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Dying is mostly seen as a dreadful event, never a happy experience. Yet, as palliative care physicians, we have seen so many patients who remained happy despite facing death. Hence, we conducted this qualitative study to explore happiness in palliative care patients at the University of Malaya Medical Centre.
Twenty terminally ill patients were interviewed with semi-structured questions. The results were thematically analyzed.
Eight themes were generated: the meaning of happiness, connections, mindset, pleasure, health, faith, wealth, and work. Our results showed that happiness is possible at the end of life. Happiness can coexist with pain and suffering. Social connections were the most important element of happiness at the end of life. Wealth and work were given the least emphasis. From the descriptions of our patients, we recognized a tendency for the degree of importance to shift from the hedonic happiness to eudaimonic happiness as patients experienced a terminal illness.
Significance of results
To increase the happiness of palliative care patients, it is crucial to assess the meaning of happiness for each patient and the degree of importance for each happiness domain to allow targeted interventions.
Recent evidence suggests that synchronizing eating-fasting schedules with body's circadian rhythms or day-night cycles is important for metabolic health. Besides food quantity and quality, food timing may contribute to weight regulation. However, it is unclear if this factor during pregnancy can influence maternal weight retention after childbirth. Using data from a prospective cohort, the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study, we examined the associations of maternal circadian eating pattern and diet quality in pregnancy with substantial postpartum weight retention (PPWR) at 18 months. We assessed 687 pregnant women for their circadian eating pattern (night-eating, night-fasting and eating episodes) and diet quality (Healthy Eating Index) based on information derived from 24-h dietary recall at 26–28 weeks’ gestation. Night-eating was defined as > 50% of total energy intake during 1900–0659 h; night-fasting duration was determined based on the longest fasting interval between consumption of a calorie-containing food or beverage during 1900–0659 h; eating episodes were defined as events that provided ≥ 210 kJ with time intervals between eating episodes of ≥ 15 min; diet quality was ascertained using the Healthy Eating Index which measures adherence to the Singapore dietary guidelines for pregnant women. PPWR was calculated by subtracting the weight at the first antenatal clinic visit from weight at 18-month postpartum. Substantial PPWR was defined as weight retention of 5 kg or more. Adjusting for maternal age, ethnicity, education, parity, night shift, mood, body mass index and total energy intake, multivariable binary logistic regression analysis was performed to estimate odds ratio (OR) of substantial PPWR in relation to circadian eating pattern and diet quality. Of 687 women, 110 (16%) had substantial PPWR. After confounders adjustment, night-eating (OR 1.95; 95% confidence interval 1.05, 3.62) and lower diet quality (1.91; 1.17, 3.10) were independently associated with higher odds of substantial PPWR. No associations with substantial PPWR were observed for night-fasting duration and number of eating episodes. During pregnancy, women with higher caloric consumption at night and lower diet quality had a greater likelihood of substantial PPWR. These findings suggest that aligning eating time with day-night cycles and adherence to dietary guidelines during pregnancy may help to alleviate overweight and obesity risk in postpartum life. There is a possibility that these eating patterns persist beyond pregnancy and pose implications for long-term obesity development. Further investigation on this area is required.
As we have seen, the domains of security cooperation in Southeast Asia sanctioned and supported by the ASEAN-based frameworks include humanitarian assistance and disaster relief, counterterrorism, maritime security, cyber security and the like. Of late, there have been hints that responsible provision could eventually extend to cover assistance to Southeast Asian countries in the area of conflict management, not least because the terrorism threat to Southeast Asia has evolved in substance and style, which in turn has prompted regional states to introduce new methods and to muster new actors – the military in particular – to the ‘war on terror’. The difficulties facing Philippine security forces in their efforts to root out ISIS affiliates occupying Marawi in the southern Philippine island of Mindanao have reportedly elicited offers of assistance from Indonesia, Malaysia and Singapore. In response, the Duterte administration has accepted an offer of military assistance from Singapore out of concern that further deterioration of the situation ‘would cause instability to the rest of ASEAN’ (Channel News Asia, 2017). More recently, in response to the burgeoning Rohingya refugee crisis as a result of the Myanmar military's offensive – some have called it a genocidal campaign – against Rohingya ‘insurgents’, regional countries such as Indonesia, Malaysia and Singapore have variously made offers of aid and assistance to help alleviate the crisis (The Straits Times, 2017a).
