mead). The social determinants of health (Marmot and Wilkinson) are sufficiently well-understood to justify government regulation to reduce inequalities in housing, education, access to health services, etc. Implicit in the criticism that the “Nanny State” treats people like children is the assumption that children are treated without dignity and respect. The positive parent or “Super Nanny” treats children with respect but recognises their vulnerability in unfamiliar or dangerous contexts. A survey of opinion in the UK in 2004 by the King’s Fund, an independent think tank, found that the public generally supported government initiatives to encourage healthier school meals; ensure cheaper fruit and vegetables; pass laws to limit salt, fat and sugar in foods; stop advertising junk foods for children and regulate for nutrition labels on food (UK public wants a “Nanny State”). The UK’s recently established National Social Marketing Centre has made recommendations for social marketing strategies to improve public health and Prime Minister Tony Blair has responded by making public health, especially the growing obesity problem, a central issue for government initiatives, offering a “helping hand” approach (Triggle). The Better Alternative Argument Wikler considered the case for more punitive government intervention in the obesity debate by weighing the pros and cons of an interesting strategy: the introduction of a “fat tax” that would require citizens to be weighed and, if found to be overweight, require them to pay a surcharge. He concluded that this level of state interference would not be justified because there are other ways to appeal to the risk-taker’s autonomy, through education and therapeutic efforts. Governments can use social marketing as one of these better alternatives to punitive sanctions. The Level Playing Field Argument Social marketers argue that many lifestyle behaviours are not entirely voluntary (O’Connell and Price). For example, it is argued that an individual’s choices about eating fast food, consuming sweetened soft drinks, and living sedentary lives have already been partially determined by commercial efforts. Thus, they argue that social marketing efforts are intended to level the playing field – educate, inform, and restore true personal autonomy to people, enabling them to make rational choices (Smith). For example, Kline’s media education program in Canada, with a component of “media risk reduction”, successfully educated young consumers (elementary school children) with strategies for “tuning out” by asking them to come up with a plan for what they would do if they “turned off TV, video games and PCs for a whole week?” (p. 249). The “tune out challenge” resulted in a reduction of media exposure (80%) displaced into active leisure pursuits. A critical aspect of this intervention was the contract drawn up in advance, with the children setting their own goals and strategies (Kline). In this view, the state is justified in trying to level the playing field, by using social marketing to offer information as well as alternative, healthier choices that can be freely accepted or rejected (Rothschild). Conclusion A real concern is that when people are treated like children, they become like children, retaining their desires and appetites but abdicating responsibility for their individual choices to the state (Knag). Some smokers, for example, declare that they will continue to smoke until the government bans smoking (Brown). Governments and social marketers have a responsibility to fund/design campaigns so that the audience views the message as informative rather than proscriptive. Joffe and Mindell (967) advocated the notion of a “canny state” with “less reliance on telling people what to do and more emphasis on making healthy choices easier”. Finally, one of the central tenets of marketing is the concept of “exchange” – the marketer must identify the benefits to be gained from buying a product. In social marketing terms, interference in an individual’s right to act freely can be effective and justified when the benefits are clearly identifiable and credible. Rothschild described marketing’s role as providing a middle point between libertarianism and paternalism, offering free choice and incentives to behave in ways that benefit the common good. Rather than shaking a finger at the individual (along the lines of earlier “Don’t Do Drugs” campaigns), the “Super Nanny” state, via social marketing, can inform and engage individuals in ways that make healthier choices more appealing and the individual feel more empowered to choose them. References Barendregt, J.J., L. Bonneux, O.J. van der Maas. “The Health