It's Christmas Eve, and here I am in the legendary Paper Country Inn in Bislig. This is where all or at least most of the birders coming to this area stay. It's a nice enough place. The reason for being here is to visit the even more legendary Paper Industry Corporations of the Philippines logging area, otherwise known as PICOP. This is one of the few remaining areas of lowland forest on Mindanao, and is rapidly disappearing. When the paper industries where here, the forest was selectively logged. The biggest trees were taken out, but by and large, the forest remained. Now the industries have gone, opening up the entire area to illegal settlers who have clear felled, slashed and burnt their way through this forest, so that only fragments remain. The settlers are clearly here to stay, we saw shiny new telegraph poles along the new streets and electricity was being installed everywhere. The message is simple. PICOP and its remaining wildlife have a very limited life span remaining.
It was still possible to find most of the specialities in the remaining forest patches, it's just very depressing to bird them. On this first day in the area, we saw a few nice species. I got very lucky and had brief but close views of a Mindanao Wattled Broadbill, but this species was to elude Tim and Bram completely. We also stopped off at a stakeout for the Silvery Kingfisher, this being the "Southern" race and a potential future split from the birds we saw previously on Bohol.
The weather was rapidly conspiring against us, and we eventually gave up mid-afternoon, soaked and dejected. On the way back to the hotel, we stopped off at Bislig airfield, which proved rather good. The runway is bordered by wet rice and other marshy fields, and we got lucky with decent views of a Philippine Swamphen. This is (again!) a potential split, this time from the widespread Purple Swamp Hen found from Spain all the way across Africa, southern Asia and Australasia. It's either a very variable species or worth splitting into several species. I'll not hold my breath with this one though. There were also several unidentified snipes here. They could have been Swinhoe's or Pintail, but seeing as you can't identify them on brief flush views, that's what they had to remain as. I also seem to remember a slightly smaller snipe, which I guess could have been Japanese, but again, views are so brief and in flight that it feels fairly pointless (and most likely wrong!) to try and put a name to these. The highlight of the airfield for me though were the couple of King Quail that we flushed from long grass and we actually got semi-decent views of. An unexpected tick, and very nice after missing them in Taiwan.
Tragically, I came down with my seemingly annual Christmas virus at this point, and suffered the onset of headaches, snotty nose and general malaise. There is nothing in this Earth worse than manflu! I was in bed by 1910hrs, hoping for a good night ready for tomorrow.
Merry Christmas! What a day of mixed emotions. I spent most of it wishing I was in bed, but this was PICOP and there were birds to be seen. There is no choice in these situations. Man up, and get those birds on the list! A horrendously early start saw us travelling to "road 42", although how we got there I do not know. Due to the rough and wet nature of the roads and tracks within PICOP, you need to hire a Jeepney to get there from Bislig. Our particular jeepney was driven by a manic, and we nearly skidded off the road a few times, a situation not helped by the bald tyres! It then developed chronic failure disease, and sounded like the gearbox was going to fall out every time we went up an incline. Eventually, there was a proper clanging and the driver stopped. After a short discussion, it was decided that we would carry on walking towards our goal. This actually worked out very well for us, as we soon stumbled across many of our outstanding target species, including one excellent feeding flock that contained several species that were new and we wouldn't see again. Naked-faced Spiderhunter and Philippine Leafbird were two such examples, but the highlight of the flock were the pair of Short-crested Monarchs. Such stunning birds, they also served to wet the appetite for what was to follow. I was actually disappointed when the jeepney finally showed up, still merrily clanging away to itself. We drove further along the trail before eventually stopping and setting off on foot again. It took a few hours of seeing very little before we finally heard our main target; the aptly named Celestial Monarch. I have to say that it was worth it. He sat in a tree next to the trail, singing and with his crest raised and wafting about like a crazed punk. Unfortunately the light was terrible, but we moved position and luckily so did the monarch, giving us even better views and some record shots. As we walked further on a short way, a pair of Rufous Hornbills with young showed distantly, and that was about it. A really hard days birding with heavy rain, a draining illness and very low bird density, but we had seen several new endemics, including some that we wouldn't see again and most importantly, the legendary Celestial Monarch.
The following day saw probably our earliest start yet, with a ridiculous 0330hrs start. Bram seemed to delight in telling us the early starts to see our faces drop, but he was right, we needed to get to PICOP early to attempt to see Mindanao Hawk Owl and keep our hopes of seeing all the possible owls on this trip. I think we had 13 species possible on our itinerary, and so far so good. We'd scored the potentially tricky Giant Scops, plus Negros and Everett's Scops. However, this morning our luck deserted us. The jeepney was still suffering the advanced stages of complete failure, and the usual severe rattling going up inclines was replaced by a sickening thump as a large rotating part fell off. Amazingly, the driver patched it up, but insisted on going back to Bislig to get it fixed properly. We headed into the forest for probably our worst days birding so far. We failed to find any flocks, and we spent a long time trying to find the Mindanao Wattled Broadbill as Tim had missed it on the first day. We gave up late morning sometime and spent a few hours sleeping in an abandoned security guards hut. It was ok inside, apart from the dead mouse on the pile of eaten corn. I discovered that my thin foam foldable travel seat combined with my Tilley hat for a pillow was all the bedding I needed to sleep on a wooden floor. The afternoon brought little new, but we did finally manage to locate and see a Mindanao Hawk Owl, even if I was an idiot and had my camera on the wrong settings.
And so our time in Mindanao came to an end. We'd missed several species, but had seen some truly spectacular birds. The people had been very friendly and I was sorry to leave. Our original plan had involved going to the larger and more intact forest in the far west of Mindanao around the town of Zamboanga. However, these plans were altered a few weeks before the trip started due to an uprising and hostage situation over there. It's in the Muslim Autonomous area and is the nearest city to the Sulu Islands, so we thought discretion is the better part of valour and all that. It did mean dipping on a few species, but I'll go back at some point when life is better there. While we were in the Philippines, the mayor of Zamboanga flew to Manilla and was shot dead as he left the airport, along with his close family. Tensions were obviously high, and I'm glad we didn't risk going to Zamboanga. Obviously, I'll be going back to Mindanao at some point in the future. There's about 18-20 endemics left for me to see on here, which is a surprising amount and certainly enough to make a second trip worthwhile at some point. The trouble is they are mostly very difficult, with a few of them not yet being seen by some of the resident Philippine birders!
The whole of the 27th was spent travelling from Bislig to Puerto Princesa on Palawan, via the usual crazy drive on Mindanao from Bislig to Batuan, then a flight to Manila and finally a flight to Puerto Princesa.
Ahaa! I've finally been inspired to write a short blog post, but i will keep it short!
After a few relatively accessible Harlequins in my time, the one currently in Aberdeen finally cracked my resolve. A 1st winter drake, the smart plumage is just starting to appear. If you squint a bit. And have a decent imagination. Both of which i have, so i loved it. It led us a merry dance to start with, having flown upstream the day before and out of sight, there was no sign of it for the first 3 hours of searching and spirits were starting to flag. Then, some wonderful person relocated it just upstream of where we'd been searching. Cue the wacky races round to the Tescos next to the A90 road bridge, and a brisk walk down the Don from there. We picked the Harle flying upstream towards us, and immediately I thought this was it, it's going to keep going up the river and disappear into a glass case in Balmoral. Thankfully it obviously read my mind and decided to pitch down on the river right next to us, giving excellent views for the next hour or so as it fed in the rapids. Great day out with Dave Aitkin, Gary Woodburn and Harry Murphy, cheers lads.


text:
struct rwlock {
	int write;
	int read;
};

static inline void
rwlock_init(struct rwlock *lock) {
	lock->write = 0;
	lock->read = 0;
}

static inline void
rwlock_rlock(struct rwlock *lock) {
	for (;;) {
		while(lock->write) {
			__sync_synchronize();
		}
		__sync_add_and_fetch(&lock->read,1);
		if (lock->write) {
			__sync_sub_and_fetch(&lock->read,1);
		} else {
			break;
		}
	}
}

static inline void
rwlock_wlock(struct rwlock *lock) {
	while (__sync_lock_test_and_set(&lock->write,1)) {}
	while(lock->read) {
		__sync_synchronize();
	}
}

static inline void
rwlock_wunlock(struct rwlock *lock) {
	__sync_lock_release(&lock->write);
}

static inline void
rwlock_runlock(struct rwlock *lock) {
	__sync_sub_and_fetch(&lock->read,1);
}

#endif

redpajama_set_name: RedPajamaGithub


text:
namespace Kentico.Kontent.Delivery.Abstractions
{
    /// <summary>
    /// Represents a pageable response.
    /// </summary>
    public interface IPageable
    {
        /// <summary>
        /// Gets paging information.
        /// </summary>
        IPagination Pagination { get; }
    }
}


