Cat in the Rain Essay

In his frictional story, â€Å"Cat in the Rain,† Ernest Hemingway sets the scene for his fiction in a hotel room in Italy on a rainy day. On the first reading of this short story it can be easily interpreted as a wife nagging her husband, who is lying in bed preoccupied reading a book. The young married American’s being in a foreign country on business or pleasure, (Hemingway does not say) one would expect that the expression of love would be more prominent even more so on a rainy day, however, this is not evident in Hemingway’s story. What Hemingway does illustrate is how an â€Å"American wife† feels starved for attention and love in her failing marriage. He uses a cat as a symbol of compassion an affection to express the woman’s need for these emotions. Her frustration with her husband, whom does not readily allow her to physically share these feelings with him, also becomes very evident in the story. Hemingway uses the heavy rains as a tool to confine the American couple to their room, thereby, allowing him to display the interaction between the couple and further demonstrate their deteriorating marriage. In the story, the â€Å"American girl† sees the cat through her window â€Å"crouched under one of the dripping green tables,† and immediately feels the need to rescue it. Here is where Hemingway begins to use symbols to express the girl’s determination to save her faltering marriage. He shows the girl’s eagerness to go through the heavy rains to save the cat. The cat represents what she wants in her marriage, affection and compassion, and the rain signifies In his frictional story, â€Å"Cat in the Rain,† Ernest Hemingway sets the scene for his fiction in a hotel room in Italy on a rainy day. On the first reading of this short story it can be easily interpreted as a wife nagging her husband, who is lying in bed preoccupied reading a book. The young married American’s being in a foreign country on business or pleasure, (Hemingway does not say) one would expect that the expression of love would be more prominent even more so on a rainy day, however, this is not evident in Hemingway’s story. What Hemingway does illustrate is how an â€Å"American wife† feels starved for attention and love in her failing marriage. He uses a cat as a symbol of compassion an affection to express the woman’s need for these emotions. Her frustration with her husband, whom does not readily allow her to physically share these feelings with him, also becomes very evident in the story. Hemingway uses the heavy rains as a tool to confine the American couple to their room, thereby, allowing him to display the interaction between the couple and further demonstrate their deteriorating marriage. In the story, the â€Å"American girl† sees the cat through her window â€Å"crouched under one of the dripping green tables,† and immediately feels the need to rescue it. Here is where Hemingway begins to use symbols to express the girl’s determination to save her faltering marriage. He shows the girl’s eagerness to go through the heavy rains to save the cat. The cat represents what she wants in her marriage, affection and compassion, and the rain signifies the struggles she is willing to go through to better her marriage, even if it means getting wet in the process. The â€Å"American girl† believes this is a challenge she alone has to endure. Thus, when she announces that she is going to rescue the cat from the rain and her husband George offers to be the hero in the rescue attempt, even though it was a halfhearted offer, she quickly replies â€Å"No, I’ll get it. With the help of the maid she goes through the rain in search of the cat but when she gets to where she saw it last it has disappeared. The â€Å"American wife† becomes even more irritated with herself and her husband when she returns to the room empty handed. She desperately wanted the cat, â€Å"I wanted it so much,† but more so, she wanted change in her marriage and change in her appearance. She was tired of her boyish look and felt she needed to be more feminine, â€Å"I get so tired of looking like a boy. However, George was contented with how things were. He barley even shifted from his book when she began scrutinizing her appearance. The only comment of support he could offer was, â€Å"You look pretty darn nice,† but she required more for herself. The cat, even though symbolic, would have allowed her to express her feelings of affection and compassion, â€Å"I want to have a kitty to sit on my lap and purr when I stroke her. † George, being insensitive to her needs, did not even offer himself as an outlet for her emotions. Instead his remark to her was, â€Å"Oh, shut up and get something to read,† as she continued to utter her discomforts in her appearance and her femininity. Hemingway’s fictional story does have a surprising ending when the maid brings the â€Å"American wife† a â€Å"big tortoise-shell cat†. The â€Å"American wife† receives what she wanted, an outlet to express her affections and compassions, but in fact, it would not help her marriage. The cat was just a symbol of what she wanted from her husband, George. Unless she can convince him to be more open with her and more lovingly expressive with her, her marriage will still falter.