Care Costs of Smoking.” New England Journal of Medicine 337.15 (1997): 1052-7. Brown, D. Depressed Men: Angry Women: Non-Stereotypical Gender Responses to Anti-Smoking Messages in Older Smokers. Unpublished Masters dissertation, Edith Cowan University, Perth, Western Australia, 2001. Donovan, R., and N. Henley. Social Marketing: Principles and Practice. Melbourne: IP Communications, 2003. Joffe, M., and J. Mindell. “A Tentative Step towards Healthy Public Policy.” Journal of Epidemiology and Community Health 58 (2004): 966-8. Hastings, G.B., and L. MacFadyen. “The Limitations of Fear Messages.” Tobacco Control 11 (2002): 73-5. Hastings, G.B., M. Stead, and A.M. Macintosh. “Rethinking Drugs Prevention: Radical Thoughts from Social Marketing.” Health Education Journal 61.4 (2002): 347-64. Henley, N. “You Will Die! Mass Media Invocations of Existential Dread.” M/C Journal 5.1 (2002). 1 May 2006 http://journal.media-culture.org.au/0203/youwilldie.php>. Henley, N., and J. Jackson. “Is It ‘Too Bloody Late’? Older People’s Response to the National Physical Activity Guidelines.” Journal of Research for Consumers 10 (2006). 7 Aug. 2006 <http://www.jrconsumers.com/_data/page/3180/ NPAGs_paper_consumer_version_may_06.pdf>. Holt, T. The Rise of the Nanny State: How Consumer Advocates Try to Run Our Lives. US: Capital Research Centre, 1995. Kline, S. “Countering Children’s Sedentary Lifestyles: An Evaluative Study of a Media-Risk Education Approach.” Childhood 12.2 (2005): 239-58. Knag, S. “The Almighty, Impotent State: Or, the Crisis of Authority.” Independent Review 1.3 (1997): 397-413. Laczniak, G.R., R.F. Lusch, and P. Murphy. “Social Marketing: Its Ethical Dimensions.” Journal of Marketing 43 (Spring 1979): 29-36. Locke, J. An Essay Concerning Human Understanding. Ed. J.W. Yolton. London: J.M. Dent & Sons, 1690/1961. Marmot, M.G., and R.G. Wilkinson, R.G., eds. Social Determinants of Health. Oxford: Oxford University Press, 1999. Mead, L. “Telling the Poor What to Do.” Public Interest 6 Jan. 1998. 1 May 2006 <http://www.polisci.wisc.edu/~soss/Courses/PA974/Readings/week%208/Mead_1998.pdf>. National Social Marketing Centre. It’s Our Health! Realising the Potential of Effective Social Marketing. Summary Report. 7 Aug. 2006 http://www.nsms.org.uk/images/CoreFiles/NCCSUMMARYItsOurHealthJune2006.pdf>. Nozick, R. Anarchy, State and Utopia. New York: Basic Books, 1974. O’Connell, J.K., and J.H. Price. “Ethical Theories for Promoting Health through Behavioral Change.” Journal of School Health 53.8 (1983): 476-9. Rasmussen, S.R., E. Prescott, T.I.A. Sorensen, and J. Sogaard. “The Total Lifetime Costs of Smoking”. European Journal of Public Health 14 (2004): 95-100. 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Brownwell. “Epidemiological and Economic Consequences of the Global Epidemics of Obesity and Diabetes.” Nature Medicine 12.1 (2006): 62-6. Citation reference for this article MLA Style Henley, Nadine. "Free to Be Obese in a ‘Super Nanny State’?." M/C Journal 9.4 (2006). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0609/6-henley.php>. APA Style Henley, N. (Sep. 2006) "Free to Be Obese in a ‘Super Nanny State’?," M/C Journal, 9(4). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0609/6-henley.php>.

Introduction Since December 2010 the dramatic spectacle of the spread of mass uprisings, civil unrest, and protest across North Africa and the Middle East have been chronicled daily on mainstream media and new media. Broadly speaking, the Arab Spring—as it came to be known—is challenging repressive, corrupt governments and calling for democracy and human rights. The convulsive events linked with these debates have been striking not only because of the rapid spread of historically momentous mass protests but also because of the ways in which the media “have become inextricably infused inside them” enabling the global media ecology to perform “an integral part in building and mobilizing support, co-ordinating and defining the protests within different Arab societies as well as trans-nationalizing them” (Cottle 295). Images of mass protests have been juxtaposed against those of individuals prepared to self-destruct for political ends. Video clips and photographs of the individual suffering of Tunisian Mohamed Bouazizi’s self-immolation and the Bahraini Abdulhad al-Khawaja’s emaciated body foreground, in very graphic ways, political struggles that larger events would mask or render invisible. Highlighting broad commonalties does not assume uniformity in patterns of protest and media coverage across the region. There has been considerable variation in the global media coverage and nature of the protests in North Africa