In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further (...) questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

Robert Nozick's adherence to Locke's puzzling doctrine about punishment can seem strange. Why does Nozick follow Locke in claiming that individuals in a state of nature have a right to punish any wrongdoer?Here reflection on this question proceeds by stages to a conclusion that Nozick as well as any other state-of-nature theorist of similar stripe should find disturbing. For, as we shall see, what Nozick describes as the general right of a minimal state to punish cannot arise within a state (...) of nature from the more plausible right of individuals to punish only those who harm them. (shrink)

In two recent studies we have examined the prose rhythms in the clausulae of late imperial Latin authors. We found two clausular systems to be prevalent, the cursus and the cursus mixtus. The cursus involves the use of accentual rhythms and consists of three basic cadences: planus, tardus, and velox. The cursus mixtus has been defined by modern scholars as a type of prose rhythm in which the clausula is structured along both accentual and metrical lines, that is by the (...) combination of one of the three forms of the cursus with one of the standard metrical forms derived from Cicero's system — cretic-spondee, dicretic, cretic-tribrach, or ditrochee. (shrink)

We argue that cognitive empathy and other instances of mental state attribution are a byproduct of self-awareness. Evidence is brought to bear on this proposition from comparative psychology, early child development, neuropsychology, and abnormal behavior.

Ethical concerns have been raised about the quality of informed consent by participants in phase 1 oncology trials. Interview surveys indicate that substantial proportions of trial participants do not understand the purpose of these trials—evaluating toxicity and dosing for subsequent efficacy studies—and overestimate the prospect of therapeutic benefit that they offer. In this article we argue that although these data suggest the desirability of enhancing the process of information disclosure and assessment of comprehension of the implications of study participation, they (...) do not necessarily invalidate consent by phase 1 trial participants. (shrink)

: The "therapeutic misconception," described by Paul Appelbaum and colleagues more than 20 years ago, refers to the tendency of participants in clinical trials to confuse the design and conduct of research with personalized medical care. Although the "therapeutic misconception" has become a term of art in research ethics, little systematic attention has been devoted to the ethical significance of this phenomenon. This article examines critically the way in which Appelbaum and colleagues formulate what is at stake in the therapeutic (...) misconception, paying particular attention to assumptions and implications that clinical trial participation disadvantages research participants as compared with receiving standard medical care. After clarifying the ethical significance of the therapeutic misconception with respect to the decision making of patients, we offer policy recommendations for obtaining informed consent to participation in clinical trials. (shrink)

This article focuses on mirror self-recognition, the ability to recognize one's own image in a mirror. It presents the result of the first experiment on mirror self-recognition which showed that chimpanzees are able to learn that the chimps they see in the mirror are not other chimps, but themselves, as evidenced by self-directed behaviour. It reviews evidence for neural network for self-recognition and self-other differentiation and cites evidence that frontal cortex and cortical midline structures are implicated in self-recognition tasks. It (...) also suggests that the mirror self-recognition ability correlates to large brain size relative to the animal's body size. (shrink)

In several recent studies we have developed precise statistical methodologies which have demonstrated that the cursus mixtus was the dominant rhythmical system for final clausulae in Latin prose from the third century a.d. to the fifth. The cursus mixtus consisted of four standard metrical forms derived from the richer variety of Cicero's Asiatic tradition – cretic-spondee, dicretic, cretic-tribrach and ditrochee –, which were structured according to three accentual patterns – planus, tardus and velox. The latter are differentiated by the number (...) of unstressed syllables intervening between and following two accented syllables. The planus has two unaccented syllables between two word accents and one after the last accent. The tardus has two between two accents and two after the last accent. The velox has four between two accents and one after the last accent. The four metrical forms are contained within the parameters of the accentual cadences. The planus contains either the cretic-spondee or the ditrochee ; the tardus either the dicretic or the cretic-tribrach ; the velox either the ditrochee or the cretic-spondee (nimium videbatur. Authors who used the cursus mixtus, however, preferred to effect an exact coincidence between the accent and ictus, and as a result evinced primarily the following standard rhythmical forms: planus/cretic-spondee; tardus/dicretic or cretic-tribrach; and velox/ditrochee. So far now we have examined only the rhythmical properties of final clausulae, but it is appropriate also to investigate for rhythm at internal positions within the sentence. (shrink)

: Originally presented during Ethic Rounds at the Dana-Farber Cancer Institute, this commentary on the case of a patient treated for life-threatening cancer explores the responsibilities of health care providers when addressing the patient's desire to adopt a child.