Deconstructing redemption in The Road

â€Å"There Is no God and we are his prophets†: Deconstructing Redemption In Corm McCarthy The Road. (paper under review: not for quotation) Stefan Skirmisher The University of Manchester Stefan. [email  protected] AC. UK 09/09/09 Abstract Despite its overwhelmingly positive reception, the apparently redemptive conclusion to Corm McCarthy The Road attracted criticism from some reviewers. They read in it an inconsistency with the nihilism that otherwise pervades the novel, as well as McCarthy other works.But what are they referring to when they Interpret redemption', the ‘messianic' and ‘God' In McCarthy novel? Some Introductory thoughts from apocalypse theory and deconstruction reveal a more nuanced approach that not only ‘saves' McCarthy from the charge of such critics. It also opens up more interesting avenues for exploring the theme of redemption and the messianic in contemporary disaster fiction. Introduction Justifiably effusive praise was heaped, by t he literary community, upon McCarthy multiple award-winner The Road (2006).But perhaps the most interesting reaction came in the form of critique of the allegedly â€Å"redemptive† and â€Å"messianic† tone of Its conclusion. Michael Cabochon's celebrated review of the book argued that McCarthy appeared to insert such a tone â€Å"almost†¦ In spite of himself',l that is, out of character with his usual nihilism. Another reviewer went as far as to suggest the novel â€Å"failed† the â€Å"modernist challenge: to write about a holocaust, about the end of everything†¦ What happens Is a redemption, of sorts, arguably absurd In the face of such overwhelming nihilism. 2 One wonders how McCarthy himself would respond. Perhaps we should begin by recalling the cautionary and prophetic injunction that Nietzsche appended to one of his last works, Ace Homo: â€Å"l have a terrible fear I shall nee day be pronounced holy: one will guess why I bring out this book beforehand; it is Intended to prevent people from making mischief of me†¦ My truth Is dreadful: for hitherto the Ill has been called truth. â€Å"3 Nietzsche feared the untimely nature of the truth he came to announce to a modernity whose ‘end' had only just begun.He predicted the unpreserved of us â€Å"murderers of God† to stand up in the ruins of the transcendent â€Å"old God† of metaphysics, and an unwillingness to create our own tragic pursuit of life. God, he would later write, would simply refuse die; the task of modern man was therefore to kill him again and again. He difficult and paradoxical redemption offered in The Road is very far from resurrecting the old God of metaphysics. Indeed, I would like to argue in the following that it interweaves themes both of resistance (the refusal to die) and mourning (the passing of irreversible loss).In doing so, the novel powerfully engages the reader with the very porous nature of redemption in the context of its post-apocalyptic environment. Engaging McCarthy text in this way invites a Adrienne, deconstructive reading of the narrative of redemption in contemporary disaster fiction in general. This is cause the conversations and thought-experiments employed by McCarthy attempt in many different ways to destabilize and provoke questions of the binary oppositions involved in that very discussion of redemptive ends (indeed, of the possibility of conceiving ‘ends' at all).There are oppositions such as the saved and the damned, the lost and the retrievable; the redeemed and irredeemable futures. McCarthy provokes the question, in particular, of what meaning we might possibly attach to human redemption and the â€Å"messianic† in an ostensibly irredeemable earth. What can be hoped for, sustained, and believed in? On the one hand, therefore, McCarthy pursuit of life and lives in the scorched wasteland bears all the hallmarks of Nietzsche tragedy – the â€Å"taming of ho rror through art†4 -as opposed to a comic rendering of the apocalypse (in which the righteous are spared the calamities of the end).On the other hand, the ambiguous sense of the messianic in The Road hints at more than lyrical or existentialist responses to tragedy. By tracing McCarthy exploration of redemption alongside developments in the continental philosophy of religion, first in the form of ‘death of God theology, and second, that of indestructibility of the messianic, I hope to open up some exploratory questions about the ambiguity of redemption in this highly influential piece of contemporary fiction.Ends of The Road Michael Cabochon states that for authors attempting a move into the futuristic post- apocalypse genre, â€Å"it is an established fact that a preponderance of religious imagery or an avowed religious intent can go a long way toward mitigating the science- fictional taint. â€Å"5 And so Cabochon believes that, in McCarthy novel, the father â€Å"f eeds his son a story'. By constructing the creed or injunction to â€Å"carry the fire†, the story is infused with a â€Å"religious sense of mission† that, incarnate in the hope given to the life of the boy, â€Å"verges on the explicitly messianic†. We would do well to pause in front of the implications of this word â€Å"messianic†. Who is saved: the boy? The promise of human community? And who or what comes to save? The boys saviors at the end present a hesitant, and uncertain departure: the guarantee only that others like him are alive. The messianic here would appear to take the form as much as a threat as a promise. And yet, taken from the Hebrew term for ‘anointed one', the concept of messiah in Jewish and early Christian literature is indeed bound up closely with the apocalyptic social upheaval. Certain expressions of the messianic thus anticipate both destruction (of the old world) and rebirth (of the new). In Jewish rabbinic thought what is crucial for messianic belief is its relationship with history and historic experience. It is visionary hope in the present for the way things could be, whether these are simply restorative or utopian. 8 The tradition that emerges is subsequently one of the announcement of such a promise of the future through the voice of the prophets.Anticipating Jacques Deride, the concept of the messianic announcement is the voice of the fringe, the outside of sanctioned, homogeneous discourse: â€Å"a call, a promise of an independent future for what is to come, and which comes like every messiah in the shape of peace and Justice, a promise independent of religion, that is to say universal. â€Å"9 Whilst The Road carries its own utopian and dyspepsia prophets, however, redemption is nowhere conceived or expressed as the restoration of peace. Nor is it infused with any hope in the renewal of the earth, or even of the narrative of new beginnings for the scorched landscape.McCarthy relentlessl y refuses reassurance that any return to a golden age is possible. The novel is an exploration of the irreversible, of â€Å"things which could not be put back†. 10 In what, then, consist its alleged religiosity, its messianic expectation, or â€Å"greater The clues lie in the relationship formed between a salvation to come (framed in the metaphor of the road itself: Mimi need to keep going. You don't know what might be down the road†12) and the ambiguous sense of endings running throughout the book. The father's own life represents a refusal of the simplicity of endings.His son must not lay down and die. Or, more precisely, he may not die of his own choosing, before the Father has calculated death's permeability on his behalf. The terror of the novel is thus generated within the narrative context of this slipping away of the control over the appropriate end. The son knows neither how to die alone, nor, symbolically, the function of the pistol in his hands: (â€Å"l d on't know what to do, Papa. I don't know what to do. Where will you be? â€Å")13 In relation to a search for the messianic, we must seek the sense of redemption only within this disestablishing sense of time.The messianic takes on a perverse sort of tension between the desire for end as closure, and the refusal to end, as the resistance of death, and finality. The boys terror at the task asked of him (to kill himself) is not complicated. But this struggle between ends and beginnings in The Road also expresses the paradoxical nature of the post-apocalyptic genre in general. If we accept James Burger's account of post-apocalyptic narrative as concerned essentially with â€Å"aftermaths and remainders†, then we must also follow his conclusion that it is always oxymoron: â€Å"the End is never the end†. The modernist assumption, in Frank Sermon's celebrated study, has been that the â€Å"sense of an ending† is what gives our living â€Å"in the middies†1 5 narrative meaning. But post-apocalypse means the very unsettling of those temporal frames. It â€Å"impossibly straddles the boundary between before and after some event that has obliterated what went before yet defines what will come after. â€Å"16 Indeed, we can see the influence of this scatological tension – a concern to much modernist and postmodernist literary exploration of the nature and meaning of narrative closure.Paul Fiddles' wide ranging study of such explorations suggests that if there is a malaise in the writing of closure into contemporary fiction, it simply reflects the more general environment of â€Å"constant crisis†, replacing the sense of completion and fulfillment of history, in which we live. 17 Such a paradox also partly reflects The Road as a study of the refusal of endings, and e ipso a refusal of the redemption normally associated with the narrative end. For our fascination is drawn not to those who are destroyed, but to those who refuse to die.If McCarthy style emulates, as some critics suggest, the biblical language of Revelation, they can't have missed SST. John's vision, borrowed probably from Job, that during the scatological calamities, â€Å"people will long for death and not find it anywhere; they will want to die and death will evade them. â€Å"18 A comedic articulation of this craving crops up in the Backbitten character of Ely, echoing precisely the post-apocalyptic dilemma: Things will be better when everyone's gone. They will? Sure they will. Better for who? Everybody. Sure. We'll all be better off. We'll all breathe easier.That's good to know. Yes it is. When we're all gone at last then there'll be nobody here but death and his days are numbered too. He'll be out in the road there with nothing to do and nobody to do it. He'll say: Where did everybody go? And that's how it will be. What's wrong with that? 19 McCarthy is arguably concerned, like Becket, to explore the experience of the death of God as instant paradox. That is, as a source of the death of hope for some, but also of an absurd affirmation of life by others, condemning them to a life of scatological suspension – of waiting, but for what?Our encounter with the ‘post' of post-apocalypse is, then, immediately one with the challenge of making narrative and ethical sense of the life that remains, rather than he purely nihilist gratuitousness of a death that won't come. It is more akin to Albert Campus' Rebel, 20 charged with the task of making an ethics of action in the absurd condition, without resorting to a leap of faith that removed the lucid reality of the absurd itself. It is the life of Sisyphus, who has made his rock his entire â€Å"universe† of meaning. 1 All talk of redemption and the messianic must take seriously this simultaneous presence of both the ‘end' and the refusal, or undesirability, of endings. The question that emanates from The Road is perhaps this one: what does nee do, given the knowledge of a certainty of the collapse of life, which might make walking possible along the remainder of the Road? How can this search operate within the traumatic experiment of post-apocalypse, of the never-ending? Dermis's interest in the concept of ‘apocalyptic time'.For Deride can be argued to echo the refusal of the security of endings that I have suggested lies at the heart of The Road. Deride refuses the scatological language of triumphal historicist (particularly in reference to Fuchsia's ‘end of history thesis), invoking Hamlet's fearful dictum, â€Å"the time is out of Joint†22 To express this refusal. Similarly, McCarthy frames the experience of this time of the ‘remainder' not as the aftermath of the singular catastrophic event. Rather, it is the perpetuity of catastrophe itself: the uncertainty of relationships, ecology, and the possibility for human community.The thought experiment becomes one of a tortuously open future, the absenc e of referents for forging new values, new rules, and new duties. The novel thus plays on the post-apocalypse genre by creating a dissonance of temporal perspectives. Time has already run out and is yet, for the boy, opening out inexorably: nothing has really knishes. For the father, the character of the time that remains is defined by the anxiety not only of the limited time allotted to him (who is really dying) but of the dubious gift of extending the time allotted the son into the future – and who's death he will not be able to oversee.Through the tender and contradictory relationship of the father and son, then, the genre of post-apocalypse is turned on its head. We grapple not so much with the post-modern fragmentation of endless traumatic symptoms,23 but the juxtaposition of these two impossible positions in the dialogue of father and child. On the one hand there is a protection of and desire for the end: the father's desire to secure the least tortuous conclusion to hi s son's life.And on the other there is the need for a beginning: the son's overwhelming concern for who and what must lie beyond: who exists? What are they like? Who looks after them? Who will guarantee their safety in the future? Apocalyptic Time Death, or limit, is thus explored in The Road as a painful loss of control over time. This resistance to the consolation of narrative ends represents the most unique and creative aspect of McCarthy apocalyptic style. But what can we say about ‘apocalyptic' literature in general that may shed light on the ambiguity of McCarthy redemptive turn?Literary apocalypses, in Jewish and Christian interdepartmental literature, intentionally sought to trace the limits of communicable discourse. It did this, crucially, against the political traumas of history, in which an old world was thought to be dying and a new one arising, which would completely overturn reality. Through visionary events bestowed upon favored emissaries or recipients, heaven ly truth revealed, through apocalypses, the â€Å"place beyond the limits of language†25 to unanimity. What is the function of this type of limit-discourse?Implicit to all apocalypses there is an ethically loaded injunction that the truth of the world is not all that is visible or conceivable by human means. 