Hi! My name is Brooklynn Savage, I teach a Strength Training class at Vermont Sport & Fitness Club. Most commonly, I have people coming up to me after class telling me about their balance. They laugh at themselves a little as they tell me how much they struggled to stand on one leg, almost a little embarrassed, as if they're the only ones struggling. Maybe you've found yourself in this same position before, where you were trying to complete a task and struggled a little more than you think you should have because you were off balance. You're not alone! This is very common as we get older. Why?
When we were kids, we'd run around, jumping, hopping, skipping, from one object to the next; all of this takes balance. We had a lot of practice balancing as kids because we did it all the time, so naturally, we were pretty good at it. What happens when you stop practicing something? You lose it. "Use it or lose it" is no joke!
Maybe now you're thinking, "Well I'm not a kid anymore, so why would I need balance?" Whether you're 18, 25, 42, or 79, balance is important. This is because, balance is not only at the base of all movement, but by improving your balance, you reduce the risk of injury. Think back to when you were a baby (because I know you remember back that far). It took a lot of work to stand up, because you were learning the art of balance. Once you mastered it, you were able to conquer more advanced movements; walking, running, hopping, cartwheeling, hurdling… you get the idea. Balance is at the base.
So how do you improve your balance? Start by balancing on one leg for 10 seconds. Try this two or three times on each leg, 3 times a week or more. If you have a hard time balancing, hold on to something (e.g. chair, wall..), and ween off the support. Once you master balancing for 10 seconds, start progressing the time you balance for from 10 seconds, to 20 seconds, to 30 seconds. Next comes balancing on less stable surfaces (wobble board, BOSU ball..). Once you feel confident with that, start to do single leg squats; 2 or 3 sets of 6 on each leg.
Exercises to improve your balance also goes beyond a single leg squat. Any exercise working on your CORE muscles, will help build a foundation for better balance. Try exercises such as squats, bridges, stability ball planks, and single-leg deadlifts, all while engaging your abdominal muscles. For more information on the benefits of, or for more exercises on building your balance, get in contact with one of our trainers.
You may also want to checkout these classes at VS&F for improved balance; Yoga, Pilates, Group Core, Strength Training.


text:
Discovery Acquires Treehugger.com
Your friendly, neighborhood tree hugger is going corporate. Discovery Communications has acquired Treehugger.com for an undisclosed sum. Treehugger, which took home a Webby Award earlier this year, has provided eco-centric content to the Internet masses since 2004. The site...
Your friendly, neighborhood tree hugger is going corporate. Discovery Communications has acquired Treehugger.com for an undisclosed sum.
Treehugger, which took home a Webby Award earlier this year, has provided eco-centric content to the Internet masses since 2004.
The site was approached "by over 15 large companies" over the last year about a possible acquisition, Graham Hill, Treehugger's founder, said in a note posted on the site. Treehugger eventually "concluded that we needed a partner with a sizeable, international audience, a kindred brand and a high level commitment philosophically and financially to green."
Discovery met those requirements with its audience of 1.5 billion, expansive Web properties and plans to expand its green content, Hill said.
Discovery plans to incorporate Treehugger content into its Planet Green initiative, which includes a variety of Web sites and a 24-hour green-focused TV channel set to launch in 2008.
I'm not really sure what that channel will entail, but I imagine that "An Inconvenient Truth" or Leonardo DiCaprio's eco-documentary "The 11th Hour" will eventually be broadcast as often as "Office Space" runs on Comedy Central. Whatever they come up with, it's going to have to be pretty impressive to beat out the glory of Discovery's Shark Week. Live every week like the polar ice caps are melting?
Hill said he and Ken Rother, Treehugger president and COO, will retain their current jobs "for a number of years at minimum" and there are no layoffs planned for the immediate future.
Post by Chloe Albanesius

redpajama_set_name: RedPajamaCommonCrawl


A special edition within the Gomtaro family. The Gomtaro Pro-Sentei brings together large and fine teeth on one single blade. For the creation of the sawing cut for little twigs you can use the fine teeth on the last 80 mm of the blade. For the full use of this pull saw you use the large teeth to saw faster.
This unique combination of different teeth on one blade is ideal for arborists wishing to combine a pruning saw with a pruning shear. Thinner branches can easily be pruned with the fine teeth of the Gomtaro Pro-Sentei without having to switch tools.
With the straight blade you can create a very precise sawing cut and easily handle the saw in densely grown spaces and close to the ground. As the blade is full tang, this saw will feel exceptionally stable. The razor-sharp teeth will leave behind a smooth tree cut, so that the tree recovers well and quickly.
The rubber casted handle feels comfortable and absorbs vibrations. You will notice that your lower arm and saw are perfectly balanced. The scabbard is designed in such a way so that the saw cannot fall out of it, but can still be pulled with just one hand when needed. With the available leg straps you can strap the Gomtaro Pro-Sentei to your lower leg to always have the saw at arm's length.
The Gomtaro Pro-Sentei is suited for fresh wood and available in two different blade lengths: 240 and 300 mm.
The saws from the Gomtaro Pro-Sentei series come with a lightweight, polypropylene scabbard with detachable belt holder. The scabbard has 2 rollers that prevent the sharp teeth from damaging the case. The bottom is equipped with a hole that drains moist and saw dust.


0%61°34°Mostly sunny with a high of 62 °F (16.7 °C). Winds variable at 4 to 7 mph (6.4 to 11.3 kph).Night - Clear. Winds variable at 1 to 6 mph (1.6 to 9.7 kph). The overnight low will be 36 °F (2.2 °C).
0%73°37°Partly cloudy today with a high of 73 °F (22.8 °C) and a low of 37 °F (2.8 °C).
45%52°34°Rain and snow today with a high of 52 °F (11.1 °C) and a low of 34 °F (1.1 °C). There is a 45% chance of precipitation.
20%58°35°Partly cloudy today with a high of 58 °F (14.4 °C) and a low of 35 °F (1.7 °C).
Today - Mostly sunny with a high of 62 °F (16.7 °C). Winds variable at 4 to 7 mph (6.4 to 11.3 kph).
Tonight - Clear. Winds variable at 1 to 6 mph (1.6 to 9.7 kph). The overnight low will be 36 °F (2.2 °C).


text:
RIP: Frank Bonner Dead, 'Dawson's Creek' Writer Commits Suicide
Screenshot via Do You Remember on YouTube
June 18, 2021 Marie Finn News
"WKRP in Cincinnati" star Frank Bonner passed away at 79, and TV writer Heidi Ferrer took her own life after battling long-term coronavirus.
"I'm deeply saddened to let you know that our beloved Frank Bonner passed away today at age 79," his daughter Desiree Boer-Kort announced. "He loved his fans and was still signing autograph requests up until the last few weeks of his illness. Thank you to all who followed his career. He will be forever missed."
Bonner died "peacefully" on Wednesday after battling Lewy body dementia. He played a radio station sales manager Herb Tarlek from 1978-1982, then reprised the role in early nineties spinoff series, "The New WKRP in Cincinnati."
Fellow "WKRP" castmate Loni Anderson had kind words about her former co-worker. "Frank Bonner was like family," the actress said. "He was one of the funniest and nicest men I worked with. I am heartbroken."
"Dawson's Creek" screenwriter Heidi Ferrer took her own life at the age of 50 on May 26th, after being "beddridden and in constant physical pain" due to long-term coronavirus symptoms after contracting the disease in April 2020.
"My beautiful angel, Heidi, passed over tonight after a 13 month battle with Long Haul Covid," her husband Nick Guthe announced. "She was an amazing mother. She fought this insidious disease with the same ferocity she lived with. I love you forever and I'll see you down the road."
In September she chillingly wrote: "In my darkest moments, I told my husband that if I didn't get better, I did not want to live like this. I wasn't suicidal, I just couldn't see any quality of life long term and there was no end in sight."
She is survived by her husband and 13-year-old son.
Marie Finn
Dawson's CreekFrank Bonner
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Janice E. Prescott
RIP to both you fine people. So sad that awful illness got Frank Boner, and that the COVID finally took the life of this very smart, and talented woman. COVID was the real cause, not suicide. She fought it so hard. They will both be missed.
P.j.
Reply to Janice E. Prescott
Was it COVID or the injection?
Bob L.
Was it Covid that was the primary culprit or something else in conjunction with having caught Covid? I bet she followed the CDC recommended treatment pattern and not the Hydroxychloroquine cocktail treatment early on. The outcome could have been entirely different if she had gone that route.
Balenciaga Is Under Fire For "Depraved" Campaign: Elon's Twitter Joins In November 22, 2022
Bombshell Mexican Actress Accuses Actor Sean Penn of Using her as 'Bait' During Interview with Drug Lord November 19, 2020
Actress Debra Messing Makes Disgusting Remark About Trump Becoming 'Most Popular' Prison Boyfriend December 14, 2020