and the Middle East (Cottle). In Tunisia, Egypt, Libya, and Yemen uprisings overthrew regimes and leaders. In Syria it has led the country to the brink of civil war. In Bahrain, the regime and its militia violently suppressed peaceful protests. As a wave of protests spread across the Middle East and one government after another toppled in front of 24/7 global media coverage, Bahrain became the “Arab revolution that was abandoned by the Arabs, forsaken by the West … forgotten by the world,” and largely ignored by the global media (Al-Jazeera English). Per capita the protests have been among the largest of the Arab Spring (Human Rights First) and the crackdown as brutal as elsewhere. International organizations have condemned the use of military courts to trial protestors, the detaining of medical staff who had treated the injured, and the use of torture, including the torture of children (Fisher). Bahraini and international human rights organizations have been systematically chronicling these violations of human rights, and posting on Websites distressing images of tortured bodies often with warnings about the graphic depictions viewers are about to see. It was in this context of brutal suppression, global media silence, and the reluctance of the international community to intervene, that the Bahraini-Danish human rights activist Abdulhad al-Khawaja launched his “death or freedom” hunger strike. Even this radical action initially failed to interest international editors who were more focused on Egypt, Libya, and Syria, but media attention rose in response to the Bahrain Formula 1 race in April 2012. Pro-democracy activists pledged “days of rage” to coincide with the race in order to highlight continuing human rights abuses in the kingdom (Turner). As Al Khawaja’s health deteriorated the Bahraini government resisted calls for his release (Article 19) from the Danish government who requested that Al Khawaja be extradited there on “humanitarian grounds” for hospital treatment (Fisk). This article does not explore the geo-politics of the Bahraini struggle or the possible reasons why the international community—in contrast to Syria and Egypt—has been largely silent and reluctant to debate the issues. Important as they are, those remain questions for Middle Eastern specialists to address. In this article I am concerned with the overlapping and interpenetration of two ecologies. The first ecology is the ethical framing of a prison hunger strike as a corporeal-environmental act of (self) destruction intended to achieve political ends. The second ecology is the operation of global media where international inaction inadvertently foregrounds the political struggles that larger events and discourses surrounding Egypt, Libya, and Syria overshadow. What connects these two ecologies is the body of the hunger striker, turned into a spectacle and mediated via a politics of affect that invites a global public to empathise and so enter into his suffering. The connection between the two lies in the emaciated body of the hunger striker. An Ecological Humanities Approach This exploration of two ecologies draws on the ecological humanities and its central premise of connectivity. The ecological humanities critique the traditional binaries in Western thinking between nature and culture; the political and social; them and us; the collective and the individual; mind, body and emotion (Rose & Robin, Rieber). Such binaries create artificial hierarchies, divisions, and conflicts that ultimately impede the ability to respond to crises. Crises are major changes that are “out of control” driven—primarily but not exclusively—by social, political, and cultural forces that unleash “runaway systems with their own dynamics” (Rose & Robin 1). The ecological humanities response to crises is premised on the recognition of the all-inclusive connectivity of organisms, systems, and environments and an ethical commitment to action from within this entanglement. A founding premise of connectivity, first articulated by anthropologist and philosopher Gregory Bateson, is that the “unit of survival is not the individual or the species, but the organism-and-its-environment” (Rose & Robin 2). This highlights a dialectic in which an organism is shaped by and shapes the context in which it finds itself. Or, as Harries-Jones puts it, relations are recursive as “events continually enter into, become entangled with, and then re-enter the universe they describe” (3). This ensures constantly evolving ecosystems but it also means any organism that “deteriorates its environment commits suicide” (Rose & Robin 2) with implications for the others in the eco-system. Bateson’s central