26 At its root, then, apocalypse claims that a deeper destiny and purpose lies underneath, and is here, through text and vision, disclosed. Revealed. It is this aspect of the coding of Revelation that so attracts Dermis's attention in his celebrated essay, On a Newly Arisen Tone in Philosophy. Dermis's fascination is with the figure of John and the complex symbolism of the fragmented, yard messages of the future contained in his vision.There is, believes Deride, something primal to Western thought in John's act as the messenger, this role of being the favored dispatcher of revelation and denouncing the false' ones, the â€Å"impostor apostles†. 27 Is there an echo of this cryptic prophecy in McCarthy – for instance, the language of God who is both announced and yet uncontainable, even within the friendly woman's talk of the â€Å"breath of God† that â€Å"passes from man to man through all of If so, the crucial lesson for an apocalyptic reading of McCarthy would be that apocalypse guarantees no certainties about future realities.On the contrary, it would be to resist the â€Å"temptation† of one apocalyptic tone, and to hear instead apocalypse as an â€Å"unmistakable polytonally'. 29 There is, in a deconstructive reading, only a deeper fragmentation and disestablishing of meaning and truth. And this is precisely the concern of Dermis's critique of an ontological and ‘contemporaneous' reading of history. As Fiddles puts it, narrative can be deconstructionist in the sense that, like the book of Revelation, â€Å"[the] ending deconstructs itself, and so disperses meaning rather than [completes] it. 30 This same ins tability and impermanence of discourse is prevalent within the illegal between father and son in The Road. The meaning of words and the possibility of language itself becomes shorn of its social or ethical grounds. McCarthy even poses the problem as one of the absurdity of text in the post-apocalyptic future. From the referent-less discussion of metaphor â€Å"as the crow flies†31 (to the boy, who has never known the existence of birds) to the man's memory of pausing in the â€Å"charred ruins of some library' and experiencing absolute dislocation between the value of words and the burnt remains of â€Å"the world to come†. 2 An attempt to speak in a world where words and meanings are disappearing mirrors ruefully the attempt to invoke faith in a world in which God is increasingly absent. The God of The Road is the impossible presence, the one whose name is invoked (by the father, and by the woman at the end) but whose very existence would pose only problems, not solu tions. To Ely, the possibility of the persistence of god or gods is a fearful prospect and impedance to the task at hand (of surviving?Or dying? ): â€Å"Where men can't live gods fare no better. You'll see. It's better to be alone. â€Å"33 But the existential struggle facing both the father and Ely is precisely the realization that, in he very act of their survival, something unshakeable of the trace of God (in the book it moves from â€Å"word†, to â€Å"breath†, to â€Å"dream† in that order) is incarnate. This appears, admittedly, as a curse to Ely, whose survival the father finds incredible.The fate bestowed on any unlucky enough to carry on down the road is to carry the remainder, the aftermath of this ineffability and this absence: â€Å"There is no God and we are his prophets. â€Å"34 It is, finally, in reference to the knowledge and memory of dying that any talk of the possible meaning of redemption must orient itself: hence hat must the remaining humans carry on being humans? The man questions Ely on this point: â€Å"how would you know if you were the last man on earth? † to which Ely replies â€Å"It wouldn't make any difference. When you die it's the same as if everybody else did too. 35 The framing of post-apocalypse narrative in this context reiterates the centrality of the question of remainders, of those who might remain to remember and to hold the consciousness of humanity and the possibility of discourse (and therefore of God? ) in their very surviving. God is Dead (again) The reference to God, and God's potential for solving the conundrum of the meander (perhaps, wonders the man, â€Å"God would know' that you were the last on earth) is typically McCarthy. He is concerned mostly to problematic belief rather than to reject it or affirm it entirely through his characters.The fragmented quasi- theological discussions echo the brilliant, extended account of the preacher who does theological battle with a dyin g faith in The Crossing. 37 But, once again, a deeper examination of what sort of theistic faith such references might imply goes some way to answering those readers unhappy with McCarthy redemptive conclusions. Ells sat remark bears similarities to attempts made in the sass to articulate a faithful religious response to the existentialist current, through a â€Å"Death of God Theology'. Alongside Thomas J. J.Altimeter, The protestant theologian Paul Italics famously argued for the language of modern theology to acknowledge not only the ontological inadequacy of speaking of God's existence (since the essence of God is a Being â€Å"beyond Being†). Theology must also acknowledge the failure of human experience to allow this access in the first place. For many of these thinkers the ‘God of the theologians' had died on the battlefields of Europe during World War l. To thus define God in negative terms was not only a semantic step. It was to couch Thee-logos as the discour se of absence par excellence.And certainly through the eyes of the other religious existentialists (Aggregated, Bereave, Dostoevsky, Auber) the search for God was the reaffirmation of the absurd, its crucifixion in the mystery of human suffering, not its resolution. Another exemplar, the Catholic convert Simons Well, had expressed it through the figure of Mary Magdalene on Easter Saturday: one moves towards the tomb motivated by death, an expectation of the corpse, not an optimistic pop in life. It is human suffering that motivates our movement â€Å"towards reality', and the mystery in which God (through his absence) is to be found.Likewise, influenced heavily by Nietzsche, Italics described the true act of faith of the believer as one who does not attempt to square the existentialist crisis of despair but who has â€Å"the courage to look into the abyss of nonbinding in the complete loneliness of him who accepts the message that â€Å"God is dead†. 38 A difficult God to f ind, to be sure, since for Well, Italics and others, the problem of nihilism was not to be squared by the gift of faith. It was to be lived in the paradox of human suffering – in the seeking, not the finding, of an answer to suffering.Perhaps The Road shares some features of these attempts to grapple with the death of God. But it is only really with Dermis's exploration of the messianic and time that deconstruction, to repeat, attempts to go beyond philosophy and society's obsessions with talking of the ‘end' of thinking, metaphysics, God, politics, Marxism, etc. Deconstruction tries to counterbalance this fascination with definitive ends by announcing the end of a â€Å"electronic† crisis rhetoric itself. Deride thus highlights the err possibility of crisis discourse as the last form of meaning that one clings to, and whose loss signals a truly existential death.The true crisis is that there may no longer be a â€Å"philosophy of crisis† : â€Å"there is perhaps not even a ‘crisis of the present world'. In its turn in crisis, the concept of crisis would be the signature of a last symptom, the convulsive effort to save a World' that we no longer in habit: no more kiosks, economy, ecology, livable site in which we are ‘at home†. 39 One recalls, in the light of this, the discussion in The Road of the possibility of both knowing, and not owing, preparing, and not preparing, for the â€Å"event†, the brief glimpse of which holds an elusive taint of horror over the narrative.Ely confides in the man: I knew this was coming. You knew it was coming? Yeah. This or something like it. I always believed in it. Did you try to get ready for it? No. What would you do? I don't know. People were always getting ready for tomorrow. I didn't believe in that. Tomorrow wasn't getting ready for them. It didn't even know they were there. 40 This intervention into crisis thinking problematical the very status of event – its u ndesirability, its uncertain definitiveness. It mirrors Dermis's critique of an Aristotelian, favored presence of the â€Å"event† itself.Ultimately, such a critique leads to Dermis's ability to pose a distinctively Jewish opposition to this privileging of the event: namely, the reassertion of a certain messianic, a therefore mystical, mysterious return to a revelatory messianic. It is, however, a messianic â€Å"without messianic†; â€Å"stripped of everything†,41 or in other words unbounded by the specificity of this or that dogmatism, religion, and metaphysics of salvation. In deconstruction, then, we can no longer speak of the privilege of the ‘contemporary. 2 What does that concept imply in the context of McCarthy narrative?It opens out the analysis to the concept of redemption without the guarantee of the ‘event' that would guarantee salvation in the manner of the promises of institutional religion. Such a sentiment recalls the â€Å"iconoclas tic† reformulation of hope that was prevalent in post-war Jewish critical theory (particularly in Ernst Bloch). This meant a redemption without reference to the face of God; only the notion of promise itself. 43 Deride expresses a notion of the future as being not a future-present' but as something perpetually out of reach.It produces, like death, the effect of interminable non-occurrence, perhaps in the manner by which the â€Å"event† of The Road is announced: â€Å"The clocks stopped at 1 Time itself, like discourse, and like belief, is suspended; shorn of its referent. The messianic impulse that survives even a book binding to the commitment of expectation: more akin, once again, to the suffering of the waiting Vladimir and Estrogen. The apocalyptic element of The Road, then, might not be the announcement of some catastrophic event in time either in the past (since this is never dwelled upon) or the future.It is rather the revelation of traces, of remainders and re minders, of the God who might also be dying since he â€Å"fares no better† than men when men can't live. 45 The apocalyptic always appears with a hidden face, in the impossible or inconceivable encounter with the end of all things, of death itself. The consolation offered to the boy by his father is that he has always been â€Å"lucky'. 46 Beyond irony, the word â€Å"luck† seems shorn of its associations with providence, destiny, and blessedness, and more like an unhappy covenant: an unspoken agreement that the boy is bound to continue, to keep going.The continuation of life is a brute fact for the boy as much as for Ely (neither apparently aware what keeps them going). And yet the boy is very unlike Ely, not because of his innocence, but because of his temporal language. What will happen, he asks of his father, to the other boy? To the man they abandoned? To the people imprisoned in the house? The conundrum for Ely is otherwise, and framed in the time that was. Wha t has happened; did we see it coming? What were we thinking? Even if we did, how could we have been expected to choose?If there is redemption in The Road, perhaps all we can say of it is the ability o ask questions of the future, as opposed to only those of the past, of mourning that which cannot be put right. Redemption without redemption The ‘event' is indeed problematic for post-apocalypse. But it is problematic not simply because finality is put off indefinitely (as Berger claims). It is problematic for its revealing, or disclosing, our lack of control over its arrival. Apocalypse is temporal catastrophe: a disruption of our chronic desires, time we possess, can control.The future is certainly terrible, but it is agonizing particularly for our thorniness into its uncertainty. Redemption, then, if it is relevant at all, must be seen as the ability to imagine that what one sees now is not all that there is. In the book of Revelation calamities are predicted that meticulously symbolism the passing of apportioned periods of time according to divine order, not those of powers and principalities. 47 In The Road, however, the father is possessed by his responsibility to Judge the ‘right time' of his son's end, and so spare unbearable life.The crisis recalls Abraham's struggle with God's command to act out the unthinkable, here repeated in the Father's own self-doubt: â€Å"Can you do it? When the time comes? When the time comes there will be no time. Now is the time. Curse God and die. â€Å"48 One passes over it easily, but by the end of the novel, the father's command to his son to leave him occurs by way of an admission of weakness; an apology for entrusting life with him: â€Å"l can't hold my dead son in my arms. I thought I could but I can't†49.Is this the conclusion thought to give some sort of redemptive lift to the narrative – a â€Å"fog leaf† to the unacceptable narrative of total disaster? 50 1 would argue cynical pe rspective, rather than the consolingly messianic one. In this view the ether's committal of the son to the future is not performed out of faith in the persistence of goodness. His commitment is, more simply, in the inability to cease suffering, to cease walking along the road. The father's sense of an open future is not hard to grasp in itself: it is the only thing left to offer his son.Yet what is the most significant imaginative turn in what follows? I would argue that it is not that the boy subsequently finds fellow travelers we are to believe are also the good guys who are â€Å"carrying the fire†. Nor even is it that they, like the woman, are also those that cosines the persistence of the divine in the world. Rather, it is an admission by all characters of a disestablishing uncertainty about that road that lies ahead. It is there in the implied pause of the man's response to the boy at the end of the novel: â€Å"He looked at the sky. As if there were anything to be see n.Yeah, he said. I'm one of the good guys. † 51 There is no evidence in what precedes this moment that any place the new community will reach can support life. Nor, I think, are we meant to intuit such a turn towards the future. One cannot ignore, in any case, the terrifying allusions that lie underneath McCarthy choice of the word â€Å"fire†. Cabochon is quick to point this out: the new hope for human community are people â€Å"carrying fire in a world destroyed by fire†. 52 But we can go further than this, since the irony recalls the central theme of another classic of the post-apocalypse genre.In William Miller's A Canticle for Leibniz, the scattered survivors of global nuclear war attempt to construct the new civilization by destroying all forms of scientific knowledge. They do this on the premise that such knowledge will lead inexorably to the same situation of nuclear terror. A secluded community of monks become the last guardians of ancient knowledge, pre serving it for such a time that knowledge will once again be responsibly applied. But the fear is vindicated by the recapitulation of humanity to a second wave of nuclear apocalypse at the novel's horrifying conclusion.