We argued last year in this journal that extensive integration of research and care is a worthy goal of health system design, and we second the call from Ruth Faden and colleagues to move toward learning health care systems. As they recognize, learning health care systems demand the coordination of research and medical ethics—two sets of normative commitments that have long been considered distinct. In offering a novel ethics framework for such systems, Faden et al. advance the scholarly debate about (...) how best to do this and challenge us to think more deeply about its practical implications. However, we believe that at least three issues they raise require additional attention. First, the research‐care distinction has more normative bite than they are willing to concede. Second, the role for independent oversight requires clarification. Finally, they neglect the concept of stewardship as a guiding obligation of learning health care systems. (shrink)

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict or (...) come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

: Medical research is widely thought to have a fundamentally therapeutic orientation, in spite of the fact that clinical research is thought to be ethically distinct from medical care. We need an entirely new conception of clinical research ethics—one that looks to science instead of the doctor-patient relationship.

Rooting, defined as a spectator’s demonstrative encouragement of a contestant’s effort, ideally has the morally positive aspects of benevolent concern and helpfulness but in practice strains against reasonable standards of conduct by being rude, excessively biased, exploitative, fanatical, and superstitious. Rooting may activate an atavistic, morally cogent sense of fighting for one’s group that is at odds with the universalism of civilized morality. The ‘merely play’ excuse can cut both ways, deflecting moral objections but also removing moral credit from rooting. (...) Although rooting is often not humane, humane rooting can occur and is supported by humane commentary by sports participants, broadcasters, and journalists. Humane rooting supports the premise of benevolence theories (Mengzi, Hutcheson) that morally ideal benevolence has a foothold in an innate general benevolence – seen in this area especially in benevolence toward efforts. Being partisan, excited, and demonstrative, rooters cannot perfectly embody ‘universal calm benevolence’, but they can consciously minimize the inhumane aspects of rooting and achieve a more fully prosocial satisfaction. (shrink)

An argument is developed at some length to show that any semantical theory which treats superficially nonperformative sentences as being governed by performative prefaces at some level of underlying structure must either leave those sentences semantically uninterpreted or assign them the wrong truth-conditions. Several possible escapes from this dilemma are examined; it is tentatively concluded that such hypotheses as the Ross-Lakoff-Sadock Performative Analysis should be rejected despite their attractions.

A concept of merit is used for spiritual accounting in many religious traditions, seemingly a substantial point of connection between religion and ordinary morality. Teachings of “merit transfer” (as in Buddhism and Roman Catholicism) might make us doubt this connection since they violate the principle that merit must be earned. If we examine the structure of ordinary schemes of desert, however, we find that personal worth is posited for a variety of reasons; the basic requirement in this realm is not (...) earning by individuals but rather a community’s program for cultivating desirable collaboration among its members. There are strong enough parallels between religiously envisioned merit transfer and socially normal conferrals and sharings of worth that we can conclude that the religious posits of transferred merit are indeed comprehensible as merit, whatever other problems of comprehensibility they pose. (shrink)

How might we think about relationships between philosophy as a way of life and the domain of the political? Or, since there are clearly, and importantly, multiple understandings of philosophy as a way of life and multiple aspects of the domain of the political, let me put my question somewhat more narrowly as: How might we think about relationships between the kind of ongoing work of self-cultivation and self-transformation which has been at least one continuing dimension of philosophy in the (...) West from its beginning and the existence, realities, and responsibilities of social life? (shrink)

Explores the basic forms of responsibility that we willingly assume and the collaborative fulfillment that we find in each.

In this book, Steven G. Smith focuses on the guidance function in language and scripture and evaluates the assumptions and ideals of scriptural religion in global perspective. He brings to language studies a new pragmatic emphasis on the shared modeling of life-in-the-world by communicators constantly depending on each other's guidance. Using concepts of axiality and axialization derived from Jaspers' description of the 'Axial Age', he shows the essential role of scripture in the historical progress of communicative action. This volume (...) clarifies the formative power of scriptures in religions of the 'world religion' type and brings scripture into philosophy of religion as a major cross-cultural category of study, thereby helping philosophy of religion find a needed cross-cultural footing. (shrink)

Considering the profoundly collaborative nature of human communication, the notion of guidance needs more careful consideration and foregrounding in the philosophy of language. The practically cruc...