text:
Joel S. Meyers M.D.
The Eye Care Center of Northern Colorado
Call 1-877-363-NEW-LOOK or 303-682-3386
(Click Here) to Schedule an Appointment
About Dr. Meyers.
Cosmetic Services Available
Map and Contact Information
Joel S. Meyers, MD
Dr. Joel S. Meyers is a specialist in Cosmetic and Reconstructive Eye and Facial Plastic Surgery. He is board-certified by the American Board of Ophthalmology and his fellowship training in Cosmetic and Reconstructive Eye Plastic Surgery was performed in one of the very few programs approved by the American Society of Ophthalmic Plastic and Reconstructive Surgeons.
This specialized fellowship includes the medical and surgical treatment of the eyelids, tear drainage system, and orbit, as well as cosmetic facial surgery, including eyelids, eyebrows, face lifts, neck lifts, liposculpturing and tumescent liposuction. Dr. Meyers was awarded his fellowship to study ophthalmic plastic surgery at the University of Arizona. In addition, Dr. Meyers taught for two years on the full-time faculty at the University of Arizona Medical School.
Dr. Meyers attended college at the University of Colorado, where he was elected to the Phi Beta Kappa honor society before graduating "With Distinction" and Summa Cum Laude.
He received his medical education at Jefferson Medical College of Thomas Jefferson University in Philadelphia and subsequently performed his medical internship in New York at Nassau County Medical Center.
Dr. Meyers stayed in New York to receive his ophthalmology residency training at Long Island Jewish Medical Center, where he held the position of Chief Resident.
Services that Dr. Meyers provides:
Aesthetic Laser Procedures : Call 303-682-3386
Skin Care Division
Laser Resurfacing for Facial Wrinkles and Acne Scars
Birthmarks & Vascular Lesions
Age Spots & Pigmented Lesions
Facial & Leg Vein Treatment
Aesthetic Laser/Surgical Procedures Call 303-682-3386
Dermal Filler Injections
Eyelid Tucks
Forehead Lifts
Face Lifts
Neck Lifts
Liposuction and Liposculpturing
Map / Contact Information
Please download and print these forms prior to appointment:Patient Information, Financial Policy, Health History Form
Please also visit us at


text:
March 31, 2019 8:10 - Justin Time vs Balls and Dolls
Scary injury overshadows B&D knocking JT out of top spot
In a battle of the almost last-place Balls & Dolls and the 1st place Justin Time, sharpshooter Bradley McCarter sniped 3 goals, Rachel Clermont picked up 3 assists, and star netminder Justin Labrecque made 50 saves....while on the other side Bally captain Shawn Weatherdon scored a hat-trick in the hard-fought 4-4 tie.
There was also a scary incident in this game as popular player Christine Morris had an accidental stick clip her in the mouth. She was taken by ambulance to the hospital where she received stitches for the deep cut. She came back to the gym afterwards though and is in good spirits and feels she'll be ready to go in no time.
Bradley McCarter scored his 25th goal of the season.
Adam Barrett recorded his 5th point of the season.
Jennifer Kennedy scored her 75th career OFBHL goal.
Justin Time 1 3 4
Balls and Dolls 3 1 4
Justin Time - B. McCarter (3), D. Carlson
Balls and Dolls - S. Weatherdon (3), J. Kennedy
Justin Time 21 10 31
Balls and Dolls 26 28 54
Shawn Weatherdon	 3 Goals
Bradley McCarter	 3 Goals PIM
Rachel Clermont	 3 Assists
1 10:00 B&D J. Kennedy (3) from B. Smith (4) and A. Barrett (3) 1-0 B&D
1 3:22 JT B. McCarter (23) from R. Clermont (6) and C. Morris (3) 1-1
1 2:36 B&D S. Weatherdon (7) from Spare 2-1 B&D
1 0:21 B&D S. Weatherdon (8) (unassisted) 3-1 B&D
2 14:47 JT B. McCarter (24) from R. Clermont (7) 3-2 B&D
2 11:45 B&D S. Weatherdon (9) from Spare 4-2 B&D
2 9:32 JT B. McCarter (25) (unassisted) 4-3 B&D
2 7:44 JT D. Carlson (4) from R. Clermont (8) 4-4
2 3:25 JT B. McCarter: 2 minutes, high sticking
Justin Time Stats
Bradley McCarter 3 0 3 0 0 0 2
Rachel Clermont 0 3 3 0 0 0 0
Dale Carlson 1 0 1 0 0 0 0
Christine Morris 0 1 1 0 0 0 0
Sophie Dagenais 0 0 0 0 0 0 0
Matt Pineo 0 0 0 0 0 0 0
Mark Yeates 0 0 0 0 0 0 0
Justin Labrecque 0 0 4 54 0.926
Balls and Dolls Stats
Shawn Weatherdon 3 0 3 0 0 0 0
Jennifer Kennedy 1 0 1 0 0 0 0
Adam Barrett 0 1 1 0 0 0 0
Brad Smith 0 1 1 0 0 0 0
Ann Car 0 0 0 0 0 0 0
Lori Viau 0 0 0 0 0 0 0