Elwyn Company Essay

In the Elwyn Company, the relationship between output (Q) and the number of hours of skilled labor (S) and unskilled labor (U) is Q 300S 200U – 0.2S2 – 0.3U2 The hourly wage of skilled labor is 10, and the hourly wage of unskilled labor is 5. The firm can hire as much labor as it wants at these wage rates. Elwyns chief engineer recommends that the firm hire 400 hours of skilled labor and 100 hours of unskilled labor. Evaluate this recommendation. If the Elwyn Company decides to spend a total of 5,000 on skilled and unskilled labor, how many hours of each type of labor should it hire If the price of a unit of output is 10 (and does not vary with output), how many hours of unskilled labor should the company hire (Chapter 5 problem 1. see answer on webct assignment 2) The Smith Company made and sold 10,000 metal tables last year. When output was between 5,000 and 10,000 tables, its average variable cost was 24. In this output range, each table contributed 60 percent of its revenue to fixed costs and profits. What was the price per table If the Smith Company increases its price by 10 percent, how many tables will it have to sell next year to obtain the same profit as last year If the Smith Company increases its price by 10 percent, and if its average variable cost increases by 8 percent as a result of wage increases, how many tables will it have to sell next year to obtain the same profit as last year Chapter 6 problem 12. see answer on webct assignment 2) Raleigh Company is a monopolist, producing and selling the product with the demand curve P 30 – 6Q where P is price (in thousands of dollars) and Q is the firms output (in thousands of units). The firms total cost function is TC 14 3Q 3Q2 where TC is total cost (in millions of dollars) What is the firms marginal revenue (MR) and marginal cost (MC) At what level of output does the firm maximize its profit What is the profit maximizing price (P) of the firm Is the price higher than marginal cost (MC) What is the profit of the firm (Chapter 8 problem page 267) 4. James Pizzo is president of a firm that is the price leader in the industry that is, it sets the price and the other firms sell all they wa nt at that price. In other words, the other firms act as perfect competitors. The demand curve for the industrys product is P 300 – Q, where P is the price of the product, and Q is the total quantity demanded. The total amount supplied by the other firms is equal to Qr, where Qr 49P.

