Inapplicability of advance directives in a paternalistic setting: the case of a post-communist health system

<p>Abstract</p> <p>Background</p> <p>The Albanian medical system and Albanian health legislation have adopted a paternalistic position with regard to individual decision making. This reflects the practices of a not-so-remote past when state-run facilities and a totalitarian philosophy of medical care were politically imposed. Because of this history, advance directives concerning treatment refusal and do-not-resuscitate decisions are still extremely uncommon in Albania. Medical teams cannot abstain from intervening even when the patient explicitly and repeatedly solicits therapeutic abstinence. The Albanian law on health care has no provisions regarding limits or withdrawal of treatment. This restricts the individual's healthcare choices.</p> <p>Discussion</p> <p>The question of <it>'medically futile' </it>interventions and pointless life-prolonging treatment has been discussed by several authors. Dutch physicians call such interventions '<it>medisch zinloos</it>' (<it>senseless</it>), and the Netherlands, as one of the first states to legislate on end-of-life situations, actually regulates such issues through appropriate laws. In contrast, leaving an 'advance directive' is not a viable option for Albanian ailing individuals of advanced age. Verbal requests are provided during periods of mental competence, but unfortunately such instructions are rarely taken seriously, and none of them has ever been upheld in a legal or other official forum.</p> <p>Summary</p> <p>End-of-life decisions, treatment refusal and do-not-resuscitate policies are hazardous options in Albania, from the legal point of view. Complying with them involves significant risk on the part of the physician. Culturally, the application of such instructions is influenced from a mixture of religious beliefs, death coping-behaviors and an immense confusion concerning the role of proxies as decision-makers. Nevertheless, Albanian tradition is familiar with the notion of '<it>amanet</it>', a sort of living will that mainly deals the property and inheritance issues. Such living wills, verbally transmitted, may in certain cases include advance directives regarding end-of-life decisions of the patient including refusal or termination of futile medical treatments. Since these living wills are never formally and legally validated, their application is impossible and treatment refusal remains still non practicable. Tricks to avoid institutional treatment under desperate conditions are used, aiming to provide legal coverage for medical teams and relatives that in extreme situations comply with the advice of withholding senseless treatment.</p

Communism and the Meaning of Social Memory: Towards a Critical-Interpretive Approach

This article was published in the journal, Integrative Psychological and Behavioral Science [© Springer Verlag] and the definitive version is available at: http://dx.doi.org/10.1007/s12124-012-9207-xUsing a case study of representations of communism in Romania, the paper offers a sketch of a critical-interpretive approach for exploring and engaging with the social memory of communism. When one considers the various contemporary appraisals, responses to and positions towards the communist period one identifies and one is obliged to deal with a series of personal and collective moral/political quandaries. In their attempt to bring about historical justice, political elites create a world that conforms more to their needs and desires than to the diversity of meanings of communism, experiences and dilemmas of lay people. This paper argues that one needs to study formal aspects of social memory as well as "lived", often conflicting, attitudinal and mnemonic stances and interpretive frameworks. One needs to strive to find the meaning of the social memory of communism in the sometimes contradictory, paradoxical attitudes and meanings that members of society communicate, endorse and debate. Many of the ethical quandaries and dilemmas of collective memory and recent history can be better understood by describing the discursive and sociocultural processes of meaning-making and meaning-interpretation carried out by members of a polity

Communism in retrospect: The rhetoric of historical representation and writing the collective memory of recent past

This article was published in the journal, Memory Studies [Sage © The Author] and the definitive version is available at: http://dx.doi.org/10.1177/1750698011434042Using a case study of official representation of communism in Romania, this article addresses the rhetoric of historical representation and some of the ways in which the collective memory of communism is managed in the context of how post-communist democracies reckon with former regimes. It specifically centres on the public accomplishment of coming to terms with the past in the ‘Tisma˘neanu Report’ condemning communism in Romania. Using an ethnomethodologically inspired critical analysis, the article examines how the report and texts supporting it address the issue of how to take the communist era into public consciousness. The shaping of a specific representation of communism and the making of political-moral judgments in the report is legitimated by (1) treating communism as a category of the macro-social and textually mediated reality, (2) constructing the need for a scientific approach, and (3) conceiving communism as Other, alien to national identity and national interest. General implications for the substance and meaningfulness of coming to terms with recent history are discussed