premise is that organisms are simultaneously independent, as separate beings, but also interdependent. Interactions are not seen purely as exchanges but as dynamic, dialectical, dialogical, and mutually constitutive. Thus, it is presumed that the destruction or protection of others has consequences for oneself. Another dimension of interactions is multi-modality, which implies that human communication cannot be reduced to a single mode such as words, actions, or images but needs to be understood in the complexity of inter-relations between these (see Rieber 16). Nor can dissemination be reduced to a single technological platform whether this is print, television, Internet, or other media (see Cottle). The final point is that interactions are “biologically grounded but not determined” in that the “cognitive, emotional and volitional processes” underpinning face-to-face or mediated communication are “essentially indivisible” and any attempt to separate them by privileging emotion at the expense of thought, or vice versa, is likely to be unhealthy (Rieber 17). This is most graphically demonstrated in a politically-motivated hunger strike where emotion and volition over-rides the survivalist instinct. The Ecology of a Prison Hunger Strike The radical nature of a hunger strike inevitably gives rise to medico-ethical debates. Hunger strikes entail the voluntary refusal of sustenance by an individual and, when prolonged, such deprivation sets off a chain reaction as the less important components in the internal body systems shut down to protect the brain until even that can no longer be protected (see Basoglu et al). This extreme form of protest—essentially an act of self-destruction—raises ethical issues over whether or not doctors or the state should intervene to save a life for humanitarian or political reasons. In 1975 and 1991, the World Medical Association (WMA) sought to negotiate this by distinguishing between, on the one hand, the mentally/psychological impaired individual who chooses a “voluntary fast” and, on the other hand, the hunger striker who chooses a form of protest action to secure an explicit political goal fully aware of fatal consequences of prolonged action (see Annas, Reyes). This binary enables the WMA to label the action of the mentally impaired suicide while claiming that to do so for political protesters would be a “misconception” because the “striker … does not want to die” but to “live better” by obtaining certain political goals for himself, his group or his country. “If necessary he is willing to sacrifice his life for his case, but the aim is certainly not suicide” (Reyes 11). In practice, the boundaries between suicide and political protest are likely to be much more blurred than this but the medico-ethical binary is important because it informs discourses about what form of intervention is ethically appropriate. In the case of the “suicidal” the WMA legitimises force-feeding by a doctor as a life-saving act. In the case of the political protestor, it is de-legitimised in discourses of an infringement of freedom of expression and an act of torture because of the pain involved (see Annas, Reyes). Philosopher Michel Foucault argued that prison is a key site where the embodied subject is explicitly governed and where the exercising of state power in the act of incarceration means the body of the imprisoned no longer solely belongs to the individual. It is also where the “body’s range of significations” is curtailed, “shaped and invested by the very forces that detain and imprison it” (Pugliese 2). Thus, prison creates the circumstances in which the incarcerated is denied the “usual forms of protest and judicial safeguards” available outside its confines. The consequence is that when presented with conditions that violate core beliefs he/she may view acts of self-destruction—such as hunger strikes or lip sewing—as one of the few “means of protesting against, or demanding attention” or achieving political ends still available to them (Reyes 11; Pugliese). The hunger strike implicates the state, which, in the act of imprisoning, has assumed a measure of power and responsibility for the body of the individual. If a protest action is labelled suicidal by medical professionals—for instance at Guantanamo—then the force-feeding of prisoners can be legitimised within the WMA guidelines (Annas). There is considerable political temptation to do so particularly when the hunger striker has become an icon of resistance to the state, the knowledge of his/her action has transcended prison confines, and the alienating conditions that prompted the action are being widely debated in the media. This poses a two-fold