Regal Marine Essay Example | Topics and Well Written Essays - 500 words

Regal Marine - Essay Example The product life cycle has four stages: introduction, growth, maturity, and decline. During the introduction stage sales are low because there are few customers buying the product (Netmba, 2011). The product needs advertising in order to attract new customers. The profits during this stage are nonexistent due to the fact that expenses are high and sales are slow. Regal Marine losses money when new boats are introduced, but eventually if the products survives and stays in the market during its entire product life cycle the firm generates a profit from the model. The maximum amounts of profits are generated during the growth stage. The growth stage of the product life cycle is considered a period of rapid market acceptance and substantial profit improvement (Kotler, 2003). Regal Marine should produce a lot of units during this stage. Investments made in advertising during this stage have a high return. The third stage of the product life cycle is the maturity stage. Competition is high during this stage which causes sales to decline (Valuebasedmanagement, 2011).The firm should lower its advertising expenses during this stage because the product is well known. The final stage, declining, is a period of downward sales and eroding profits. At the end of the declining stage the boats model is taken off the market.

Impacts of Sarbanes-Oxley Act on UK Companies Essay

Impacts of Sarbanes-Oxley Act on UK Companies - Essay Example The law has eleven sections, each with a varying amount of subsections. Each title has tremendous effect on the business and legal environment, with titles ranging from auditing, inspection of registered public accounting firms, accounting standards, establishment of an accounting oversight board, auditor partner rotation, corporate responsibility for financial reports, and probation to personal loans to executives, among others. Sarbanes - President George W. Bush signed Oxley in July 2002. The authors of the law are Paul Sarbanes and Michael Oxley. Sarbanes is the longest serving U. S. senator in Maryland history, having won his fifth term in 2000. He received his undergraduate degree from Princeton University, and a Harvard law degree. Sarbanes is the senior Democrat on the Senate Banking, Housing, and Urban Affairs Committee. Representative Michael Oxley was elected to the Ohio House in 1972 at the age of twenty - eight. Oxley has his undergraduate degree from University of Miami in Oxford, Ohio, and received a law degree from the University of Ohio. He is now the chairman of the House Committee of Financial Affairs. The largest part of the Sarbanes - Oxley Act is not all the sections that it covers in the law, not who signed it, or even authored it; it is how corporations will comply to this extensive piece of legislation. Enron, Tyco, and WorldCom all were under much scrutiny in the last couple of years because of personal loans given to executives for personal use. SOX bans the use of nearly all personal loans. These loans that corporations would give out to their executives were not really loans at all, but large sums of money, not expected to be paid back. Â  

How far do you agree with the intentionalist perspective that Hitler Coursework

How far do you agree with the intentionalist perspective that Hitler had always intended the extermination of the Jews - Coursework Example Hitler insisted to the German population that the Jews were socialists as well as democrats who eagerly exploited the Aryan people’s need for social justice to grab social power over the Aryan population (Victor, 2000). The same school affirmed that Hitler made a blue print of his step by step architectural plan. The plan prioritised removing the Jews from the face of the earth. The intentionalists declared the Hitler Germany policy to exterminate the Jews led to the 1941 German invasion of USSR. The attack on the Jews was dubbed as Hitler’s final solution. Intentionalist philosopher Gerald Fleming branded Hitler as the Fighing Prophet. (Totten, 2000). Further, the Nazi anti-Semitism policy from 1933 to 1939 focused on the discrimination of the Jewish people. Hitler’s government priorities included removing the Jews’ rights. For example, the business companies implemented the Hitler government policy by terminating Jews from their workplaces. In Germany, the Jewish youth did not have equal societal opportunities with non-Jewish youths (Friedlander, 2014). In terms of how far Nazi leaders achieved prescribed policy goals, the Hitler government implemented a new civil service law on April 7, 1933 prohibiting the hiring of Jews. On April 26, the German government ordered the public burning of all Jew-authored books. On July 14, 1933, the German government cancelled the citizenship of its Eastern Jew residents (Friedlander, 2014). Concentration camps, including the Oranienburg_camp and the 1936 Dachau_concentration camps, were set up starting in 1933. During 1937, the government set up the Buchewald concentration_camp to accommodate the growing number of new Jewish prisoners. The camps were used for the consequent massacre of the German Jews. Instead of forcing Jewish prisoners to help in the production of German military equipment, Hitler preferred

The Wife of Bath's Prologue and Tale written by author Geoffrey Essay

The Wife of Bath's Prologue and Tale written by author Geoffrey Chaucer - Essay Example He identifies shortcomings in the society in his impeccable style and hits out without hurting. His criticism of that era holds well in the present times. Chaucer’s writing style has a unique, humor-filled double meaning. Here is an example as to how he handles the pair of opposites, traps a negative thought within the positive. He blends his ideas with latent humor. â€Å"She used to weep if she saw a mouse Caught in a trap, if it were dead or bleeding And she had little dogs she would be feeding, With roasted flesh, or milk, or fine white bread, And bitterly she wept if one were dead Or someone took a stick and made it smart, She was all sentiment and tender heart.†(p.7) The female character that defies the established role-model of a woman of the 14th Century: The Wife, for example, is a tough female character but the reader is unable to gauge whether she is feminist or anti-feminist due to the style in which Chaucer deals with her character. This is his unique way o f writing, whether he is making jest or quite serious while highlighting the traits. An author may be crafty, yet one cannot sweep under the carpet one’s own views, while making the characters speak on some issue and Chaucer is no exception to this rule. Chaucer has brought all his administrative experience and his interaction with many types of people in the discharge of his duties in various capacities. Alisoun, the Wife of Bath, is an extraordinary character in medieval literature. She is over-confident and possesses all the negative tendencies like lust, masculine will, and will never allow men to dominate her. She believes that she is the creator of her own destiny. Chaucer gives such a confusing description about her traits, which has set a clash between the scholars whether she is feminist or anti-feminist. Unquestionably, The Canterbury Tales is Chaucer’s masterpiece which he wrote around 1386.The stories in it are told by a group of people on pilgrimage to a h oly shrine in Canterbury. The book begins with the General Prologue, in which pilgrims are introduced with apt descriptions. Lively exchanges between the pilgrims add to the suspense and beauty of the stories. The stories are rendered highly interesting on account of the themes and subjects they tackle, in various literary genres. The Wife of Bath’s Tale a woman-special story, that gives extraordinary insight into the life and passions of a woman in the secular world. Chaucer is at his best in this story and he seems to enjoy the various issues related to women, which he has craftily tackled. Through the twists and turns and witty wordplay, he makes the story highly enjoyable for the reader. Theme--marriage roles and power: In this story Chaucer deals with two important themes relating to women. The first concerns marriage roles and power. The women of this story Alisoun, is aware of the utility of the body for access to power and control over men and to secure financial inde pendence which is an important part of the power of women. She has married not once, twice but five times. Her marriage number one was when she was twelve, to an older man but wealthy. She applied the body advantage principle

ART Essay Example | Topics and Well Written Essays - 250 words - 2

ART - Essay Example amous 16th century portrait by Leonardo da Vinci, has been painted in oil on a poplar panel which illustrates the essential features of the Italian Renaissance. To perceive it visually, it is a length portrait depicting a woman who has an enigmatic expression on her face and the piece was celebrated for the ambiguity concerning the woman’s expression. The social relevance of the work by da Vinci is due to the monumentality of this half-figure composition and the delicate modeling of forms and atmospheric illusionism. These features were central to the progress of painting and there is a sense of mystery connected with the work. â€Å"Given the fact that Da Vinci manages to capture so many different emotions and character-traits in one painting, it seems natural that every time one looks at the Mona Lisa, one sees something different, irrespective from which direction the painting is looked at. In that light her ‘mysterious smile’ seems nothing out of the ordinary .† (Da Vinci’s Mona Lisa) In comparison with this celebrated work by Da Vinci, Marilyn Diptych, the 1962 painting by the American pop artist Andy Warhol, is an illustrious example of silkscreen painting which is important to the pop art style in painting. This work of acrylic and silkscreen on canvas makes use of the juxtaposition of the color images in order to depict the meaning of the artist. â€Å"The ‘Marilyn Diptych’ divides into 25 colored Monroes on the left and 25 black and whites on the right, with the image passing through near total blackening and disfiguration in the seventh column to extreme faintness on the far right. The more you look at the coloured panels, the more the hair, eye-shadow and lips look like paper cutouts that have been stuck on the faces, emphasising the artificially constructed nature of the Monroe ‘image’.† (Molyneux) Also, the misregistration or the failure of the color to fit exactly with the underlyin g black and white photograph gives the painting its great

The Market System and the Circular Flow Essay Example | Topics and Well Written Essays - 250 words

The Market System and the Circular Flow - Essay Example The idea of the invisible hand suggests that when competition is assumed, public and private interests coincides. The visible hand also suggests that if the profits of the firms are maximized, the society’s output would in return be maximized. The visible hand theory has two main virtues in the marketing system where it creates room for economic freedom and allocates resources effectively and efficiently. The invisible hand theory also suggests that it is individual’s motivation that drives the growth and development of the economy. EcoCommerce101 suggests that invisible hand theory should the concept of transaction among two individuals. The generated information is absorbed by the two economic participants, therefore, allowing proper allocation of resources. Individuals will always try to produce and provide best goods and services that the people are willing and able to buy; therefore, promoting the interests of the society (Basu, 2010). Meanwhile, the government is also responsible in regulating the types of businesses to be established in a certain region to avoid congestion. The government uses the idea of imposing high taxes to its resources. Conclusively, it does not mean invisible hand is only beneficial t o the economy, but the participants might also experience