To the extent that these neighbourly acts constitute efforts in conflict management, the R2Provide arguably approximates the ‘sovereignty as responsibility’ concept proposed by Deng and associates (Deng et al, 1996). Yet it should be noted that nowhere in the Southeast Asian practice is the notion of outside intervention entertained. Whilst Southeast Asian countries may agree with Deng concerning the putative responsibility and accountability of states to both their domestic and external constituencies, social persuasion and peer pressure, rather than outright coercion, serve as the principal means through which provider countries work with prospective recipient countries to reach consensual outcomes (Tan, 2013a). In this chapter, we explore the exercise of responsible provision in the three areas, the first being HADR, and another two areas from which the region has traditionally kept its distance because they constitute the realm of ‘domestic’ or ‘internal’ affairs of states, namely conflict management and human rights.
With few exceptions, one of the unfortunate consequences of scholarship on the R2P and Southeast Asia is its conclusion, tacit or otherwise, that the region's weak acceptance of the R2P norm effectively denotes the relative absence of a responsible form of sovereignty there. Nonetheless, it has taken a while for the region to talk openly about what responsibility in its neck of the woods looks like or could conceivably look like, not least because security matters have long remained (and in some ways, still remain) the near exclusive preserve of policymakers and the academics and policy intellectuals who study and pontificate about it (Acharya, 2003a). As we shall see later, among the many regional developments in Southeast Asia, the region-wide debate among academics and policy practitioners that arose in the immediate aftermath of Cyclone Nargis, which devastated huge swathes of Myanmar in May 2008, was among the most useful in helping Southeast Asian leaders clarify what responsible sovereignty in their regional context could conceivably look like. Accordingly, Southeast Asian governments ought to exercise their sovereign obligation to provide for the security and well-being of their respective populations. However, in the relative absence of any such ability, governments ought to do their utmost to ensure that other resources are brought to bear in realizing those same objectives. What this book calls the ‘responsibility to provide’ – or the ‘R2Provide’ – can be defined, in the words of a former defence minister from Southeast Asia, as ‘a responsibility of all national governments to provide for the welfare of the people. If they are not able to provide for it, then it is their responsibility to see what other resources they can garner to help provide for the people’ (Teo, 2008).
However, as will be argued later, such a narrow and ultimately selfserving definition is insufficient, not least because it does not fully accord with the actions and activities of Southeast Asian countries themselves in their efforts as responsible providers. Granted, there is no question that when measured against the more exacting standards set by R2P, whatever sense of national and regional responsibility inherent and emergent within Southeast Asia falls short of the former.
The principle of ‘the responsibility to protect’ (R2P) is quite possibly the most important concept to be introduced in international relations in recent times. The aim of this chapter is to trace the emergence and evolution of this norm and to examine how it has fared in the context of Southeast Asia. The region's reactions to it can best be described as ambivalent. On the one hand, they accept for the most part of the notion that states bear certain responsibilities to protect their people from genocide, ethnic cleansing and other crimes against humanity, and should seek international assistance and enhance their capacities to implement those responsibilities. On the other hand, they have expressed reservations over the supposition that unilateral decisive action – including military action – can and should be employed by the international community against errant states that fail to protect their own populations. The chapter concludes by arguing that its relative ambivalence towards the R2P does not, indeed should not, preclude Southeast Asia from embracing a form of responsible sovereignty that may not satisfy all the conditions of the R2P norm, but which speaks to the particular conditions of the region in question and, as a consequence, is no less significant to the region's international relations.
Sovereignty: From right to responsibility
Despite its exalted status within international law and international relations, the concept of sovereignty – variously described as a ‘fundamental pillar of the international system’, a ‘basic element of the grammar of politics’, and the ‘grundnorm of international society’ – has also been declared ‘ambiguous’ and ‘fuzzy’ (Jackson, 1993: 431; Weber, 1995: 1; Biersteker and Weber, 1996: 2; Reus-Smit, 2001: 519; Badescu, 2011: 20). As the international jurist Lassa Oppenheim has correctly noted, ‘there exists perhaps no conception, the meaning of which is more controversial than that of sovereignty. It is an indisputable fact that this conception, from the moment when it was introduced into political science until the present day, has never had a meaning which was universally agreed upon’ (cited in Nagan and Hammer, 2004: 142). While it is probably appropriate and necessary for Alice in Wonderland to ask whether it is right that Humpty Dumpty can make any word mean whatever he chooses, the latter's logic has prevailed over that of the former so far as the story of sovereignty goes.