danger for the state. On the one hand, there is the possibility that the slow emaciation and death while imprisoned, if covered by the media, may become a spectacle able to mobilise further resistance that can destabilise the polity. On the other hand, there is the fear that in the act of dying, and the spectacle surrounding death, the hunger striker would have secured the public attention to the very cause they are championing. Central to this is whether or not the act of self-destruction is mediated. It is far from inevitable that the media will cover a hunger strike or do so in ways that enable the hunger striker’s appeal to the emotions of others. However, when it does, the international scrutiny and condemnation that follows may undermine the credibility of the state—as happened with the death of the IRA member Bobby Sands in Northern Ireland (Russell). The Media Ecology and the Bahrain Arab Spring The IRA’s use of an “ancient tactic ... to make a blunt appeal to sympathy and emotion” in the form of the Sands hunger strike was seen as “spectacularly successful in gaining worldwide publicity” (Willis 1). Media ecology has evolved dramatically since then. Over the past 20 years communication flows between the local and the global, traditional media formations (broadcast and print), and new communication media (Internet and mobile phones) have escalated. The interactions of the traditional media have historically shaped and been shaped by more “top-down” “politics of representation” in which the primary relationship is between journalists and competing public relations professionals servicing rival politicians, business or NGOs desire for media attention and framing issues in a way that is favourable or sympathetic to their cause. However, rapidly evolving new media platforms offer bottom up, user-generated content, a politics of connectivity, and mobilization of ordinary people (Cottle 31). However, this distinction has increasingly been seen as offering too rigid a binary to capture the complexity of the interactions between traditional and new media as well as the events they capture. The evolution of both meant their content increasingly overlaps and interpenetrates (see Bennett). New media technologies “add new communicative ingredients into the media ecology mix” (Cottle 31) as well as new forms of political protests and new ways of mobilizing dispersed networks of activists (Juris). Despite their pervasiveness, new media technologies are “unlikely to displace the necessity for coverage in mainstream media”; a feature noted by activist groups who have evolved their own “carnivalesque” tactics (Cottle 32) capable of creating the spectacle that meets television demands for action-driven visuals (Juris). New media provide these groups with the tools to publicise their actions pre- and post-event thereby increasing the possibility that mainstream media might cover their protests. However there is no guarantee that traditional and new media content will overlap and interpenetrate as initial coverage of the Bahrain Arab Spring highlights. Peaceful protests began in February 2011 but were violently quelled often by Saudi, Qatari and UAE militia on behalf of the Bahraini government. Mass arrests were made including that of children and medical personnel who had treated those wounded during the suppression of the protests. What followed were a long series of detentions without trial, military court rulings on civilians, and frequent use of torture in prisons (Human Rights Watch 2012). By the end of 2011, the country had the highest number of political prisoners per capita of any country in the world (Amiri) but received little coverage in the US. The Libyan uprising was afforded the most broadcast time (700 minutes) followed by Egypt (500 minutes), Syria (143), and Bahrain (34) (Lobe). Year-end round-ups of the Arab Spring on the American Broadcasting Corporation ignored Bahrain altogether or mentioned it once in a 21-page feature (Cavell). This was not due to a lack of information because a steady stream has flowed from mobile phones, Internet sites and Twitter as NGOs—Bahraini and international—chronicled in images and first-hand accounts the abuses. However, little of this coverage was picked up by the US-dominated global media. It was in this context that the Bahraini-Danish human rights activist Abdulhad Al Khawaja launched his “freedom or death” hunger strike in protest against the violent suppression of peaceful demonstrations, the treatment of prisoners, and the conduct of the trials. Even this radical action failed to persuade international editors to cover the Bahrain Arab Spring or Al Khawaja’s deteriorating