E-business strategy and design exercise Assignment

E-business strategy and design exercise - Assignment Example The value proposition of the company has also been explained in this section. In the second section, few of the areas where improvement need of Amazon have been identified were assessed and correspondingly, suggestive measures have been recommended on the basis of the evaluations made in section 1. In the third and final section of the paper, the e-business strategies of Amazon along with its management issues have been explained. Introduction E-business has emerged as one of the pivotal concerns for every contemporary business that strives to mark its presence in the global realm and obtain competitive success over its long-run performance. In the present market scenario, most of the global companies have realized that with the adoption of the e-business strategy, they can develop their business model in a manner that satisfies the varying needs and diversified concerns of international business partners as well as customers. If the meaning of e-business is to be termed in general s ense, it can be justifiably described as the use of internet or the virtual space in the operational activities of the business to gain a leading position within the targeted market (Turban et al., 2010). When focusing on this subject matter, Amazon.com Inc has often been regarded as an example of best practices in its industry whereby its e-business model has been quite beneficial and productive in adding value to its services among its customers (Damani & Damani, 2007). Amazon, an American multinational, is one of the renowned and largest global e-commerce retailing companies. Amazon has been a pioneer in the application of e-commerce business model that runs its functions through virtual space entirely. It is not only involved in the selling of books and other products, but also renders due significance on gathering the valuable suggestions from the buyers so as to define its customer satisfaction and industrial leadership competencies. It records various movements of its buyers such as the number of visitors who visit its site and how much time do they spend on it while purchasing from a particular category of its product line. All these movements of the buyers are utilised by the company in order to analyse the buying behaviour of consumers in various targeted markets to identify its developmental needs along with its growth potentials. Through the advanced technologies of the e-business, Amazon has been successful in introducing the one stop shopping trend successfully (McGraw-Hill Education, 2013). Section 1 Effective technological tools Amazon has been operating with a mission and a vision to serve its customers as per their conveniences and in a productive manner for the company. Undoubtedly, in doing so, the company has to witness pressures from various international business forces that can be comprehensively addressed through the application of a PESTEL analysis framework. Political. From a critical point of view, it can be observed that because th e e-retail industry is yet in its developing phase within the global context, governmental interventions and political limitations bestowed on the industry as well as faced by Amazon correspondingly, is less. Subsequently, the international sale procedure of Amazon involves various risks mainly in terms of the requirement for import and export licensing that

Adolescent Student Attitudes Towards Mathematics Essay

Adolescent Student Attitudes Towards Mathematics - Essay Example Mathematics not only helps one individual in building his skills but also teaches one individual how to use them in his practical life. Keeping the importance of mathematics in mind this subject is compulsory in almost all sorts of education systems. As this subject is compulsory for everyone some students face difficulties while studying it while some do not. However the subject of Mathematics is considered the most difficult one by the students too. The pace of learning of a student depends on many factors. A student's attention should be focused on the topic he is learning. The attitude of learner and the environment in which he is studying are the major factors of his learning process. In this article, I would further discuss the attitude of students and their environment and background in detail to find out the reasons of changing attitudes of students towards mathematics. Students' background means the situations and conditions of their daily routine and their relation to their home. In contrast, the attitude of the students talks about their awareness, approach and feelings about mathematics. It is observed that the situations in the home make the base of the students' future formal learning either strong or weak. A student always needs his mother, who is known to be the first teacher of a child, to help and guide him in solving complex mathematics topics and questions. The understanding, feeling and concerns of students' also play a magnificent role in their progress of learning a particular subject. The pace of learning and level of understanding of a particular subject can be determined and assessed properly if these factors are kept in mind. Many researches have evaluated the result that students' personal and family background contribute to a great extent in the accomplishment of their goals including their success in mathematics. The changing attitudes of students towards mathematics and other studies also depend on their social life. Certain questions must be answered to understand why their attitude changes. Q1: Are their any resources available for the students at their home If so what are they and if not what would be the effect How does it affect their attitudes Home has been verified to be the greatest support for the students to carry good marks along with the willingness to study further and more efficiently. The environment provided to the student greatly influences the student to focus on his studies. Mathematics, being a complex subject for the students, requires attention and time. A student having an educational environment at home is observed to be more competent in his studies than the student having a less-educated environment around him. The learning opportunities, physical and mental relaxation and the peaceful environment of home play a great role in the success of a learner. A number of researches have already shown the positive relationship of learning accomplishments and home issues. The availability of books makes the first impression and acts as the first motivation for the student to work hard in his studies. The students follow the path of their parents and elders. Although books are believed to be the fundamental learni ng resources, other support stuff are thought as supplements which provide ease in the learning particularly that of mathematics. Such materials are calculators, computers, laptops, dictionaries, guidebooks and study tables. The educational qualification of parents also affects the students' academic life. If the parents are well educated and know the importance of education they would always emphasize on the students' learning. Mathematics needs a lot of attention and

Statistics Essay Example for Free

Statistics Essay 1. Age, income, length of labor, return to work and number of hours working per week 2. Mean and standard deviation were used to describe the length of labor. These were appropriate since mean and standard deviation can be calculated on an interval level of measurement. 3. Range could also be used to describe the length of labor since this statistic can be used on interval data with no natural zero point. 4. The distribution of scores was similar for the experimental and control groups for length of labor. The experimental group had a mean of 14.63 hours and the control group had a mean of 12.79 hours which is a difference of less than 2 hours with a SD of 7.78 for experimental and 7.2 for control. 5. The experimental and control groups were similar in the type of feeding. More people fed with a bottle than breast or breast and bottle in the experimental and control group. The percentages in both were lowest for breast and bottle with 6.3% for experimental and 5.6% for control. 6. Married was the marital status mode for the experimental group and control group since it was the largest group. The frequency and percentage are 25 and 78.1% for the experimental group and 31 and 86.1% for the control group who are married. 7. Yes a median can be determined for the educational data. The median for the experimental and the control group are the people in the some college group. The median is the â€Å"middle† category and can be determined for ordinal data like education. 8. The findings from this study cannot be generalized to Black women since the sample size is so low in the experimental group and there are no Black women in the control group. Black women might have different self- care interventions to manage post- partum fatigue than white women. 9. There is a note at the bottom of the table that mentions that there is missing data. Perhaps some mothers did not reveal that data. 10. The sample was adequately described. However, adding information about any complications before or during birth, the type of delivery for example C-section vs. natural, or if the women had any help such as a nanny would add to the description.