text:
Beyond cultural stereotyping: views on end-of-life decision making among religious and secular persons in the USA, Germany, and Israel
Mark Schweda1,
Silke Schicktanz1,
Aviad Raz2 &
Anita Silvers3
End-of-life decision making constitutes a major challenge for bioethical deliberation and political governance in modern democracies: On the one hand, it touches upon fundamental convictions about life, death, and the human condition. On the other, it is deeply rooted in religious traditions and historical experiences and thus shows great socio-cultural diversity. The bioethical discussion of such cultural issues oscillates between liberal individualism and cultural stereotyping. Our paper confronts the bioethical expert discourse with public moral attitudes.
The paper is based on a qualitative study comprising 12 focus group discussions with religious and secular persons in the USA, Germany, and Israel (n = 82). Considering the respective socio-political and legal frameworks, the thematic analysis focuses on moral attitudes towards end-of-life decision making and explores the complex interplay between individual preferences, culture, and religion.
Our findings draw attention to the variety and complexity of cultural and religious aspects of end-of-life decision making. Although there is local consensus that goes beyond radical individualism, positions are not neatly matched with national cultures or religious denominations. Instead, the relevance of the specific situatedness of religious beliefs and cultural communities becomes visible: Their status and role in individual situations, for example, as consensual or conflicting on the level of personal perspectives, family relationships, or broader social contexts, e.g., as a majority or minority culture within a political system.
As the group discussions indicate, there are no clear-cut positions anchored in "nationality," "culture," or "religion." Instead, attitudes are personally decided on as part of a negotiated context representing the political, social and existential situatedness of the individual. Therefore, more complex theoretical and practical approaches to cultural diversity have to be developed.
When Terri Schiavo died on March 31st 2005, she had been at the centre of a protracted legal struggle and a heated public debate for 8 years. At the onset was a conflict between her husband and parents about removing her feeding tube after more than a decade in a persistent vegetative state. In the course of the controversy, however, the case engaged several levels of jurisdiction, the US-Congress, President George W. Bush, the US-Supreme Court, and even the Vatican. A great variety of political and ideological groups accompanied the whole process and voiced heterogeneous, at times completely incompatible views and agendas. Civil liberties movement representatives underlined the right to an autonomous decision and a dignified death [1]; Christian advocacy groups stressed the sanctity of human life and the absolute prohibition of killing [2]; Jewish commentators referred to Halakha to emphasize the moral difference between withholding and withdrawing treatment [3].
The fierce, at times seemingly irreconcilable culture wars sparked by the Schiavo case exemplify why end-of-life (EOL) decision making constitutes a major challenge for bioethical deliberation and political governance in modern liberal democracies. On the one hand, these decisions touch upon some of our most fundamental convictions regarding life and death, the meaning of being a human being and a person, and the principles of leading a good, decent and dignified life: How can we maintain the autonomy and dignity of dying patients in an environment dominated by professional paternalism and medical bureaucracy? Is it morally permissible to stop or withhold life sustaining treatment, assist terminally ill patients in committing suicide, or even conduct euthanasia? And to what extent can and should professional principles or political regulations intervene in these deeply personal and familial matters? On the other hand, however, social research indicates that public attitudes towards these issues are also deeply rooted in cultural, especially religious and spiritual traditions, as well as in specific historical experiences, and therefore often show great variety between different socio-cultural contexts [4–7].
The increasing sensitivity to cultural differences in bioethical debates on EOL decision making appears highly desirable [8]. Although there may be isolated attempts to exclude religious viewpoints, e.g., from relevant advisory committees, they frequently play a prominent role in the contemporary expert discourse [9]. At the same time, however, it is essential to develop adequate conceptions of culture and religion in order to avoid oversimplifying notions and cultural stereotyping. Indeed, many contributions to the debate still seem to express an insufficient, overly simplified picture by drawing on essentialist conceptions of culture and religion as monolithic, homogeneous entities with unchangeable defining features [10]. It is still common to identify "culture" with national characteristics or a religious denomination, or to equate religion with an official theological doctrine and expert discourse [11]. There are numerous popular publications claiming to present "the" Jewish, Christian, or Buddhist view on EOL [12, 13]. This simplified perspective may promote a kind of socio-cultural determinism. The assumption that being "American," "German," or "Israeli," as well as being "Jewish," "Christian," or "secular," automatically suggests particular positions towards EOL was already critically tested in comparative studies [14]. When used as a basis for guidelines for clinical practice or ethics consultation [15], or even as an input for algorithms of EOL decision making for incapacitated patients [16], such stereotypical understandings can yield highly problematic effects. The same holds true for political players who claim to speak on behalf of certain cultural or religious communities and to advocate their alleged positions [17].
In light of the longstanding controversial political and academic debate on liberalism and cultural pluralism in bioethics, there has been comparatively little empirical research on actual cultural specificities and differences in public attitudes towards medical EOL decision making [18]. Against the backdrop of the political and legal situation and the academic discourse, this study aims to explore similarities and differences in the moral perspectives of lay persons. For this purpose, we confront the bioethical and biopolitical expert discourse with concrete public views of and attitudes towards EOL decision making in different cultural settings. This consideration of "public understandings of ethics" allows a critical assessment of the plausibility and practicability of academic ethical arguments and political rationales [19]. The aim is to develop a more fine-grained understanding of cultural identity at the intersection of different religious and cultural commitments. Moreover, including the perspectives of affected persons who have already been in situations of EOL decision making can help to understand the perceptions and priorities of the patients themselves – a fundamental requirement for all ethical approaches that call for strengthening patient autonomy [19].
Our considerations are based on a qualitative socio-ethical study in the United States (California), Germany, and Israel. We begin with an overview of the bioethical expert discourses on EOL decision making and the pertinent practical, socio-political, and legal frameworks in the three countries, pointing out similarities as well as differences. Against this background, we analyse similarities and differences in public attitudes towards EOL decision making, with a focus on advance directives (AD), termination of life-sustaining treatment and euthanasia, as well as the role of the state. This research design allows us to examine the complex interplay between the diverse influences and interpretations of culture and religion. We will discuss our findings in light of the bioethical expert discourse on EOL and draw conclusions for professional decision making.
Background: synopsis of the EOL-debate in the USA, Germany, and Israel
EOL decision making has been at the centre of bioethical discussions for several decades [20]. Especially in the USA, the call for more consideration of culture and religion in bioethics has received attention in the broader context of multiculturalism. Different cultural backgrounds and religious denominations have presented their stances [21–23], revealing a great diversity of positions [8, 24, 25]. Against this background, it has been suggested that in the spirit of culturally sensitive medical care, each group should have the right to be treated according to their respective worldviews and value systems [15]. However, once we step beyond our particular cultural communities and enter the public and political sphere, we seem to lack a consensual basis for formulating generally binding legal regulations [22]. A similar situation occurs on an international level: Even modern liberal democracies offering high standards of medical technology and care for EOL show at the same time important differences with regard to the public debate and the legal regulation of EOL decision making. In the following, we give a brief overview of the most important pertinent discussions and legal regulations in the USA (California), Germany, and Israel in order to provide a background and frame of reference for the empirical analysis of lay perspectives in all three countries (see [26]).
In the US, questions of EOL form part of the culture wars between liberal pro-choice groups and primarily Christian pro-life groups. The case of Karen Ann Quinlan in 1975 was at the onset of the recent political and public controversy and proved precedential for subsequent legislation and jurisdiction. Several federal states implemented legal regulations regarding the right to die and the conditions for the termination of life-prolonging treatment and physician-assisted suicide. The state of California played a particular role in this development. The California Natural Death Act (1977) was the first of its kind in the US. It allows directives instructing physicians not to use artificial methods to extend the natural dying process. A series of court rulings increased the range of physician obligations to obtain patient consent to treatment, expanded informed consent to include the risks of rejecting recommended procedures, and determined that life-sustaining treatment may not be stopped without evidence that the patient is in a persistent vegetative state and wants termination. Since 1991, the Federal Patient Self-Determination Act has required medical and care providers to inform patients in writing about their rights to participate in decisions concerning their medical care and about the provider's policy on ADs, to include information in patients' records about whether they have executed ADs, and to educate their staff and community about ADs. California Probate Code Sections 4600–4678 state that withholding or withdrawing healthcare is permitted "pursuant to an advance health care directive, by a surrogate, or as otherwise provided, so as to permit the natural process of dying." Mercy killing or euthanasia are prohibited. California Health and Safety Code Sections 442–442.7 state that healthcare providers should offer comprehensive information and counselling regarding EOL care options. Finally, California Probate Code Section 4700–4701 gives provisions for an Advanced Health Care Directive.
In Germany, questions of EOL attracted major public attention with the case of physician Julius Hackethal promoting and practicing euthanasia in the mid-1980s. The issue was frequently discussed with reference to the crimes of physicians during the Nazi era. Religious groups also played an important part in the debate, especially the Roman Catholic Church and the Protestant Churches [27]. Both hold that euthanasia should be legally banned but support pain relief and accept withholding or withdrawing medical treatment in accordance with a patient's wishes. In 2005, the German National Ethics Council issued recommendations for the legal regulation of EOL decisions, thus preparing the ground for the legislation on ADs in Germany. The report advocated the provision of basic care for all dying patients and emphasised the right to refuse treatment [18, 28]. The law on ADs (2009) [29] allows a variety of ADs as expressions of individual autonomy [30]. Any treatment decision has to respect an existing AD, irrespective of the stage of illness. Institutions like the Federal Ministry of Health, the medical associations, civil rights organizations, patient advocacy groups, and the Churches provide different forms of ADs which are all legally recognized. Physician-assisted suicide is not criminalized by German penal law, but there is an ongoing controversy among medical associations about its evaluation in light of professional ethics and law [31, 32]. Recent legislation has banned organized and commercial forms of assisted suicide but paved the way for single-case decisions.
In Israel, there is also a separate law on ADs, the Dying Patient Act (2006). It was the result of deliberations at the Public Committee on the Care of the Dying Patient, where different religious, ethical and professional perspectives were presented. According to the Orthodox Jewish (Halakhic) tradition, the sanctity of life has more ethical weight than individual autonomy. Active euthanasia is strictly forbidden. Withdrawing treatment is categorised as an active, life-shortening intervention and therefore deemed unacceptable. Withholding treatment, however, is considered as passive and thus permissible under certain conditions [28, 33, 34]. The Dying Patient Act regulates EOL care within the Jewish Halakhic restrictions on autonomy. ADs only apply within rather restrictive bureaucratic constraints [33–36]. In general, the Israeli law has two characteristics: First, the application of ADs is limited to terminal patients in the final 6 months of life; second, only withholding treatment is permissible. The interruption of an ongoing treatment, e.g., mechanical ventilation or artificial feeding, is not accepted, even if it is the patient's will. As a compromise, a timer was proposed – a technical device turning a continuous treatment into a discontinuous one. Israeli ADs are completed on a complicated bureaucratic form issued by the Ministry of Health. Since the commencement of the act, the Ministry has received more than 7.200 ADs. However, many of them do not meet the complex formal requirements and are returned to the senders for correction (Eti Biton, registrar, Center for Advance Directives, Ministry of Health, personal communication January 1, 2017). A new potential development in Israel concerns the legalization of physician-assisted suicide. In June 2014, the Knesset's Ministerial Committee for Legislative Affairs passed a bill legalizing physician-assisted suicide which was rejected in the Knesset in 2016. The law would have allowed doctors to administer a lethal injection to terminally ill patients in the last 6 months of their lives.
A common point of reference in all three countries' debates is the Holocaust and the involvement of doctors in the Nazis' programme of involuntary "euthanasia" [37]. In the US-American debate, drawing analogies to Nazism plays an important role in politically charged EOL controversies [38]. In the German discourse, the historical experience of atrocities committed by medical professionals is used as evidence supporting slippery-slope arguments against physician-assisted suicide or euthanasia. Remarkably, the views of Israeli Holocaust survivors regarding euthanasia (which only played a minor role in the legislation) are opposed to those of German professionals [39]. They argue that there are significant differences between the Nazis' involuntary "euthanasia" programmes and physician-assisted suicide in accordance with a patient's will. Cultural factors such as religion and the experience of the Holocaust also influence the attitudes of healthcare professionals [40] and the role of patient-support groups [41].
