In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 11.4 (2004) 357-359 [Access article in PDF] A Madness for the Philosophy of Psychiatry John Z. Sadler His enthusiasm brimming over with the rich set of ideas and problems he has discovered, Louis Charland's essay on identity, ethics, and the Internet should be grist for the philosophy of psychiatry mill for years. Indeed, a brief commentary cannot answer the many questions raised (...) by his paper. In response, I would like to focus on two general issues for this essay. Labels, Diagnoses, Reference, Experiences Many psychiatrists will take issue with Charland's use of the term label in reference to mental disorder concepts in this paper. I did not, but his relatively uncritical use of the labels and labeling terms in his essay prompts me to unpack some concepts that lurk behind the many other conceptual issues raised here. Psychiatric "labels" and "labeling" have a derogatory sense for many psychiatrists, because they are associated with a virulent antipsychiatry temperament dating back to the 1960s, at least in the United States (Sadler 2003). For many clinicians (as well as others) labeling implies that there is nothing more to psychiatric diagnosis and "mental illness" than the names given to various sorts of human diversity. This sort of psychiatric nominalism, the viewpoint goes, serves to pigeonhole people for the purposes, primarily, of political control or power. Charland's own viewpoint is more subtle than this, illustrated by his discussion of Hacking's "looping effects" and the related idea that social factors are influential in the manifestations, even causation, of mental disorders, but are not exhaustive in explaining mental disorders. However, because the whole matter of social construction of clinical phenomena is at the heart of Charland's discussion, further consideration of this metaphysical territory is warranted.The notion of a mental disorder concept as "label" betrays little about what, substantively, mental disorders are. A label on a can of peas tells us little, ultimately, about the nature of the contents; indeed, it is only a clue. When we shift labeling from a can of peas to a person—a self—then such a shallow clue to the "contents" of a person is an offensive simplification of a person's identity and selfhood. Hence the railing against psychiatric labeling in the 1960s through today.The general goals for psychiatric diagnosis and classification in systems like DSM-IV is are multiple, but at minimum, such denotations of clinical conditions are intended to advance the generation of knowledge about the conditions as well as provide a "shorthand" for clinicians in communicating about and understanding patients' conditions. How successful these diagnostic classification systems are for these and other purposes is a discussion for another time, but the [End Page 357] point here is that some sort of method of characterizing people's distresses is a precondition for understanding and explaining such distresses. The scientific processes of validation of psychiatric categories, at core, are to ensure that, as Gorenstein notes (1992), our clinical concepts are not empty, self-fulfilling prophecies, but rather refer to other, hopefully predictable, features of the patient's distress. Such validation of clinical "constructs" is the basis for developing and testing specific treatments, as well as understanding more richly and deeply the clinical phenomenon. To have a label, then, under this view, is to have an empty nominalization, which is offensive and scientifically vapid. To have a diagnostic construct—a disorder—is to have a concept which empirically refers to, as Paul Meehl put it, a "nomological network" of predictable, lawlike, implications (Sadler 2004a).However, as Charland, Hacking, and others have noted, the reflexivity of the human self and our ultimately crude ways of characterizing selves leads to a serious problem, even for the most rigorously validated psychological categories. That problem is the changeability of the self, the capacity of people to remake themselves according to their own ideas along with the sociocultural ether of ideas that surrounds us all. This means that our understanding of mental disorders, both as aggregates of features, and well as individual patients over time, are "moving targets," the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Uselessness of Polygenic Scores for Addressing Campus DrinkingBennett Knox (bio), Hannah Allen (bio), and Stephen M. Downes, PhD (bio)Here we articulate a negative answer to Turkheimer and Greer’s question: “Is it possible to envision a genetically informed program that ethically intervenes on campus drinking?” (Turkheimer & Greer, 2024). However, first, we note that the authors cover an immense amount of ground in their paper. They lend insight into (...) how psychiatric genetics, at its very core, is conducted through their detailed examination of a large body of work in one specific area of this large field. A main result of this is to explain the gulf between results and conclusions, work that provides an invaluable service not just to various areas in philosophy and bioethics, but that are deserving of readership by a very wide