health despite being “one of the most important stories to emerge over the Arab Spring” (Nallu). This began to change in April 2012 as a number of things converged. Formula 1 pressed ahead with the Bahrain Grand Prix, and pro-democracy activists pledged “days of rage” over human rights abuses. As these were violently suppressed, editors on global news desks increasingly questioned the government and Formula 1 “spin” that all was well in the kingdom (see BBC; Turner). Claims by the drivers—many of who were sponsored by the Bahraini government—that this was a sports event, not a political one, were met with derision and journalists more familiar with interviewing superstars were diverted into covering protests because their political counterparts had been denied entry to the country (Fisk). This combination of media events and responses created the attention, interest, and space in which Al Khawaja’s deteriorating condition could become a media spectacle. The Mediated Spectacle of Al Khawaja’s Hunger Strike Journalists who had previously struggled to interest editors in Bahrain and Al Khawaja’s plight found that in the weeks leading up to the Grand Prix and since “his condition rapidly deteriorated”’ and there were “daily updates with stories from CNN to the Hindustan Times” (Nulla). Much of this mainstream news was derived from interviews and tweets from Al Khawaja’s family after each visit or phone call. What emerged was an unprecedented composite—a diary of witnesses to a hunger strike interspersed with the family’s struggles with the authorities to get access to him and their almost tangible fear that the Bahraini government would not relent and he would die. As these fears intensified 48 human rights NGOs called for his release from prison (Article 19) and the Danish government formally requested his extradition for hospital treatment on “humanitarian grounds”. Both were rejected. As if to provide evidence of Al Khawaja’s tenuous hold on life, his family released an image of his emaciated body onto Twitter. This graphic depiction of the corporeal-environmental act of (self) destruction was re-tweeted and posted on countless NGO and news Websites (see Al-Jazeera). It was also juxtaposed against images of multi-million dollar cars circling a race-track, funded by similarly large advertising deals and watched by millions of people around the world on satellite channels. Spectator sport had become a grotesque parody of one man’s struggle to speak of what was going on in Bahrain. In an attempt to silence the criticism the Bahraini government imposed a de facto news blackout denying all access to Al Khawaja in hospital where he had been sent after collapsing. The family’s tweets while he was held incommunicado speak of their raw pain, their desperation to find out if he was still alive, and their grief. They also provided a new source of information, and the refrain “where is alkhawaja,” reverberated on Twitter and in global news outlets (see for instance Der Spiegel, Al-Jazeera). In the days immediately after the race the Danish prime minister called for the release of Al Khawaja, saying he is in a “very critical condition” (Guardian), as did the UN’s Ban-Ki Moon (UN News and Media). The silencing of Al Khawaja had become a discourse of callousness and as global media pressure built Bahraini ministers felt compelled to challenge this on non-Arabic media, claiming Al Khawaja was “eating” and “well”. The Bahraini Prime Minister gave one of his first interviews to the Western media in years in which he denied “AlKhawaja’s health is ‘as bad’ as you say. According to the doctors attending to him on a daily basis, he takes liquids” (Der Spiegel Online). Then, after six days of silence, the family was allowed to visit. They tweeted that while incommunicado he had been restrained and force-fed against his will (Almousawi), a statement almost immediately denied by the military hospital (Lebanon Now). The discourses of silence and callousness were replaced with discourses of “torture” through force-feeding. A month later Al Khawaja’s wife announced he was ending his hunger strike because he was being force-fed by two doctors at the prison, family and friends had urged him to eat again, and he felt the strike had achieved its goal of drawing the world’s attention to Bahrain government’s response to pro-democracy protests (Ahlul Bayt News Agency). Conclusion This article has sought to explore two ecologies. The first is of medico-ethical discourses which construct a prison hunger strike as a corporeal-environmental act of (self) destruction to achieve particular political ends. 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