Pathophysiology of Systemic Lupus Erythematosus

Pathophysiology of Systemic Lupus Erythematosus Introduction This essay will explore the pathophysiology relating to a call I attended while on practice placement as a student technician. The initial call details were that it was a 45 year old female in pain. On our arrival the patient was sat in a chair and was breathing rapidly and had a very flushed face. After introducing ourselves and gaining the patients consent we then proceeded to take her basic observations and take her history. Most of her observations were within acceptable limits however her blood pressure was slightly high, she had a raised pulse at 120 beats per minute and slightly high temperature at 38 degrees Celsius. On questioning the patient had a localised pain score of 8/10 in her back and a pains in her joints and muscles with a pain score of 4/10. When questioned about her medical history, she stated she had a condition called systemic lupus erythematosus. This is not a condition I had heard of before I, therefore, questioned her more about it. Differential Diagnosis A 20 year-old women patient presented with fatigue, heart palpitations and anxiety. Reviewing the patient’s history revealed that she started experiencing anxiety, fatigue and heart palpitations approximately two years ago when she was still pregnant and she arranged to visit her own doctor. At that time her doctor stated that this was was due to stress. However, her symptoms became worse after she had another child. She stated that before going into labour she experienced premature contractions, headaches, increased fatigue, and swelling of her legs. Her doctor advised her to stay off work and have some bed rest. Shortly after giving birth to her third child, the patient began experiencing several new symptoms. Her knees and ankles started swelling, she also developed sever pain in her knees, wrists, elbows, and fingers. During the winter the patient started feeling painful and her peripheral joints became discolored whenever exposed to cold. She had recently been admitted to hospital in order for tests to be carried out and although she was still waiting for a definative outcome, a rhueamatology consultant she was under stated he was fairly certain that she had stemic lupus erythematosus. Epidemiology According to Somers et al (2007) approximately five people in every ten thousand suffer from systemic lupus erythematosus. Ninety percent of patients who are diagnosed with systemic lupus erythematosus are female (GinzlerTayar 2012; Blank et al 2009). It most commonly develops in women aged between 20 and 40 although anyone of any gender and age can develop it at any time. With regards to ethnic origin systemic lupus erythematosus is more prevalent in those with Afro-caribean, Asian or Chinese ancestry. Although there is a possibility of having a genetic pre-disposition to the disease only 3 of 100 children of those diagnosed with systemic lupus erythematosus will go on to develop it. According to National Health and Nutrition Examination Survey (2004) a survey in which it was observed that 100% of patients with System lupus erythematosus were receiving treatment. Aetiology Although there is no definate cause of systemic lupus erythematosus (Giannouli 2006), there is thought to be several factors increasing the likelihood of developing systemic lupus erythematous they include Genetics {where members of the family have lupus this condition will often increase the childs chances of developing it} (Hemminki 2009). It is also thought it can also be triggered by environmental factors such as trauma, ultraviolet rays and also emotional stress. Gender and hormones is thought to be the biggest factor affecting the chances of developing systemic lupus erythematous as it is proven that it mostly affects women than men especially when they are in menstrual periods or in their pregnancy, it is said to occur nine times more to women in comparison to men (GinzlerTayar 2012). Pathophysiology System lupus erythematosus is an autoimmune disease. The autoimmune system is responsible for fighting foreign and often harmful bacteria in the human system. However with systemic lupus erythematosus the immune system will attack itself, the pathology of this disease is similar to that of rheumatoid arthritis and can affect any part of the body (GinzlerTayar 2012). Systemic lupus erythematosus may also occur in the form of periarticular inflammation that affects the tendon sheaths, the illness causes the patient to experience coexisting fibromyalgia that results to poor sleep, chronic disease, inactivity ,mood problems and depression (Knott 2012). Patients who suffer from this condition have abnormalities when it comes to their immune system, this includes the B cell function, apoptosis and also the T cell function. Systemic lupus erythematous mostly attacks the blood vessels, the skin, the heart, nervous system, liver, lungs and the kidneys (Knott 2012). Unfortunately when System lupus erythematous persists without effective treatment it may result in serious complications such as stroke, heart inflammation, lung damage, blood clots and if the patient is female it may result in miscarriage or pregnancy complications. Research shows that the exact cause of immune deregulation is not yet clear but it may be as a result of interference of endogenous metabolism that affects the function of antigens in the human system (GinzlerTayar 2012). The abnormalities caused by System lupus erythematosus may vary from one ethnic group to another for instance East Asians who have this problem they have extra cytotoxic T lymphocyte antigen-4 while the white populations abnormalities is observed through having more Fc-Y receptors (Hemminki 2009) . For effective diagnosis of System lupus erythematosus it is of essence to deal with specific autoantibodies in order to treat the root cause of the disease (GinzlerTayar 2012). The symptoms of systemic lupus erythematosus will vary from patient to patient as the signs and symptoms displayed will depend on the body part or system that is being affected by the systemic lupus erythematosus (Arthritis Research UK 2014). However there are some generalised symptoms and these are about to be discussed. Dermatological symptoms caused by systemic lupus erythematosus could include rashes and in some cases a specific rash to the cheeks known as a â€Å"butterfly rash† can be identified (Knott 2012). Another common issue for the majority of people with systemic lupus erythematosus find that they become much more sensitive to sunlight. It is also common for the blood vessels under the skin in the joints to become inflamed and this can lead to poor circulation to these areas (this is called Raynauds phenomenon)(GinzlerTayar 2012). Oral ulceration can sometimes occur for this very reason. Blood disorders have been known to develop especially in children, the most common being anaemia. Having anaemia would obviously cause lethargy and low mood (Giannouli 2006). Patients with systemic lupus erythematosus are much more at risk of developing cardiac issues than the general public as the disease often causes inflammation of the blood vessels within the heart, thus increasing the risk of developing atherosclerosis which in turn could lead to a myocardial infarction if one of the blood vessels was to become blocked(Blank et al 2009). If the kidneys were to become inflamed due to the systemic lupus erythematosus, this could cause symptoms including haematuria (blood in the urine). Also, if the kidneys become inflamed this could lead to the patient developing a kidney infection which will result in the patient having moderate to severe back pain (GinzlerTayar 2012). The most common issue for patients suffering from systemic lupus erythematosus is to do with their joints (Somers et al 2007). Most people suffering from systemic lupus erythematosus will develop pain in their muscles, joints and peripheral joints such as joints in their hands and knees can often become inflamed. This can be due to a condition known as Osteonecrosis developing due to the systemic lupus erythematosus (Giannouli 2006). Osteonecrosis is a condition that develops when there is a reduced blood supply to the bones. Osteonecrosis will affect the bones ability to replace old bone with new bone and if an injury is sustained it may never be able to heal properly (Knott 2012). Most patients find that it is worse when they wake up in the morning and as this is a chronic condition, it can often feel better in periods of remission and more painful during a relapse period (GinzlerTayar 2012). Diagnosis The process involves the blood tests including antibody tests, urinalysis and a chest X-ray which is mostly overseen by Rheumatology Consultants whose area of specialisation is autoimmune diseases and also soft tissue treatment. Musculoskeletal symptoms are analysed when trying to diagnose System lupus erythematous and it can be manifested as arthritis or arthralgia in which the patient expresses it as stiffness and pain, when it occurs in System lupus erythematous it can be in the form of migratory or transient pain and it is difficult to be diagnosed since it may be present when the patient makes the appointment with a doctor only to be resolved in the process of evaluation(Ginzler Tayar 2012 and Knott 2012). Systemic lupus erythematosus caused fewer erosions or fixed deformities unlike rheumatoid arthritis which is much more degernerative to the joints (GinzlerTayar 2012). There is also the possibility of around 4% of the patients will suffer from myositis ( which is the inflamat ion of the muscle tissue) and this can be examined by taking a biopsy of muscle tissue (Giannouli 2006). Pharmacology and associated treatment: Unfortunately there is no cure for Systemic lupus erythematosus and the treatment plan is based on symptom relief as opposed to direct treatment of the disease(GinzlerTayar 2012, Blank et al 2007, Knott 2012). Treatment of Systemic lupus erythematosus is very specific to the individual patient and it always depends in manifestation of the symptoms, the disease severity and most importantly the specific organ affected(Giannouli 2006). In order to devise the most appropriate treatment plan the rheumatology consultant will perform a number of diagnostic tests and depending on what the results are will influence the treatment plan (Giannouli 2006). Patients suffering from systemic lupus erythematosus will often need to take a group of medications called non-steroidal anti inflammatory drugs (Knott 2012). This group of medications work by reducing the inflammation in the affected joints and hopefully reducing the amount of pain the patient is in. Some common non-steroidal anti inflammatory drugs are ibuprofen, aspirin and diclofenac sodium (these are all available without a prescription from a pharmacy), the rheumatology consultant may recommend Naproxen or pirixicam in certain circumstances (BNF 2014). With non-steroidal anti inflammatory drugs there is a risk that they may cause damage to the lining of the stomach and could even cause ulceration in the stomach when taken over long periods of time in high doses(Knott 2012). If the patient is taking frequent non-steroidal anti inflammatory drugs they may be prescribed a proton pump inhibitor medication in order to protect the stomach. These medications work by reducing the amount of acid the stomach produced and thus protecting the lining of the stomach (Knott 2012). Common proton pump inhibitor medications include; omperazole, lansoprazole, pantoprazole and esomeprazole (BNF 2014). A further treratment that a rheumatology consultant may consider is the use of a medication called hydroxychloroquine (Giannouli 2006). Hydroxychloroquine was originally an anti-malarial drug however it has recently started being used to treat the symptoms of systemic lupus erythematosus and is a disease modifying anti-rheumatic drug (also known as DMARD)(Knott 2012). Hydroxychloroquine works by reducing the response from the immune system which is causing the symptoms (this is probably the closest treatment to treating the cause as opposed to just the symptoms). It is used as a long term treatment to try and prevent relapses or flare ups of the disease (GinzlerTayar 2012). Corticosteroids may be used in severe systemic lupus erythematosus (GinzlerTayar 2012). They may be prescribed during relapses of the disease. Corticosteroids work by blocking the normal function of the white blood cells and reducing the inflammation response(Knott 2012). However the negative aspect of this is that it leaves patients very vulnerable to infections(GinzlerTayar 2012). Other side effect could include the patients bones becoming more fragile, the skin becoming thinner, hypertension and also weight gain. For this reason corticosteroids will only be used to treat flare ups at the minimum effective dose and then reduce the dose slowly as the symptoms ease. Corticosteroids used in the treatment of this disease are hydrocortisone and predniselone(BNF 2014). Often used in conjunction with corticosteroids during a relapse are a group of medications called immunosuppressants . These medications will work by reducing the action of the immune system and will be used when the immune system is attacking a healthy part of the patients body(Knott 2012). Again these medications will reduce the pateints ability to fight harmful infections and can cause many side effects. Immunosuppresent medications used include: azathioprine, mycophenolate mofetil and cyclophosphamide (BNF 2014). The final medication to be discussed is called Rituximab. Rituximab was originally created to treat blood cancer however an â€Å"off-label† use for this medication is to treat autoimmune diseases. The way Rituximab works is by destroying the B-Cells(The B-Cells which cause the release of antibodies resulting in the symptoms). As with all the other medications there could be side effects the most common being dizziness and vomiting. Rituximab can only be administered intravenoulsy so will normally require hospital admission for the patient to receive it . (Knott 2012) Other interventions include an advice session from the doctor regarding the patients lifestyle and diet may be of vital importance this may help the patient and minimise lifestyle related stress (GinzlerTayar 2012) . The patient may be suggested to work with a support group or even receive counselling as the condition can cause severe and life limiting symptoms while in relapse. Most patients with systemic lupus erythematosus are also advised to avoid the sun as it can aggravate and skin symptoms(Knott 2012). Conclusion Systemic Lupus Erythematosus is a very complex disease and can present itself in many different ways depending on the patient and the part of the body affected. In the pre-hospital environment it is very important to get a detailed history in order to identify whether they have been diagnosed with this disease. Clinicians must remember systemic lupus ertythematosus can limit a patients quality off life while they are having a relapse so it is important to assess each patients individual symptoms and if necessary administer pain relief and position them so they are comfortable. It is also important for ambulance clinicians to be mindful of the patients joints when using moving and handling techniques as this could obviously cause the patient discomfort or even pain due to the condition. References: Arthritus Research UK. (2014). Systemic Lupus Erythematosus. Available: http://www.arthritisresearchuk.org/arthritis-information/drugs/hydroxychloroquine/what-it-is.aspx. Last accessed 20/03/2014. Blank M, Shoenfeld Y, Perl A. 2009. Cross-talk of the environment with the host genome and the immune system through endogenous retroviruses in systemic lupus erythematosus. Lupus. Nov;18 (13):1136-43 Giannouli, S (2006) Annals of rheumatic disease, Anaemia in systemic lupus erythematosus from pathophysiology to clinical diagnosis. 65(2) p144-148 Ginzler E, Tayar J. 2012. Systemic lupus erythematosus (lupus). Updated: January 2012. Available at http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/lupus.pdf#search=sle. [Accessed on February 21, 2014 at 21:30] Hemminki K, Li X, Sundquist J, Sundquist K (February 2009). Familial associations of rheumatoid arthritis with autoimmune diseases and related conditions. Arthritis Rheumatology. 60 (3): 661–8 Knott, L. (2012). Systemic Lupus Erythematosus. Available: http://www.patient.co.uk/health/systemic-lupus-erythematosus. Last accessed 20/03/2014. Somers E, Thomas L, Smeeth L .2007. Incidence of systemic lupus erythematosus in the United Kingdom, Arthritus Rheum 15;57(4) p612 – p618.