Crucial as they are, words and sentiments alone do not make the R2Provide ethos. This chapter examines the efforts Southeast Asian countries, more often than not under the rubric of ASEAN and through its various functional subsidiaries and its ‘Plus’ derivatives, have undertaken to develop the requisite capabilities – build their ‘response ability’ if you will – that would enable them to translate aspirations regarding responsible provision into reality. So far as the regional experience goes, the regionalization of responsibility in Southeast Asia is very much inextricably tied to the regionalization of defence and security in Southeast Asia, even though the latter has had a much longer developmental history. In this respect, the place and role of the ASEAN Defence Ministers’ Meeting and the wider regional offshoot, the ADMM-Plus – whose respective formations are discussed in detail later – are rather central to any realization of the R2Provide.
Developing responsibility and ‘response ability’ in Southeast Asia
Significantly, the formation of the ADMM and then the ADMM-Plus were by no means a given, not least in a region whose historical instincts have been to eschew overt forms of defence regionalism. This section looks at the sources and drivers of an indigenous brand of regionalism in the form of ASEAN, as well as the numerous constraints and facilitating conditions that respectively hindered and helped the rise of the ADMM and ADMM-Plus. It bears reminding that the categorical rejection of collective defence, whether with or without the great powers, has long been a guiding principle of regional organization. This rejection of collective defence, according to Amitav Acharya, is one of three ‘path dependent’ dispositions common to regional institutions in Asia – the other two being a general acceptance of Westphalian norms of sovereignty, non-interference and territorial integrity, and a preference for ‘soft’ or non-legalistic and formalistic regional cooperation (Acharya, 2003b: 219). The existence of the ADMM and the ADMM-Plus reveal a contemporary Southeast Asia not averse to institutionalized multilateral defence dialogue and cooperation at the highest levels with major military powers. These forums form the apex of a burgeoning tangled web of disparate initiatives and modalities including meetings of senior officials and uniformed chiefs as well as military-to-military exercises and exchanges, not all centred upon or inspired by ASEAN.
Deeds speak the language of the great virtues far better than words do. Words limp outside the gates of the mystery of compassion for strangers. (Hallie, 1997: 42)
Are Southeast Asians responsible? Are the sovereign states of Southeast Asia responsible actors that care and provide for their own people and societies? Do they hold a sense of obligation towards their neighbours in need within Southeast Asia? Do their foreign policies and neighbourly conduct reflect that sense of obligation and responsibility towards others? These questions are motivated by an incipient ‘ethos’ of intraregional responsibility that appears to be emerging among Southeast Asian countries – in an embryonic and uneven fashion, to be sure, and more evident in some than in others. This ethic or norm has been expressed in terms of acts of hospitality shown to strangers across national boundaries, who may be victims of earthquakes, typhoons and other natural disasters. It has manifested as forms of assistance given – rendered in forms varying from relief aid, financial assistance, military equipment and training, boots on the ground and the like – to neighbours coping with economic difficulties, problems of militancy and terrorism and so on. Arguably, it has also materialized as a mutual readiness by governments to resort to pacific and increasingly rulesbased approaches to manage and, where feasible, resolve their disputes with one another. While ideology could well be a driver behind this sense of responsibility, the story of what I call responsible provision in Southeast Asia suggests a considerably more complex narrative that sees, among other things, illiberal nations engaging in acts of hospitality, sometimes more so than professedly liberal democratic nations, towards their neighbours. On the other hand, strategic intentions and interests have been known to motivate the conduct of states, and Southeast Asian nations are obviously not exceptions. And yet it has neither always and only been due to cunning reason or realpolitik considerations that states, including Southeast Asian countries, do what they do (Jonas, 1996: 188; Peou, 2002/03; Eaton and Stubbs, 2006).
The foregoing considerations raise intriguing questions about the evolving relationship between sovereignty and responsibility in Southeast Asia.