In order to explore lay perceptions on EOL decision making, we conducted twelve focus groups (FGs) with religious (Jewish/Christian) and non-religious persons (personally affected and non-affected) in the United States (California), Germany, and Israel between 2010 and 2012. FGs are moderated group discussions with 6–10 participants. They are an established tool in qualitative research to explore common arguments and public topoi on a general level [42, 43]. The participants in our FGs were recruited by posters, flyers, and information sheets outlining the central aims and methods of the study and distributed in different public places. All interested persons responded voluntarily by submitting a flyer with their basic socio-demographic data and contact information. IRB approval had been obtained in advance from the Jewish Home San Francisco as well as San Francisco State University for the US groups, the University Medical Centre Göttingen for the German groups, and Ben-Gurion University for the Israeli groups.
Participants in the FGs were selected to reflect different contexts with regard to being affected and socio-economic background. "Being affected" was defined as having personal experience with EOL decision making, either due to own decisions or caring for a terminally ill friend or relative (compared to "non-affected" persons who had no such personal experience) [44]. In the US, two groups consisted of residents of the Jewish Home San Francisco and two of volunteers at the same facility. Participants in all US-groups identified as Jewish, but only roughly half of them as religious. The volunteers had primarily professional experiences with terminal care. In Germany and Israel, one non-affected group was composed of participants identifying as religious and the other of participants identifying as secular. The participants in the religious groups identified as Christian in Germany and as Jewish in Israel. Ultra-orthodox Jews were not represented in the Israeli sample. The participants in our FGs were by no means regarded as representative of the overall populations of the US, Germany, or Israel. Rather, we used the sample to explore how being religious or not interacts with other factors such as legal frameworks and historical backgrounds. For example, we were interested whether participants identifying as religious would refer to national policies or arguments of religious authorities in the respective public debates.
All FGs lasted between one and two hours. A semi-structured questionnaire with similar scenarios and questions was used. The discussions were audio recorded and transcribed. The German and Israeli FGs were translated into English to facilitate analysis. All material was pseudonymised using a number/letter code and later anonymized for publication (speakers are identified as M = male; F = female, as rel = religious, sec = secular, and as living in US = USA; GE = Germany, IL = Israel). Transcripts were coded using Atlas.ti software and analysed thematically in order to identify discursive themes and main lines of argument recurring within and across the groups [45, 46]. The focus was on moral perspectives on ADs, physician-assisted suicide, euthanasia, withholding and withdrawing life-sustaining treatment, and political regulation of EOL decision making [26]. To juxtapose lay moralities and the expert discourses, topics emerging through inductive coding were compared with the general categories of the bioethical discourse collected from analyses of public policies and expert committee statements [18, 28]. This helped to examine whether and how common ethical principles were embedded in public opinions and how they differed with regard to cultural factors in the context of EOL decision making.
The FGs had between 5 and 9 participants, with 82 participants (29 male and 53 female) in total, 23 in the US, 29 in Germany, and 30 in Israel. Participants were between 20 and over 90 years old. Their educational backgrounds differed, but the self-recruitment led to a slightly higher proportion of persons with an academic education.
A central topic of concern throughout all group discussions in all three countries was the meaning, scope, and limits of individual autonomy in EOL decision making. At the same time, however, autonomy was interpreted in different ways and different arguments were brought forward in favour of or against autonomous decision making in the different FGs, depending on varying situational aspects and socio-cultural contexts. The subsequent sections explore these similarities and differences with regard to ADs, termination of life-sustaining treatment and euthanasia, as well as the role of the state in EOL.
A) Advance directives and planning EOL decisions
Participants in the German and the US FGs showed a rather strong tendency to emphasize the relevance of individual autonomy in EOL decision making, especially regarding the validity and binding character of ADs. In the corresponding discussions, different intellectual traditions of conceptualizing autonomy seemed to come into play. Thus, in line with a Kantian understanding of autonomy, a person's will as put down in an AD was often considered as strictly "sacrosanct" (M-rel US), her right to self-determination as a matter of fundamental human dignity. At the same time, however, autonomous decisions did not necessarily have to be rational, but rather free from external interference in the sense of Anglo-American liberalism. In this vein, an individual's autonomous decision was, for example, supposed to trump all familial and professional reservations. Thus, combining both aspects, many speakers were convinced
that the will of the patient should be determining, regardless what the doctors say; regardless what the relatives say. The patient has decided that when he was still healthy and of sound mind. One would go over his head and act against his will if one would do something else than what he has written down. And I believe that this is part of the dignity of the human person, and of the […] self-determination of humans, that he can decide what he wants (F-sec GE).
Furthermore, especially in the German FGs, many speakers expressed the conviction that there is not only a right, but actually a moral responsibility towards one's next of kin or attending physicians to hold an AD. Individuals were expected to take care of their own EOL matters, that is, to make up their mind, come to a clear decision, and finally complete "a precise document" in order not to "burden another person with this responsibility" (F-sec GE) of making serious proxy decisions regarding other people's life and death.
The Israeli groups, by comparison, were much more reluctant and ambivalent in this regard. Participants frequently suggested that the application of ADs has to be coordinated with other formal requirements including a restriction of the options that can be chosen. However, there were additional differences underlying this "Israeli" stance. Secular speakers mainly discussed the tension between individual self-determination and moral responsibilities towards others, e.g., relatives or attending physicians. The latter should not be burdened with executing problematic directives, especially if they have lethal consequences. The religious speakers, on the other hand, also pointed out further preconditions and limitations of individual self-determination, such as divine will, creation, and the natural order of things:
Many religious people believe that the time of death is written – that God knows when death will occur, and humans shouldn't interfere. If that is true, how can anyone know when medical life support is appropriate, or when it merely prolongs dying? It is futile to man, but on the other hand – we are not the ones to do the work of nature, it would be taking a role that is conflicting with the creation and nature. (M-rel IL)
In contrast to the secular speakers, many religious participants saw "a great difference" (F-rel GE) between withholding and withdrawing medical treatment when it comes to ADs. The underlying intuition seemed to be that a purely consequentialist, outcome-oriented moral perspective ignores that it makes "a major difference if I omit something, or if I act directly" (F-rel GE). Especially the Israeli religious participants were practically unanimous in this respect. In consequence, they frequently contested the validity of ADs if these demanded a withdrawal of life support. Such demand was considered illegitimate and repeatedly equated with "promoting suicide" or even killing:
I agree, the directives in this case are not binding for the doctors. Generally speaking […], nobody can determine the fate of another person. In this case particularly – disconnecting from life support machines is the same as killing. It is legally forbidden and it is prohibited by Judaism. (M-rel IL)
Our findings thus indicate a certain tension between a secular emphasis on individual autonomy and more comprehensive religious perspectives. Thus, while many secular participants defended autonomy in the sense of unhampered self-determination, religious participants often complemented and weighed individual self-determination with other aspects such as responsibility for others or respect for divine creation or natural law. Furthermore, the distinction between withholding and withdrawing treatment played a decisive role in this context. Interestingly, however, it did not seem to be exclusively linked to Judaism as could be expected against the backdrop of the corresponding Halakhic teachings. Thus, while the participants at the Jewish Home San Francisco unanimously rejected the idea that there is a morally significant difference between withholding and withdrawing, the other religious speakers, including the Christian ones in Germany, expressed the sense that this difference should be taken into account.
B) Termination of life-sustaining treatment and euthanasia
We also found a complex array of moral stances towards termination of life-sustaining treatment and euthanasia amongst our respondents. In line with a liberal understanding of autonomy, many participants in the German and US-groups applied the right to self-determination to include withholding or withdrawing life-sustaining treatment. In the groups of aged residents at the Jewish Home San Francisco, this attitude was also backed by a sense of urgency due to being personally affected:
I believe in … euthanasia. … I have had so much experience in my own family with death directly, uh, to the point of uh, holding my sister when she died, and feeling her life spirit leave her body, that my attitude has changed a great deal on that score. … I think it's very important even that the families change their attitudes and let people go (F-rel US).
By contrast, especially in the German groups, moral responsibilities towards other actors involved, such as relatives or medical professionals, were frequently weighed in and played out against individual self-determination. The underlying concern was that it is not legitimate to burden other persons with the responsibility of executing one's own dying wish:
But one must also consider who can be burdened with that. I think, well even if one could talk about it with someone, a relative: "I want this and this not so," but then one still has to stand up for this decision before the doctor: "Please turn the machine off, he shall die." This is indeed a heavy burden. To burden one person with all of that … (F-sec GE).
The Israeli FGs generally expressed strong reservations against euthanasia. Thus, especially the religious speakers were strictly opposed to euthanasia and – although to a lesser degree – also to termination of life-sustaining treatment. Theological doctrines and interpretations figured prominently as a basis for the arguments expressed. Thus, for many Jewish Israeli respondents, life is given and taken by God, so that human decisions and actions are not allowed to interfere:
According to Jewish religion it is forbidden to hasten death, that would be equivalent to murder, and allowing doctors to decide about hastening death can lead to incorrect decisions and recklessness bordering on murder. M-rel IL: Yes, I also agree with this prohibition … We have to let nature take its course. (M-rel IL)
It is important to note, though, that the opposition to euthanasia was not necessarily attributed to Jewish religion or theology in a narrow sense, but often also to a broader notion of Jewish cultural identity. Thus, the idea of ending life was repeatedly described as being alien to one's own cultural tradition and values, with one Israeli Jewish speaker finding it "actually quite curious" that "this concept never invaded Jewish thought, even though Jewish people suffered throughout history" (M-rel IL). This clear idea of a historical and cultural Jewish identity played an important role in the Israeli FGs. Thus, while the FG participants at the Jewish Home San Francisco articulated a rather lenient understanding of being Jewish – "you talk to … ten Jews and they probably have ten different ideas about that" (F-rel US) – the Israeli groups tended to formulate a much more compact, homogeneous conception:
As Jews, modern religious or otherwise, we should value life and respect our bodies. Furthermore, we have the responsibility to care for ourselves and seek medical treatment needed for our recovery-we owe that at least to ourselves, to our loved ones, and to God. (M-rel IL)
Interestingly, in the German groups, references to the country's Nazi past seemed to play a similar role. They created a presumed cultural identity which precluded overly liberal stances towards euthanasia. In this sense, the following speaker alluded to the historical Nazi "euthanasia"-programmes in a slightly embarrassed manner:
I believe if one is thinking now that they possibly continue to live disabled, then this is actually…That will pretty soon go into the direction of [laughs] Auschwitz. Well, this is what the Nazis wanted too. That is only healthy people and so on. Life is not this way. (F-sec GE)
Our participants' responses to the moral problem of euthanasia confirmed the impression that attitudes towards EOL decision making do not so much depend on a specific "culture" and "religion" as such, but on many different and interlaced factors. Thus, a general idea of individual autonomy played a major role for participants in both the US and German groups, religious or otherwise. This stance could be supported by the perspective of being personally affected through advanced age or ailing health. At the same time, however, the idea of responsibility for others, as well as lessons learnt from national history such as the Nazi euthanasia programme suggesting slippery slope effects, could act as a counterbalance against overly individualistic and liberalistic interpretations of autonomy as unrestricted personal self-determination. Once again, participants in the Israeli groups – religious as well as secular – drew a somewhat different picture with regard to euthanasia. But even there, opposition to euthanasia was not based on theological arguments alone (not even in the religious group), but rather on the cultural interpretation of Jewish identity as centring on a high valuation of life.
C) The role of the state regarding EOL
When it comes to the question how the state and political or legal regulations should deal with EOL decision making, rather clear-cut national differences emerged in the FGs. Thus, in the German groups, the state was mainly viewed as a neutral authority which should set general legal framework conditions, but stay out of concrete decision making processes regarding ADs or EOL situations. The state "should draw up a recommendation" but "must not exert pressure" (F-sec GE). Respecting highly individual decisions, e.g., regarding the format of ADs, was also expected:
Death is not a bureaucratic act, and neither is the way to it. And correspondingly, I would plead to keep the state as far as possible out of it. It can issue recommendations. It can lend a helping hand, especially with respect to such lists. …But otherwise it should stay out of it. Of course we want to make life easier for our doctors, but the patient comes first. (M-sec GER) It is ok for the state not to have a say. This is actually a condition. (M-sec GE)
In addition, the participants in the German FGs discussed the political regulation of EOL-issues in a European context. Thus, they compared the German setting to the situation in the Netherlands or Switzerland which have more permissive legal regulations regarding assisted suicide or euthanasia. Participants also discussed issues of euthanasia tourism and the different legal and juridical situation between the national and the European levels, addressing the complicated questions arising from transnational standardisation:
There is a woman, who … was in a condition that she could not react or decide anymore. There existed an advance directive, but the husband did not want to switch off. He wanted that she will be helped and is given a certain medication. … And this was not possible in Germany. … Now he travelled with her to Switzerland where she, so to say, was put to sleep. And now he sued at the Federal Court of Justice, which has dismissed the suit, but the European Court of Justice has accepted it. Now it will be decided, if the doctors acted here wrongly in refusing this euthanasia. (F-sec GE)
The Israeli FGs reserved a much more central role for the national state, albeit with completely different motives: The secular speakers put great trust in the state and its bodies (especially courts) as neutral, rational authorities which are above arbitrary individual preferences as well as partisan quarrels. The state "functions to maintain order and protect its citizens, and not leave it to the whims of everyone" (F-sec IL). It has the power to defend individual life and rights against majority pressure and religious influence and to enforce generally binding rules. In consequence, its impartial courts should decide in cases of conflict and doubt:
You need to consider all views and take into account all the contexts of a situation. Probably every one of those who are involved will have arguments that are very convincing. In the end who I think need to decide – it's the court because the court looks at things objectively – or at least that's what it should do. (F-sec IL)
The Israeli religious speakers, on the other hand, articulated the almost diametric view that the Israeli state indeed embodies a substantial religious stance. Many participants expressed a rather strong belief that state regulations regarding EOL decision making are legitimate since (and inasmuch as) they are actually in accordance with Jewish law (Halakha). Some participants were convinced that the national "law was made in agreement with the rabbis; otherwise it would not have become a law" (M-rel IL). This was perceived as a relieving reassurance that legally permissible decisions will also be morally irreproachable.
By contrast, the attitudes in the US FGs at the Jewish Home San Francisco showed much more reservation towards the state. Speakers repeatedly expressed the experience of being members of a religious or cultural minority in a political culture dominated by Christianity. The US was perceived as "primarily a Christian country" (F-rel US) which has also an impact on political regulations of EOL decision making "because here in the United States, we want to protect life, so much, that … you're going to have some difficulty…, especially when it comes to … suggesting changes" (F-sec US). Since the mainstream Christian culture was seen as influencing political decisions and legal regulations that affect one's own personal situation at the end of life, there was concern about ensuring individual autonomy and personal rights in EOL decision making among the Jewish Home residents:
That's just as important as how you end your life, having the right to end it. Unfortunately, we don't have that right. Not legally anyway. And sometimes I worry about that. Cause I live with a lot of pain that I manage, but what if I couldn't manage it? Would I be able to say I don't wanna live anymore please say goodbye, I wanna call my family? No! I don't have that right. That worries me, I wish I could go to Congress and change the laws. Or find a new Dr. Kevorkian to come into the world. [CHUCKLES] (F-sec US)
Maybe due to the experience of being marginalized in a predominantly Christian culture, there was a strong awareness of the cultural aspects and differences of attitudes towards EOL in the US groups. In Israel, the Jewish homeland, the strong nexus between religion and nationality could explain the support and trust expressed by many of the Israeli respondents toward the role of the state. By contrast, the US experience could have led to a sense of alienation from mainstream culture and the political governance of EOL. Indeed, this sense was sometimes articulated by way of grim sarcasm in view of the perceived perplexities and inconsistencies of the majority position:
I mean um, Christians live to go to Heaven, and why, why is there such a fear of death? When Terry Schiavo died that was a big political case here, that was what, that's what got me to do my first advance directive! And, as soon as she died, her brother went on the air, who was totally against pulling the tubes and said, "Well, she's in a better place now." […]: What's wrong with this picture?! Why wouldn't you let her go there, if she's in a better place? (F-rel US)
Discussion: taking culture and religion seriously
Our findings draw attention to the variety and complexity of cultural and religious aspects of EOL decision making. In contrast to stereotypical prejudices, e.g., about rational secularists and unthinking "religionists," moral reasoning among those identifying as religious often proved to be rather varied and nuanced. Narrow interpretations of individual autonomy in the sense of personal self-determination were complemented with and sometimes relativised by other aspects, such as responsibility for others, natural law, or divine will. Furthermore, purely consequentialist views levelling the moral relevance between withholding and withdrawing treatment were put in perspective.
At the same time, however, the group discussions indicate that there are usually no clear-cut positions anchored in "nationality," "culture," or even "religion"; rather, attitudes are personally decided on as part of a negotiated context representing the specific political, social, and existential situation of the individual. Although there is local consensus that goes beyond radical individualism, cultural specificities and differences in this field generally do not seem to be neatly matched with national cultures or religious denominations. Instead, the fundamental relevance of the specific situatedness of religious beliefs and cultural communities becomes visible: Their status and role in individual situations, for example, as consensual or conflicting on the level of personal perspectives, family relationships, and broader social contexts, e.g., as a majority or minority culture within a political system (Table 1).
Table 1 Synopsis of public attitudes in US, GE, and IL
Of course, the specific qualitative design of our study and the composition of the samples have limitations that need to be taken into account when interpreting the findings. Thus, we only conducted group discussions with secular, Jewish, and Christian persons in Germany, Israel, and the US (only in California). Moreover, there was a slight bias towards higher education which might have influenced the way EOL-issues were perceived and discussed. Finally, our sample is not symmetrical as it does not include Jewish persons in Germany or Christian persons in the USA or Israel. Further, more systematic empirical research will be needed in order to draw a richer and more differentiated picture of the respective influences of and interactions between the religious commitments and the national situatedness of participants. Moreover, similar studies including additional countries and denominations could help to explore whether laypeople from other national or religious backgrounds and in different sociocultural settings would express divergent perspectives on EOL, e.g., Muslims in the US, Israel, and Germany (for an Islamic theological perspective on EOL, see [23]).
Conclusions: towards a comparative empirical bioethics
On a practical ethical level, our findings suggest that there are good reasons for being suspicious of academic positions, professional stances, and practical guidelines that seek to derive persons' moral attitudes towards EOL mainly from their cultural or religious backgrounds. Cultural and religious perspectives seem to be far too complicated to predict individual preferences regarding limitation of care or euthanasia. As our findings show, this may not just be a pragmatic problem of dealing with complexity in the sense that we need more statistical information about additional factors potentially modifying cultural or religious convictions. Indeed, no statistical model, however complex, seems to do justice to the fundamental reflexivity of modern cultural and religious attitudes: the fact that people not just belong to certain cultural or religious communities, but frequently position themselves in relation to their respective commitments by interpreting, reviewing, modifying, or even abandoning them. In this sense, our speakers often explicitly articulate their own stances as "Christian" or "Jewish" while at the same time qualifying them with reference to particular authoritative traditions or cultural circumstances, e.g., as a Jewish minority in a Christian majority culture. Thus, rather than going through great pains to develop elaborate decision making algorithms, our findings suggest that the conditions and standards of actual decision making need to be improved. One important way of doing so would be by strengthening the reflexive and communicative practice of completing ADs [47], as newer efforts of so called Advance Healthcare Planning conceptualize this rather as process than as a fixed document [48].
On a theoretical level, these findings can provide an important clue for a contemporary bioethics that is willing to engage seriously with cultural and religious diversity. It suggests that the discipline has to be informed by adequate theoretical conceptions and empirical insights. In this sense, culturally informed bioethics should not rely on a do-it-yourself approach to culture, but systematically take into account the approaches and results of contemporary cultural theory. This can help to question essentialist and monolithic conceptions in discussions about EOL decision making. Furthermore, it facilitates the differentiation between various factors that play into "culture," as well as the analysis of their dynamic interaction and development, e.g., effects of migration, acculturation, collective history, family story, and individual biography [49, 50]. The same holds true in view of the religious dimension: In order to develop an adequate understanding of religion and avoid stereotyping, bioethical theory needs to include the perspectives and insights of religious studies. They can help to differentiate between diverging interpretations of religious sources like the Bible or the Halakha, and to distinguish authoritative theological positions from lived religious experience and practice influencing personal attitudes, e.g., in the context of cultural Judaism [51]. Hence, cooperation between bioethics and religious scholars can be fruitful when it comes to working out a more fine grained understanding of religious factors in bioethical decision making processes [52].
The theoretical implications of this study thus encourage bioethics to develop in a direction that can be called "comparative empirical bioethics" [53]. In contrast to the classical division between deductive and inductive approaches in bioethics, this approach uses both, narrative, empirically induced findings about moral experience as well as theoretically informed categories to understand and critically reflect moral attitudes. A major attempt is to understand, analyse, and reflect on "implicit" assumptions made in everyday life morality as well as in expert statements. This methodology helps to flesh out some parts of the "whole" picture, while others still remain vague and need to be examined. Here, we focused mainly on religion, but other studies might evidently focus on the empirical implications of ethnicity, gender, patient identity, or their intersection. This is exactly the kind of inductive uncertainty which makes empirical bioethics so difficult to embrace for a deductive approach, but also a necessary challenge to test theoretical pre-assumptions.
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Schicktanz S, Raz A, Shalev C. The Cultural Context of Patient Autonomy and Doctors' Duties: Passive Euthanasia and Advance Directives in Germany and Israel. Med Health Care Philos. 2010;13(4):363–9.
Schicktanz S, Schweda M, Wynne B. The Ethics of 'Public Understanding of Ethics' – Why and How Bioethics Expertise Should Include Public and Patients' Voices. Med Health Care Philos. 2012;15(2):129–39.
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Inthorn J, Schicktanz S, Rimon-Zarfaty N, Raz A. "What the Patient Wants…": Lay Attitudes towards End-of-life decisions in Germany and Israel. Med Health Care Philos. 2014;18(3):329–40.
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The authors would like to thank the Jewish Home San Francisco for permitting and facilitating our research, Marcus Chen, Lizdebeth Elizalde, and Nancy Retana for help with the preparation, implementation, and analysis of the US FGs, Dr. Nitzan Rimon-Zarfaty for organising the Israeli FGs, and Dr. Julia Inthorn for organising the German FGs.
The study was funded by the German-Israeli-Foundation (GIF), the German Ministry for Education and Research (BMBF) (Grant no. 01GP1004), the Humboldt-Foundation, and the German Academic Exchange Service (DAAD). The funding bodies did not have any influence on the design of the study, the collection, analysis, and interpretation of data, and the writing of the manuscript.
Availability of data and material
Access to original transcripts of FGs can be granted upon request.
MS made substantial contributions to the conception and design of the study and the acquisition and analysis as well as interpretation of data and has been involved in drafting the manuscript and revising it critically for important intellectual content; SS made substantial contributions to the conception and design of the study and the acquisition and analysis as well as interpretation of data and has been involved in drafting the manuscript and revising it critically for important intellectual content. AR made substantial contributions to the conception and design of the study, the analysis and interpretation of data and to drafting the manuscript and revising it critically for important intellectual content. AS made substantial contributions to the conception and design of the study, the analysis and interpretation of data and to drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript
Ethics approval was obtained from the Jewish Home San Francisco, San Francisco State University, Ben-Gurion University, and the University Medical Center Göttingen. Consent to participate was obtained from all FG participants.
Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Humboldtallee 36, 37073, Göttingen, Germany
Mark Schweda & Silke Schicktanz
Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Be'er-Sheva, 84105, Israel
Aviad Raz
Department of Philosophy, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA, 94132, USA
Anita Silvers
Mark Schweda
Silke Schicktanz
Correspondence to Silke Schicktanz.
Schweda, M., Schicktanz, S., Raz, A. et al. Beyond cultural stereotyping: views on end-of-life decision making among religious and secular persons in the USA, Germany, and Israel. BMC Med Ethics 18, 13 (2017). https://doi.org/10.1186/s12910-017-0170-4
Attitudes toward death