Systematic Review of the Mental Health Review Tribunal

Systematic Review of the Mental Health Review Tribunal A Systematic Review of the Mental Health Review Tribunal: Processes, Roles and Impact 1. What is the Mental Health Review Tribunal? The Mental Health Review Tribunal is a collection of independent judicial bodies that aim to review the cases of suitable applicant patients who have been appropriately detained under the Mental Health Act 1983[1]. Following strict guidelines and statutory criteria for discharge, collectively, members of the tribunal have the power to direct the discharge of applicant patients who satisfy the relevant discharge criteria. According to the official website of the tribunal (Mental Health Review Tribunal[2]), its other principal powers are: To recommend leave of absence from employment or school as appropriate To recommend supervised discharge To recommend transfer to other hospital or relevant health care professional To issue directions regarding procedural matters To reconvene if any of their recommendations from a past Tribunal hearing is not complied with In general, the Mental Health Review Tribunal serves as a safeguard against wrongful admission or unwarrantedly long detention (Wood, 1993[3]). As such, they give detained patients access to an effective appeal mechanism in order to ensure, as far as possible, legal protection of their liberty. All this is carried out in accordance with the Human Acts Right. There are five Tribunal offices in the United Kingdom (Mental Health Act 1983; Memorandum on Part V[4]). Each region in England is operated under a separate MHRT and a separate Tribunal covers the whole of the country of Wales. Accordingly, there are five Tribunal offices that provide administrative support to the respective MHRTs. The MHRT operates under the provisions of the Mental Health Act 1983 and the Mental Health Review Tribunal Rules 1983 (Her Majesty’s Stationery Office, 1983[5]). The powers and duties of the Tribunals are as set out by the Mental Act 1983, subsequently amended in the ensuing policy document, the Mental Health (Patients in Community) Act 1995. The actual Tribunal process usually takes place in the hospital where the applicant patient is being retained, and is usually held in private, unless otherwise agreed by the patient in question and the members of the Tribunal. The actual processes and review procedures of the Tribunal are defined in the Mental Health Review Tribunal Rules 1983 (Her Majesty’s Stationery Office, 1983); similarly, this has also been amended to a more current version. Tribunal procedures and deliberations should always be carried out in accordance with the principles of the statutory instrument and the principles in which the other subgroups operate when considering Definitions, Guardianship and the Mental Health Commission under the Mental Health Act. These include: Non-discrimination Equality Respect for diversity Reciprocity Participation Respect for carers Least restrictive alternative and informality Respect for rights All patients that have been detained under the Mental Health Act 1983 or that are eligible for guardianship or supervised post-discharge care have the fundamental right to appeal, i.e. to apply for a review by submitting an application to the Mental Health Review Tribunal, within the specified time limits as specified in the Mental Health Act. Furthermore, in order to ensure regular reviews of all cases, if the patient fails to make such an application the Tribunal, the appropriate body or personnel is obliged to make a referral of the case to the appropriate regional Tribunal. The party responsible for making this mandatory referral differs for various patients and depends on the restriction status of the patient (discussed further in section on types of patients): In the case of restricted patients, it is the responsibility of the Secretary of State for Justice to refer the case to the Tribunal In the case of non restricted patients, the onus falls on the hospital managers In a review of Representing the mentally ill and handicapped (Gostin and Rassaby, 1980[6]), the authors who are incidentally representatives of the National Association for Mental Health (MIND), highlights the unmet need for legal representation for applicant patients at Tribunal hearings of over 20,000 patients annually. However, as pointed out by John Hamilton (1980)[7] of the Royal College of Psychiatrists, 90% of these patients are, in fact, on short term detention orders and remain as informal patients after the expiry of the said order. In fact, a great majority of patients are compulsorily detained only for very short period of times and (from 72 hours to 28 days) and may not be eligible for a review process during that limited amount of time (Rollins, 1980[8]). As a result, the informal status of the applicant patient is very important because most of the hospitalised mental health patients in England and Wales are informal (Andoh, 2000[9]). Thus applying one safeguard provid ed in the Mental Health Act 1983, less than 10% of mental health patients who are compulsorily detained have a statutory right of appeal from an independent Mental Health Review Tribunal. In Gostin’s replying correspondence (1980[10]), he revisits the Percy Commission, and emphasises the glaring discrepancies in expected and actual rates of Tribunal hearings. According to Gostin (1980), the Percy Commission envisioned that there would be approximately 8000 ­ – 9000 Tribunal hearing every year. However, in reality, there norm is a figure of about 750, with the maximum ever annual rate being 1515 hearings. As a consequence, most Tribunal members hear only one or two cases each year and thus do not have the opportunity to garner experience and familiarity with a diverse breadth of cases that would have been beneficial to improve future judgements. In the past two decades though, there has been a major increase in the number of applicants to the Tribunals (Crossley, 2004[11]). In fact, as reported by Blumenthal and Wessely in 1994[12], applications to the Tribunal rose dramatically in the 10 years between 1983 and 1993, with the figure approaching 10,000, i.e. almost a three-fold increase since 1984 and costing approximately 12 million pounds ( £). 2. Mental Health Legislation Mental health legislation in the Commonwealth countries is changing in some common law jurisdictions (Carney 2007[13]). There is an increasing debate on whether it is, in fact, a health or legal issue and certain schools of thought question the need for special legislation in the present day. There is controversy over the non-therapeutic nature of criminal law, especially in its sentencing and penological aspects; can the inherent workings of law ever be adjusted to incorporate the perspective of therapeutic jurisprudence (McGuire, 2000[14])? Furthermore, some critics also question the beneficial role of Tribunals or legal adjudication of the detention requirements. The very fact that the term ‘detention’ is used to describe the process of admission of these often vulnerable patients is probably evidence of the need for legal contribution. As mental health patients are frequently prone to violence and can be considered a risk to the public and themselves, it is evident t hat both disciplines of health and the law need to collaborate to achieve optimal long-term management of this population. 2.1 The Mental Health Act 1983 The Mental Health Act 1983 provides legislative guidance for the compulsory ambulatory assessment, care and treatment (i.e. the overall management in hospital) of patients with a mental disorder. In the Mental Health Act document mental disorder is defined as â€Å"mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind†. As an amendment from the Mental Health Act 1959, the 1983 policy document requires that in order for a patient to fall within the criteria for ‘severe mental impairment’ or ‘mental impairment’, the patient in question has to be associated with abnormally aggressive or seriously irresponsible behaviour (Singh, 1984[15]). This definition excludes an appreciable amount of severely impaired or impaired mental health patients that are neither ‘abnormally aggressive’ nor ‘seriously irresponsible’, and thus these equally vulnerable patients rema in unprotected under the amended Mental Health Act 1983. Thus it would appear that the definitions of, under the Mental Health Act 1959, of severe mental subnormality and mental subnormality would be more considerate and fair towards such patients, as it certainly encompassed in the definition the vulnerability of this mental health patient population (Singh, 1984). In part, the Act states that, ‘severe subnormality being of such a nature or degree that the patient is incapable of living an independent life or of guarding himself against serious exploitation or will be incapable when of an age to do so, and in the case of mental subnormality of a nature or degree which requires or is susceptible to medical treatment or other special care or training of the patients’. Thus the recommendations outlined herein in this document apply not only to patients suffering from ‘more violent mental disorders’, but also vulnerable patients who may find it difficult to express their various needs, or who in some extreme, cases, may not even recognise that they need specialist help. It has been proposed that mental health should be given the same priority as physical health (Kmietowicz, 2005[16]). Application of the 1983 Act should also take into consideration exclusions from the definition of ‘mental health’, as set out in Section 1 (3) of the Act. This section of the policy document states that a person should not be treated under the provisions of the Act, if they are suffering from mental disorder purely by reason of promiscuity, other moral conduct, sexual deviance or substance misuse, including dependence on alcohol or drugs. However, the Act recognises that such behavioural problems as listed above may be accompanied by, or assoc iated with, mental disorder, and as such should be overlooked in its entirety. Real life experience apparently shows that the Act is usually fully implemented with appropriate communication and collaboration between the various disciplines involved (Ourashi and Shaw, 2008[17]). A recent of judicial practice and assessment of risk to the public in detained individuals, based on Sections 37/41 of the Act, showed that, in addition to the primary need to protect the public, an additional and almost equally important intention was to ensure compliance with both after-care services and medication. In the study sample, which was made of 12 judges from crown courts in England, it was found that restriction orders were rarely made contrary to the recommendations of the affiliated medical practitioner. It is worthy of note to consider that the recent Mental Health Act of 2007 have introduced some important modifications to core recommendations and standard roles and responsibilities of mental health practitioners (Kousoulou, 2008[18]). These amendments perhaps gain even more importance when we consider the revolutions that have occurred in psychiatry since the original Mental Health Act 1983 was implemented. Of particular importance, is the notion in 1983, that there was no link between mental illness and violence which has now since been proved invalid (Monahan 1992[19]). From October this year (2008), the Mental Health Act 2007 will be fully implemented in the procedures associated with the Mental Health Review Tribunals. 2.2 The Mental Health Act 2007 Amendments to the 1983 Mental Health Act policy document in the Mental Health Act 2007, which are directly related to any aspect of process of the Mental Health Review Tribunal and outlined topline below (Office of Public Sector Information, 2007[20]): Removal of categories of mental disorder: the key definition of ‘mental disorder’ is amended from that which is outlined in Section 1 (2) of the 1983 Act. For the definition of ‘mental disorder’ and mentally disordered’, substitute ‘mental disorder’ means any disorder or disability of the mind; and ‘mentally disordered’ shall be construed accordingly’. In addition the following statements are omitted in the recent amended version: Those of ‘severe mental impairment’ and ‘severely mentally impaired’ Those of ‘mental impairment’ and ‘mentally impaired’ That of ‘psychopathic disorder’ Amendments to the section on the Mental Health Review Tribunal include specific issues related to: Patients absent without leave Duty of hospital managers to refer cases to the Tribunal Power to reduce periods under Section 68 Restriction orders: in relation to restricted patients Conditionally discharged patients subject to limitation directions 2.3 The importance of making the right decision There have been reported cases of mental health patients who commit suicide within a mere 12 months of contact with mental health services. For example, in a national clinical survey that was carried out in England and Wales, over 2,000 mentally impaired suicide victims had had previous contact with mental healthy services in the year before (Appleby et al, 1999[21]). A review by mental health teams concluded that suicide could have been prevented in more than 20% of these cases. In conclusion, the researchers made logical recommendations for suicide prevention measures in mental health services, including strategies to improve compliance and sustain contact with the appropriate mental health services. In addition, there is also the additional threat to the innocent people of the public. The perceived threat of mentally disordered patients, who have been released from detention, to the public has been explored severally (Norris, 1984[22]; Buchanan, 1998[23]; Jamieson and Taylor, 2002[24]). In fact, several years ago, in New Zealand, there was a controversial case of a mental health patient who committed murder six hours after being released from detention (Zinn, 2003[25]). Interestingly, the said patient was found not guilty of the murder by reason of mental illness. Furthermore, the patient was awarded compensation of the value of  £300,000 after he sued the health authority for failing to detain him as an involuntary patient under the Mental Health Act. As such, it is evident that there are many incentives here for ensuring that the right intervention is applied to the right patient. 3. Members of the Tribunal: The Relevant Stakeholders Essential members who must be present at each Tribunal hearing are (Mental Health Review Tribunals website) include: The regional chairmen A legal member A medical member, and A lay member For each geographic region, the Lord Chancellor makes appointments and decides who sits on the different panels. For the other members other than the legal member (i.e. the medical and lay members), the Secretary of State for Health, for cases in England, and the Secretary of State for Wales, for cases in Wales, are also consulted in the decision making process. Each member has a specific and individual role in the co-ordination of the Tribunal hearing. In addition to the essential Tribunal members outlined above, there are other stakeholders involved in the long-term process of the review process. These could be private non-governmental organisations, such as the National Association for Mental Health (MIND). Whether these members are salaried or not is usually discretionary, but the norm is that there is no salary payable, but that members receive an attendance fee and travel and subsistence allowance. On the contrary, the Tribunal chairman is a salaried role. 3.1 Role of the regional chairman A regional chairman is appointed for each of the two Tribunal regions in England: the North Region and the South Region, which are conveniently based in Manchester and London, respectively. The roles of the regional chairman of the Tribunal are multi-factorial and include (Mental Health Review Tribunals website): The regional chairman appoints specific members to particular Tribunal hearings The regional chairman has the responsibility of ensuring that all the statutory requirements are complied with, making judicial decisions and giving necessary direction a timely and fair decision is reached in each and every case The regional member is also responsible for organising training for the members of the Tribunal to ensure that all members have the updated skills and knowledge that would be necessary to effectively carry out their individual roles It is the role of the regional member to oversee the appraisal mentoring scheme of the members of the Tribunal, thus highlighting training needs (see point above) to continually improve the review process The onus also falls upon the regional chairman to handle any complaints about the conduct of any members of the Tribunal, or to refer the case to higher authorities if warranted 3.2 Role of the legal member The legal member, more often than not, presides over the Tribunal hearings. Legal members of the Tribunal are usually elected or appointed on the basis of their specific expertise in the particular area of jurisdiction (Ferres, 2007[26]). They are required to â€Å"have such legal experience, as the Lord Chancellor considers suitable† (Department for Constitutional Affairs, DCA[27]). In addition, interpersonal skills and a good understanding of the health system are crucial as fundamental qualifications of the Tribunal legal member. The official website of the Mental Health Review Tribunal provides relevant specific information on the requirements of becoming a legal member and outlines the roles of the legal members as: The legal member acts as President of the Tribunal. Revisiting the primary role of the MHRT, which is to review the legality of the applicant patient’s detention in hospital and to direct the discharge of those to whom the statutory discharge criteria apply; and to safeguard the patient’s fundamental human right to be free from unjustified hospital detention (Richardson and Machin, 1999[28]), it is evident that this process is essential a legal one. It is thus only logical that the Tribunal be presided over by a member of the legal profession. In addition, the legal member of the Tribunal has the responsibility to ensure that the proceedings of the review process are carried out in a fair and balanced manner. The legal member is also responsible for ensuring that the legal requirements of the Mental Health Act are properly observed The legal member of the Tribunal also has the role of advising and addressing any questions of law which may arise before the hearing, during the hearing and during the deliberation discussions with the other members of the Tribunal In collaboration with the medical member and the lay member of the Tribunal, the legal member is also responsible for drafting the reasons for the reached decision, and for endorsing the record of the agreed decision One of the major that the legal members of the Tribunal face is the danger that the medical member could dominate what must essentially be a legal process (Peay, 1989[29]). 3.3 Role of the medical member As stated above, a medical practitioner is one of the necessary members of the Tribunal and their role, though clearly invaluable, is fraught with opposing views from the multidisciplinary stakeholders in the field. In 2000, Gibson[30] proposed that the role of the medical member was introduced in the 1959 Act to make the process of medical notes review less arduous â€Å"without ruffling medical feathers†. However, according to Prins (2000[31]), the origin of the required disciplines to sit in Tribunal hearings is much more complex than that, as there were conflicting views that arose during the parliamentary debates leading up to the 1959 Act, as to who was best suited to make that all-important decision regarding the patients’ release or continued detention. It is worthy of note, here, that in those early legislative days, the commonplace law was one which involved a purely judicial decision, which probably explains the disinclination to acknowledge the need for a me dical aspect in the decision making process. The medical member could be the patient’s treating psychiatrist, a nurse or any other member of the mental health team. According to the Mental Health Review Tribunal website (Mental Health Review Tribunal), the medical member is customarily a consultant psychiatrist with several years of extensive experience who is able to advise other members of the Tribunal on any relevant medical matters that should be taken into consideration in the patient’s review. There is evidence that the dual role that is expected of medical practitioners on the Tribunal is a potential barrier to having the fairly balanced and effective hearing that is the main objective of the review or appeal process. As with the legal member and all other members of the Tribunal board, interpersonal skills and a good understanding of the relevant health system are important for all Tribunal members (Ferres, 2007). In addition to this fundamental criterion, Ferres (2007) emphasises the dilemma that is brought upon the medical member as a direct consequence of his/her role as a medical practitioner and a sitting as part of the Tribunal. According to the official website of the Mental Health Review Tribunal (Mental Health Review Tribunal), the basic roles of the medical member of the Tribunal can be categorised as outlined below: Medical role: this member is required to carry out an examination of the patient before the hearing and, in so doing, make any necessary interventions – or simply make any necessary steps – that could potentially aid the decision making process in forming an opinion of the patient’s mental health condition. This is clearly in accordance with Rule 11 of the Mental Health Review Tribunal Rules (Her Majesty’s Stationery Office, 1983), which requires the medical member of the Tribunal to â€Å"at any time before the hearing†¦examine the patient and take such other steps as he (or she) considers necessary to form an opinion of the patient’s mental condition†. Judicial role: the medical member, together with the other members of the Tribunal, have a judicial responsibility to decide the patient’s fate, in terms of if the patient could still represent a danger to self or others and should thus remain in detention, or if the patient is suitably fit to be released into the public domain. Researchers in the past have shown that the duality of their roles on the Tribunal need not lead to knowledge bias, which could cause a flawed opinion (Langley 1990[32]; Brockman B; 1993[33]). However, in drastic contradiction to this, some more recent opinions expressed by critical schools of thought believe that the dual nature of the expected medical member’s role is a possible barrier to open-mindedness (Gibson, 2000; Richardson and Machin, 2000[34]). The, somewhat logical, fear is that doctors’ judicial opinions of patients’ eligibility for release would undoubtedly be swayed by findings from their preliminary observations and assessments. Apparently, for the review process to be carried out fairly, medical members of the Tribunal should strive to make their decisions based only on reports, evidence and witness and patient reports that presented to them during the Tribunal hearing. As such, any details divulged by the patient prior to the Tribunal hearing sh ould not be considered as evidence and must not be taken into account. Similar to this notion, the Law Reform Committee, in 1967, recommended that a doctor should not be compelled to give evidence of issues that he may have had access to with the patient that have no bearing on the patient’s mental or physical health (Law Reform Committee, 1967[35]). Putting it logically, general human nature may well be a barrier to such sentiments. Having conducted an examination of the applicant patient, and presumably consequently forming a clinical opinion, the medical member of the Tribunal is expected to morph into a decision making member to attend the review hearing. As the Council of Tribunals have very aptly described it, the medical member is â€Å"effectively a witness and a member of the Tribunal, deciding the validity of his own evidence† (Council on Tribunals, 1983, paragraph 322[36]). The unanswered question, thus, is: how can the medical member be expected to detach his previous medical knowledge of the said patient from evidence that is presented in the Tribunal and remain objective in his opinions and, if this distinction is necessary, does the inherent benefit of the preliminary assessment then become invalid? These questions also corroborate the idea of the protection of the doctor’s professional confidence una voidably conflicting with the interest of justice (No authors listed, 1967[37]). However, in his correspondence to the editor of the British Journal of Psychiatry, Gibson (2000) stresses the inherent advantages of the preliminary examination prior to the Tribunal hearing. The main benefits are outlined below: The preliminary examination session gives the medical member a chance to review the applicant patients’ clinical notes which may contain crucial data and clinical findings that are omitted from the reports The preliminary examination session also prepares the medical member to ask the most appropriate questions at the hearing, thus ensuring that the benefits of the review process is optimised Furthermore, Gibson (2000) has suggested that, in order to eliminate the potential prejudice that could accrue from the preliminary assessment and the associated disadvantage of the often time consuming nature, that the applicant patients’ notes should be made available to all of the Tribunal members in the half hour before the Tribunal hearing is scheduled to take place, thus dispensing with the need for the historical preliminary examination. The limitations of this proposal, as succinctly put forward by Prins (2000) are two fold: As we all know from our practical clinical experience, in many cases, medical notes are too voluminous and complex to do a proper review in half an hour. In some cases, it would take days to form an understanding of the contents of such files. Also, the feasibility of medical notes review by all members of the Tribunal is doubtful. Without a certain degree of medical expertise, it would be near impossible for the two non-medical members of the Tribunal to comprehend the contents of the applicant’s patients’ medical notes. This would then necessitate the additional step of medical interpretation for the benefit of these members, leading to longer duration of the review process, and thus, increased costs and burden on the health system. 3.4 Role of the lay member According to the official Mental Health Review Tribunal website, the lay member of the Tribunal serves to provide some form of balance to the Tribunal as a representative of the community outside the dominating, and often clashing, legal and medical professions. Normally lay members would have a background or practical experience of working in the health and welfare field in the National Health Service, voluntary organisations or private health sector. The lay member may also be experienced in social services on administration (Lodge, 2005[38]). 4. Other stakeholders involved in the Mental Health Review Tribunal 4.1 Legal representation for the mental health patient In addition to the legal member of the board, legal representation is usually advised for the patient. A legal representative can be useful to explain the law to the patient and help to protect his or her best interests (Mental Health Review Tribunal website). As a matter of circumstances, the mental health patient’s handicap or mental illness, coupled with the possible effects of having been institutionalised and various antipsychotic medications, make self-advocacy invariably difficult (Gostin, 1980). These patients do, however, have the right to choose to represent themselves; nevertheless, this option is not advisable. Furthermore, Larry Gostin of the National Association for Mental Health (MIND), in London, goes on to convincingly justify the need for legal representation for the mental health patient. Patients who attend the Tribunal without legal representation are frequently denied access to the full reasons for his confinement and subsequent decision, and medical and social reports pertaining to his or her case may be withheld from the patient as confidential (Gostin, 1980). When a legal representative is involved and present during the hearing, he or she is party to all relevant documents and can share the information with the client (in this case, the mental health patient). Another even more important advantage of having legal representation is the ability of such a legal professional to examine provision in the community for housing, care and support. Thus as highlighted above, the benefit of legal representation for the mental health patient in the Tribunal cannot be overemphasised. This calls to question the ethics of the preliminary examination session, during which the vulnerable mental health patient is examined by the medical member of the Tribunal towards forming an opinion of his or her ment