audience. This gulf is explained via a careful accounting of the statistical measures used to assess the impact of genes on alcohol-related behavior in the college students sampled and comparisons between the strength of these measures and the strength and scope of conclusions drawn by the Spit for Science (S4S) researchers.A brief mention of the statistical measures in question helps set up our main focus. As Turkheimer and Greer note, before advances in sequencing technology, human behavior geneticists generated heritability coefficients for traits of interest. These coefficients were standardly produced from twin study work, which historically was the best way of getting a sense of the relative contribution of genes to a trait of interest as we cannot, or rather should not, conduct breeding experiments on humans. Current descendants of heritability coefficients come from genome-wide association studies (GWAS), which can be conducted on large groups of unrelated people. One key measure of interest arising from GWAS is a polygenic score (PGS), which “can be thought of as an observed manifestation at the individual level of the abstract variance ratio estimated by a heritability” (Turkheimer & Greer, 2024). Turkheimer and Greer focus on R2 values, which roughly “describe the magnitude of the relationship between the polygenic score and the phenotypes [of interest]” [End Page 437] (Turkheimer & Greer, 2024). They point out that the largest R2 reported in an S4S study is 6.5% (0.065). R2 are taken to be small at 0.01, medium at 0.09, and large at 0.25 in many areas of social science research but there are fields, for example, drug assay work, where only much higher R2 values are considered indication of a large effect. By this assessment, most of the R2 values reported by the S4S researchers, or calculated by Turkheimer and Greer when not reported, are very, very small, sitting well below the level of small effect of 0.01.Given these very low R2 measures, we agree with Turkheimer and Greer that S4S researchers did not uncover genetic information that could be informative, let alone actionable, for administrators concerned with campus drinking. However, it is worth asking what it would have looked like if S4S had produced such information. Suppose that S4S had been wildly successful, producing the Gattaca-like genetic information of “polygenic scores making reliable predictions that individuals had a 35% chance of developing a psychiatric disorder [here, alcoholism]” (Turkheimer & Greer, 2024). If a student was given their PGS, how are they to interpret it and act on it? How would this information be put to use by an administrator to address the problem of campus drinking?For the information to be leveraged at all, it would require consent from a significant number of students to have their PGS calculated and made available to themselves or administrators. Were scores to be calculated without active consent from the student (perhaps by using the sample provided to S4S), this would be a serious ethical violation. But even if a sufficient number of students did consent to having their PGS for alcoholism calculated, it is still not clear how this information could be used in an ethical manner to address the problem of campus drinking.If this student was already aware of a family history of alcoholism, then the PGS might do little more than quantify... (shrink)

Failings of a categorical systemFor decades, standardized classification systems have attempted to define psychiatric disorders in our mental health care system, with the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association (APA), 2013) and International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10; World Health Organization, 2010) being internationally best-known. One of the major advantages of the DSM must be that it has seriously diminished the international linguistic confusion regarding psychiatric disorders. Since (...) its introduction, it contributed extensively towards one common international language for defining and conceptualizing psychiatric disorders. Strikingly, within the field of psychological testing a similar step forward seems to have not yet been taken. At present, there exists no international standard for the use of psychological tests that takes the definition of a specific symptom as listed in DSM-5 as its starting point, and reliably and validly measures this symptom. Rather, the majority of tests are measuring constructs consisting of a multitude of symptoms. For example, the Beck’s Depression Inventory (Beck et al., 1996) measures core symptoms of depression summing up to a depression score. Accordingly, we believe it is time for a change. The diagnostics of psychiatric disorders, where disorders are defined as nosological units with a single cause, a single organic substrate, and a single time course, has been problematic for centuries. The field of psychiatry has always been ambivalent about its desire to follow a medical model (Blaney, 2015), but afflicted due to its definitions of pathology. The definition of a psychiatric disorder in DSM-5 offers little room for a clear cut pathogenesis and harsh demarcation of syndromes. This is reflected in the DSM-5, where it states: “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013, p.20). An unfortunate and recognized consequence of this definition within the current system is that many symptoms overlap within categories of psychiatric disorders and patients end up diagnosed with many co-morbid disorders.Two fundamental problemsRegardless of new attempts to improve the diagnostics of psychiatric disorders, the DSM-5 represents the status quo. Consequently, the distinction between diagnosis and classification remains substantial and more than a discussion on semantics. We identify two fundamental problems within the current framework. Generally, a psychiatric diagnosis is considered to be descriptive (Hengeveld and Schudel, 2003). The clinician will describe a syndrome (its nature, timespan, and severity) within the framework of a disorder, and often include a differential diagnosis, predisposing protective or vulnerability factors, and provoking or maintaining factors. Within the DSM-5 framework, a similar ‘approach to clinical case formulation’ is taken (APA, 2013, p. 19). Evidently, a descriptive diagnosis has a hypothetical character. It consists of the clinician’s hypothesis and is based on his or hers professional considerations according to the abovementioned factors. Once the clinician has formulated a descriptive diagnosis, it is then complementary ‘translated’ into a DSM-5 classification. Herein lies the problem. For the layman, the existence of this distinction between diagnosis and classification is usually unknown. Preceding treatment, the clinician will give the client a classification of the existing psychiatric problems and the client may attribute more meaning to it than appropriate, thereby fostering the risk of reification. Second, the DSM-5 is a categorical system. Thus, individual disorders are regarded as discrete units – ‘you either have it, or you don’t’. DSM-5 states about this: “(…) scientific evidence places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors (…)”. And “(…) we have come to recognize that the boundaries between disorders are more porous than originally perceived.” (APA, 2013, p. 6). This leads to a fundamental problem. Because the overwhelming majority of psychiatric disorders examined thus far using taxometric methods appear to be dimensional in nature (Haslam, 2003; Widiger and Samuel, 2005), consequently all of their categorizations become artificial and debatable. Even though DSM-5 took a modest step towards a more dimensional approach, its core remains categorical. To illustrate, consider the Borderline Personality Disorder (BPD). This classification consists of nine diagnostic criteria of which a minimum of five need to be present for the diagnosis of BPD. A simple numerical combination algorithm leads to a staggering number of 256 distinct presentations of BPD (Albion et al., 2013). Due to this chameleon-like nature, the disorder’s diagnostic validity becomes questionable. Strikingly, this number is relatively small when compared to other conditions, e.g., there are 636,120 ways to have posttraumatic stress disorder (Galatzer-Levy and Bryant, 2013).DSM-5 does propose an alternative model for personality disorders based on personality functioning and traits (APA, 2013, p. 761), as a possible answer to the problem that most patients fit with multiple co-morbid personality disorders or to the category of personality disorder not otherwise specified. In November 2012, the chair committee of APA decided to move this alternative model to section III of DSM-5 and to sustain the categorical system in section II. A potential solutionDSM-5 and its predecessors have brought about an invaluable improvement regarding the formulation of a common international language for psychiatric disorders. However, the individual disorders fit poorly with its starting point of discrete units and strict boundaries. Van Os (2014) has argued for a better balance between the categorical and personalized aspects of psychiatric disorders. We argue for a two-step approach.Particularly due to the ‘weak boundaries’ between disorders, it might be beneficial to limit ourselves by merely categorizing clients into the main categories of the DSM-5 according to their most prominent symptoms (Van Os, 2014), i.e. their main complaint. In other words, clinicians could first ask themselves whether the symptomatology is concerning a neurodevelopmental disorder, or a bipolar and related disorder, or a depressive disorder, and so on. It will drastically reduce the over 400 classifications in DSM-5 down to 20 categories. Van Os (2014) even argues to combine some of the main categories, reducing this number even further to 15 categories. The advantages of reducing the over 400 classifications are fivefold: 1) a syndrome, being an aggregation of symptoms, creates a false relation between symptoms that are that are already heterogeneous themselves; 2) 15 broad categories are functional: it results into a very heterogeneous group of clients within a category and thus prevents stereotypes and invites further personalizing of complaints; and 3) a dimensional measure of a symptom rather than a syndrome will correspond better with the client regardless of it not providing the complete picture. Focusing on the main