The aim of this chapter is twofold. Firstly, it explores the ideas of Emmanuel Levinas, whose concept of responsibility for the other arguably provides an alternative vision of sovereignty and subjectivity in Southeast Asia to communitarian and liberal ethics. As we established in the previous chapter, both those ethical systems hold to the axiom that responsibility is first and foremost to the self, which for Levinas represents a totalizing imperative that always and already relegates and reduces the other through the all-consuming insistence to privilege the self. Beginning with Levinas’ themes of hospitality, reciprocity and justice, the chapter also pays close attention to how sympathetic interlocutors of Levinas have engaged with and reinterpreted those themes in ways that render them more practicable and actionable – indeed, Levinas’ ideas can at times seem otherworldly, even excessively idealistic, a drawback which Levinas himself has acknowledged – but without diluting their substance or diminishing their power. Secondly, the chapter unpacks the ethical and political ramifications of Levinas’ ethics for the responsibility to provide (R2Provide) as expressed in the various manifestations of responsible sovereignty in Southeast Asia examined in Chapters 4‒6. In particular, Levinas’ ideas (re)define the terms of the relationship between responsible providers and their recipients in three key ways: one, the assumptions and expectations over one's extension of hospitality to one's neighbours; two, the rethinking of mutuality and reciprocity between providers and recipients; and three, the ways in which the considerations of justice (as understood by Levinas) play out within the diplomatic and security contexts of Southeast Asia and, at least where responsible provision is carried out through the ADMM-Plus is concerned, the broader Asia-Pacific.
We begin with Levinas’ ethics. The overarching leitmotif in his thought is that of responsibility: responsibility not to the self, but to and for the other. Responsibility for the other therefore comes before everything else; indeed, it is the very thing that renders thought possible at all (Derrida, 1992b: 92). For Levinas, ethics as ‘first philosophy’ is a highly problematic assumption because of the emphasis in Western philosophy – at least until that of Heidegger, to whom Levinas’ own work is indebted but which he also sought to transcend (Heidegger, 2010) – on presence and self, without consideration for the other except in instrumental or utilitarian terms, opens it up ironically (as we shall see later) to the possibility of tyranny and evil.
In front of the face, I always demand more of myself. (Levinas, 1997: 294)
In an address to a symposium on human security at the University of Tokyo in February 2010, the late Surin Pitsuwan, speaking then as the Secretary General of ASEAN, contended that when states focus on securing the well-being of human individuals, they are helping to make sure that ‘state security and state sovereignty are effectively implemented to help, to protect, to promote the welfare, the wellbeing and the dignity security of their own people’ (ASEAN, 2010b). Using language reminiscent of the ‘responsibility to protect’ or R2P but not necessarily referencing that principle or its specific terms, Surin further insisted that ‘sovereignty and national security and state security need to be implemented with responsibility to protect the people, to promote the wellbeing of the people and certainly to guard against their indignity and the suffering that they may have to suffer as member [sic] of our human family’ (ASEAN, 2010b). As his words suggest, there is no question that the R2P – the doctrine of humanitarian intervention for which Southeast Asian countries have furnished at least their declaratory support – has had an impact on the regional debate in Southeast Asia within policy circles and most certainly within academia and the security studies communities. Although Southeast Asian governments have pushed back vigorously against the R2P's advocacy of military intervention against ‘irresponsible’ states – worrisome for a region where sovereignty and non-intervention/non-interference norms remain sacrosanct – it should however in no way, as this book has argued, be seen as a rejection of the notion of responsible sovereignty by the region's leaders and elites.
This book in summary
This book began with the proposition that traces of an ethos of regional responsibility are increasingly evident among the countries of Southeast Asia, some more than others, to be sure. We started the discussion in Chapter 2 by showing what this ethic is not: the UN-endorsed doctrine of ‘the responsibility to protect’ or the R2P. However, short of external intervention, there is in fact much about the R2P – such as the protective responsibilities of states and the timely provision of assistance and capacity-building by the international community (UN, 2009) – that Southeast Asian countries actually welcome if not embrace.