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What is Hypergryd?
The Challenges
The Objectives
The Impacts
Platform & Services
Collaboration with other projects
Live-In Labs
Publication & Results
Communication Materials
The HYPERGRYD consortium is composed of 19 partners from 7 countries: Spain, Italy, Sweden, Germany, Austria, Poland and Belgium. They conform an interdisciplinary group that brings together methodology, know-how and expertise.
Project partners have been chosen to form a well-balanced and complementary set of research organisations (RTOs) and innovation focused SMEs to enable breakthroughs to the system and its key technologies.
ARCbcn
Project Coordinator and WP1 Leader ARCbcn is an energy engineering company aimed at the design of technical systems developed in various branches of engineering and consulting. Founded upon strong expertise in technical installations, energy efficiency measures and BIM, ARCbcn is now committed to strengthen its presence in the energy digitalisation domain.
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Leading Communication and Dissemination activities. Communication Manager Comet Global Innovation is a private entity specialized in the field of technological innovation based in Barcelona, Spain. One of Comet's main missions is to drive European R&D achievements to effective commercialization, including both public and private sector funded initiatives. Comet is led by a team of highly qualified experts in their areas of expertise, with more than 25 years of experience in the development of innovative research projects aimed at achieving sustainable objectives.
WP3 Leader and Technical Coordinator. Development of demand response, data-driven prediction and optimization methods for 4th-5th DHC with buildings, and control techniques driven by IoT for LEC-integrated DHC energy systems KTH Royal Institute of Technology in Stockholm has grown to become one of Europe's leading technical and engineering universities, as well as a key centre of intellectual talent and innovation. We are Sweden's largest technical research and learning institution and home to students, researchers and faculty from around the world. Our research and education covers a wide area including natural sciences and all branches of engineering, as well as architecture, industrial management, urban planning, history and philosophy.
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WP2 Leader. Design of sorption storage module; Thermochemical storage integration, thermal-electric grid simulation and interaction CNR ITAE is part of National Council of Research of Italy. Core focus of research carried out is energy technologies related to thermal/electric energy storage, utilization and conversion, integration of renewables in energy systems and hydrogen production, storage and utilization.
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Sorption Technologies
Manufacturing of thermochemical storage module and control system Sorption Technologies develops, manufactures and sells adsorption chillers. Furthermore, we are involved in R&D projects on advanced applications of adsorption technology, such as heat & cold storage, dehumidification and desalination. The company is head-quartered in Freiburg, Germany and has an R&D and Sales Center in Rovereto, Italy and a production facility in Zywiec, Poland.
Design of the heat pump with PCM storage and load simulation The AIT Austrian Institute of Technology takes a leading position in the Austrian innovation system and a key role in Europe as the RTO focusing on the key infrastructure topics of the future. AIT provides research and technological development to realize basic innovations for the next generation of infrastructure related technologies in the fields of Energy, Low-Emission Transport, Health & Bioresources, Digital Safety & Security, Vision, Automation & Control and Technology Experience. These technological research areas are supplemented by the competence in the area of Innovation Systems & Policy. As a national and international network node at the interface of science and industry AIT enables innovation through its scientific-technological expertise, market experience, tight customer relationships and high quality research infrastructure.
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RANOTOR
Development and delivery of a prototype of a CHP unit with small-scale steam power engine, including the control system Ranotor AB was founded by the former project leader of SAABS steam engine for vehicles. We have carried out comprehensive studies regarding waste heat recovering with automotive industry and now we have customers that want us to use biofuel, solar thermal and other fuels such as hydrogen and ammonia. We have conducted comprehensive research on technology for small-scale steam power emboddied as a modern steam engine. We have also built a detailed software tool to simulate the piston engine in terms of leakage, heat and friction losses based in heat transfer, fluid mechanics and mechanical issues.
Güssing Energy Technologies
Data collection from DHN providers, development of the exergoeconomic optimization tool and modelling Güssing Energy Technologies is a non-profit R&D institute, based in the south-east part of Austria. Our focus is on Renewable Energy, especially district heating up to the 5th generation.
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WP4 Leader. Development of the HYPERGRYD PaaS based on BIM-GIS models and integration of other tools/services as well as heterogeneous data/information through an ICT environment and open APIs. Visualization tools IDP is a global and multi-sector technical services company, founded in 1998 , working in the fields of engineering , environment , architecture and ICT. IDP has offices in Spain, Peru, and Chile.
ENCOORD
Development of the large-scale multi-physics modelling tool (grid simulation) and management of virtual demonstrators Encoord provides software tools to plan today's energy systems and their transition to a decarbonized future. Our core technology is SAInt, a planning software to model coupled energy networks & markets. Our offices are located in Denver, CO, USA and in Essen, Germany.
Grid Singularity
Development of the distributed heat pump and district heating features and interaction with smart DER algorithms for its digital twin platform, Grid Singularity Exchange, to simulate and operate local energy trading for coupled networksGrid Singularity is an awarded, open source energy technology startup, developing the Grid Singularity Exchange to simulate and operate grid-aware local energy markets, and a co-founder of Energy Web Foundation . Our mission is to build a sustainable, inclusive and democratic energy market that facilitates ultimate degrees of freedom for the individual and the energy communities, allowing you to consume, trade or share energy based on your preferences of an energy type, location source, price or trading partner.
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RINA-C
Design and regulatory framework and integration in local energy communities. Impact analysis of demonstration (LCA, LCC, S-LCA) RINA is a global corporation that provides services across the Energy, Marine, Certification, Transport & Infrastructure and Industry sectors through a global network of 200 offices in 70 countries. As the engineering consultancy division of RINA, RINA Consulting provides a wide range of services covering the whole project life cycle from feasibility and specialized technical studies to conceptual and detailed design, prototyping and testing, project management, site engineering as well as operation and maintenance management.
R2M
WP7 Leader and Innovation Manager. Exploitation leader, IPR management and market development. Support to dissemination R2M Solution srl. is an integrated and multi-disciplinary entrepreneurial innovation company that aggressively targets filling the gap between research activities and market implementation across the fields of Innovation, Engineering, Energy Services & Sustainability and ICT/Automation. R2M is a strategic innovator itself and as part of its business model helps organizations and projects plan and execute the strategic use research funding carried out over a comprehensive development strategy from idea to market. In doing so, R2M provides leadership, links high performance exploitation-oriented networks, and leverages public and private funding instruments.
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ENVIPARK
Italian Live-in Lab to test ENCO tool. Contribution to Stakeholder Engagement during demonstration Environment Park is Turin's Technology Park. Built in the 1990s applying green building technologies and sustainable architecture principles, the Park hosts 70 tenants companies (about 600 people), research infrastructures and communal areas for a total of 30000sqm. ENVIPARK owns and manages the site, including the energy grids. The site hosts a mini hydro turbine (450 kWe power and annual electricity production of 1700 MWh) and a small PV plant (peak power 16,7 kWp e annual electricity production of 13 MWh) and is connected to the urban District Heating. ENVIPARK is interested in better balancing its energy requirements with availability whilst ensuring maximum comfort and satisfaction of its tenants and minimising costs.
OCHSNER
Development and manufacturing of modular and cascadable heat pump OCHSNER Wärmepumpen GmbH has built up a reputation as a technology leader in the heat pump sector thanks to its outstanding technical achievements and innovations. The company's vision is to use sustainable energy to contribute to solving the challenges of our future global energy needs and of climate change. OCHSNER offers a complete range of products for all heat sources, as well as for heating, cooling and domestic hot water heating in the heating output range from 2 kW to 2.5 MW.
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EURAC Research
Support in the development of the CHP unit serving for both heating provision and service to the electric grid. Testing of RANO prototype CHP unit and integration of technologies. Italian Live-in Lab Eurac Research is a private research center founded in 1992 in Bolzano/Bozen(South Tyrol). Our research addresses the greatest challenges facing us in the future: health, energy, well-functioning political and social systems and an intact environment
IMP-PAN
WP5 Leader. Particular support in the demonstration of the HYPERGRYD platform. Polish Live-in Lab to test integrated hardware solutions Institute of Fluid-Flow Machinery Polish Academy of Sciences conducts research in the area of design, construction and development of machinery for energy conversion in flows. The investigations are being carried out in the fields: machine and fluid mechanics, multiphase flows, thermodynamics and diagnostics of machinery. Activities in KEZO Research Center (IMP-PAN's advanced off-site research facility and a Living Lab) are focused on: energy transition planning, energy management, RES and energy storage technologies integration in smart energy systems and the implementation of clean transport
Sonnenplatz Großschönau
Austrian Live-in Lab, where HYPERGRYD ICT tools will be tested. Contribution to Stakeholder Engagement Sonnenplatz Großschönau GmbH has set itself the goal to broadly disseminate information about alternative energy systems, energy efficiency, sustainability, preservation of resources, energy efficient building and reconstruction, as well as healthy and comfortable living. Its permanent exhibition SONNENWELT is reaching about 20.000 people every year. Sonnenplatz is arranging excursions, seminars and trainings to these topics. The company has successfully completed various national and international projects in the broad field of energy efficiency (including smart grids, intelligent metering of buildings, educational measures and others). Within the framework of its existing activities Sonnenplatz established a wide network of research, development and technological partners active in the field of energy efficient building, smart living, IoT, and smart grids.
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Contribution to communication, dissemination and exploitation activities EIM ASBL (The European Innovation Marketplace) is an Association sans but lucratif providing s a wide range of non-profit research, innovation, tech transfer and advisory supporting services to private companies as well as to public and institutional organisations in Energy, Infrastructure, ICT, Transport and automotive, circular economy (covering water and waste management), consumer goods (including FCG) and Industry 4,0 fields.
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This project has received funding from the European Union's H2020 programme under Grant Agreement No. 101036656
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A list of Citizendium articles, and planned articles, about Reflux (distillation).
See also changes related to Reflux (distillation), or pages that link to Reflux (distillation) or to this page or whose text contains "Reflux (distillation)".
This page was last modified 03:10, 11 March 2011.