Hitherto this book has explored the emergence in Southeast Asia of an incipient ethos of responsible provision, whose consolidation in the region remains hugely problematic and unsettled. It has sought to map out the material and conceptual contours and contents of the R2Provide as such in a number of distinct but interrelated domains that are ostensibly ‘non-military’. Yet as we have seen in the context of areas such as HADR and counterterrorism, Southeast Asian states rely on their military assets and resources frequently and regularly. In this chapter and the following one, the book turns its attention to the philosophical and normative foundations that hitherto underpin responsible sovereignty or sovereign responsibility in Southeast Asia. The focus here is on the ways in which communitarian and liberal approaches – which I shall treat as ‘rival’ or contending ethical explanations to Levinas’ ethics introduced in the next chapter – understand and advance their respective conceptions of sovereignty as responsibility in Southeast Asia. As noted in Chapter 2, the R2P is a concept with African roots but a liberal mien (Luck, 2008; Williams, 2009; Mabera and Spies, 2016). As such, some of the assumptions and expectations of the R2P run counter to the illiberalism that still characterizes much of Southeast Asian political and diplomatic life, even though economic liberalization is an established convention in the region, notwithstanding the protectionist proclivities of some Southeast Asian economies (Rahardja and Patunru, 2015). Although the Southeast Asian region has experienced a level of democratization, the persistence and prevalence of unresolved tensions and disputes over sovereignty among most if not all Southeast Asian states – among themselves as well as with external powers such as China – have both underscored for Southeast Asian states the continued relevance of the non-interference norm and the ‘sovereignty as right’ idea, and hindered their full acceptance of R2P. Indeed, developments such as the military coup which brought Thai army chief Prayut Chan-o-cha to power in Thailand in May 2014, Cambodian leader Hun Sen's actions against his political opposition and domestic media organizations (Pongsudhirak, 2017), the rise of President Rodrigo Duterte in the Philippines and his administration's brutal war on drugs and crime that – at least according to the human rights group Amnesty International – has reportedly caused more deaths than was the case during the Ferdinand Marcos years (Caro, 2017),
Despite the long-held and jealously guarded ASEAN principle of non-intervention, this book argues that states in Southeast Asia have begun to display an increasing readiness to think about sovereignty in terms not only of state responsibility to their own populations but also towards neighbouring countries as well. Taking account of the realities of interstate cooperation in the region, and drawing on the work of Emmanuel Levinas, the author develops a new theoretical framework reflecting an evolution of attitudes about state sovereignty to explain this emerging ethic of regional responsibility.
So far, I have sought to develop the thesis that responsible sovereignty in Southeast Asia is best understood and embodied in the notion of a shared responsibility to provide. But in a conventional sense, responsible sovereignty is equally about the willingness of states to resolve their claims to their perceived sovereign rights through subjecting disputes they have with one another to mediation, arbitration and possibly even adjudication, with the end goal of regional resolution and reconciliation – even if they end up on the ‘losing side’. This includes the ability of states at times to dial down their nationalist and populist proclivities, whether in terms of tempering the nationalist demands of their citizenry or the resort by their political leaders to playing the nationalist card in the attempt to harness its force in support of their claims (Krebs, 2017), as well as adopting a middle approach that includes the use of tough rhetoric against a rival without overplaying the nationalist card, which reportedly describes Vietnam's approach to the diplomatic standoff sparked by China's deployment of the Haiyang Shiyou – or Hải Dương for the Vietnamese – 981 oil rig near the disputed Paracel Islands from May to July in 2014 (Nhung, 2016).
The aim of this chapter therefore is to trace Southeast Asia's embryonic experimentation with a rules-based approach – which could involve legal means but is not exclusive to them – to the management of its intra-regional and extra-regional relations, and to assess its implications for regional order and security. Understood here, ‘legalization’ – or ‘institutionalization’ if you like – involves the degree to which common rules and norms shape the behaviours of states, whether or not they actually go before the courts (Kahler, 2000). Efforts in this respect include ASEAN's on-going (and challenging) implementation of its charter and the selective resort by several ASEAN countries to legal means to settle disputes involving trade and territorial concerns. Although Southeast Asia generally lags behind some other regions in its willingness to countenance legalization, a growing number of Southeast Asian countries have in fact relied on third-party arbitration and/or adjudication. That they have sought to settle disputes between themselves and external parties, on one hand, and among themselves on an intra-mural basis, on the other, implies a slow but gradual willingness to seek legal recourse.