The School of Global Environmental Sustainability is hosting a panel discussion Oct. 10 on CRISPR, a technology that could lead to the next generation of genetically engineered products. The event will run from 5 – 6:30 pm at Avogadro's Number.
Known for its simplicity and ease of use, CRISPR — which stands for Clustered Regularly Interspaced Short Palindromic Repeats — promises to provide an accurate and cheap means of transforming agriculture to meet the growing food demands of the future. CRISPR is a genome editing technique that is used in a wide variety of fields and is currently most prevalent in bio-agriculture.
Unlike the current understanding around genetically modified organisms, which inserts foreign genes into DNA sequences, CRISPR technology cuts out genes and splices in new ones with the purpose of treating for genetic diseases. This editing of an organism's natural genome comes with questions regarding the security, safety and ethical risks to the environmental system.
Will this technology be critical for making crops and other ecosystems better equipped to handle heat, drought, and disease, or will it pave a path toward "designer babies" and "gene drives"?
The discussion will be moderated by Gene Kelly, faculty research liaison at the School of Global Environmental Sustainability, deputy director of the Agricultural Experiment Station and associate dean of Extension.
The panel discussion, part of a Managing the Planet series, is free of charge and open to the public. Visit sustainability.colostate.edu for more information about the School of Global Environmental Sustainability.
Avogadro's Number is located at 605 S. Mason Street in Fort Collins.


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Q: Azure KeyVault: how to retrieve clientId, clientSecret and the tenantId for an existing Service Principal? The cloud engineer in my organization has set up an Azure KeyVault and a Service Principal. I know the id of this Service Principal, but I also need clientId, clientSecret, and tenantId.
The documentation shows that these variables are exposed to you when you create a Service Principal using Azure CLI, but in my case, there is one already. I don't have the credentials to create a new one, and frankly speaking, I don't need to.
So, how can I retrieve the clientId, clientSecret, and tenantId associated with the existing Service Principal?

A: You can get the Service Principal's Client Id and Tenant Id using CLI command like below:
az ad sp list --query "[].{id:appId, tenant:appOwnerTenantId}"

You can even get many more values of the Service Principals - refer to ServicePrincipalInner class.
Further, as mentioned in the comments, you cannot retrieve the Client Secret created by somebody else. You will have to reset it:
az ad sp credential reset --name APP_ID

redpajama_set_name: RedPajamaStackExchange