complaint will indicate where there is an immediate need for care (Van Os, 2014); 4) it will allow clinicians to recognise subthreshold conditions more easily (Magruder and Calderone, 2000); and 5) it might facilitate the development of clear demarcations between normal and abnormal functioning (Kessler, 2002; Widiger and Samuel, 2005). Please, see also Table 1.This also fits well within scientific advances, as thus far strongest evidence has been found for a distinction between internalizing and externalizing disorders, even superseding these 15 main categories (DSM-5; APA, 2013, p.13, but see Weiss et al., 1998). The second step would concern the personalized aspect, which we argue to define on a level of core symptoms of the specific main category, to be agreed upon later. To assess these core symptoms, the field of psychological testing could develop an internationally applicable instrument to reliably and validly measure each (core) symptom on a dimensional scale. Many of these instruments are readily available and have proven its psychometric properties within scientific research. Elements from these instruments could be easily transformed to work within the new system. Within the field of psychology, this approach could aid development of a common international language to define symptoms, analogous to the field of psychiatry. Importantly, current psychological testing mainly implies the use of self-report measures. This leads to an abundance of auto-amnestic information. To increase the reliability and validity of psychological tests to assess DSM-5 symptoms, it may be important to add two additional information resources. This would entail psychological tests where a next of kin answers questions about the symptom of the client, and psychological tests that include the clinicians’ judgment, such as structured clinician-based interviews. Conversely, we also need to acknowledge the well-known limitations of clinical judgment (e.g., Faust, 1986; Garb, 1998). Advantages of a new frameworkThe changes we suggest have big implications and are not easily implemented in the current framework. Clients may prefer the comfort of a single clear label, similar to what they are used to in other areas of medicine. Health insurance providers and policy makers may argue for single labels as well. Therefore, it would require a lot of explanation from our clinicians to promote a change. Our suggestions for broader categories may not disambiguate the current situation better than the existing approach, but it will promote personalisation of health care. Difficulties in diagnostic reliability will remain in disorders that fall on the boundaries of the taxons, e.g., schizoaffective disorder versus bipolar disorder with psychotic characteristics, which may benefit from further study. There are also some politically tinged questions to keep in mind: How will we finance our health care, and how will we ensure a gradual transition from the current financing system, including clients who already have their labels? What about visitations from insurers and health inspection? How can they control for a good standard of quality in health care when considering the increasing heterogeneity? Nevertheless, we argue that the benefits outweigh the disadvantages. We will see a shift from a categorical to a personalized approach, which will lead to less (self) stigmatizing, less estrangement, and it will challenge reification thinking. DSM-V states that “a reformulation of research goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches to diagnosis in coming years” (APA, 2013, p. 13). Our proposition for psychological testing on symptom level could contribute to this development. Furthermore, this new approach will do more justice to the heterogeneity of symptoms within and outside of classification categories, see also Table 1. Moreover, in this new approach we join forces of expert knowledge from the fields of psychiatry and psychological science. Finally, it offers new and potentially better opportunities to map health care needs. This in turn will lead to a better interface for allocation of appropriate treatment. It will present a clearer picture of when preventative care is preferred over treatment and vice versa. Importantly, health care needs will be more closely attuned to the ‘own story’ of the client.We argue for the national and international psychological associations in Europe and the United States of America to support the idea of a collective approach to develop an internationally standardized psychological testing battery to reliably assess all the core symptoms of the main categories in DSM-5. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Future Is Political and TransdisciplinaryAwais Aftab (bio)Philosophy, psychiatry, & psychology (PPP) is a transdisciplinary oasis, one of the few journals in mental health care that facilitate a meaningful dialogue between philosophers, psychiatrists, psychologists, and scholars from related disciplines. The fact that PPP successfully provides such a space is of no small importance, especially from my perspective as a psychiatrist. The multidisciplinary nature of the undertaking has been (...) a central aspect of the identity of the journal from the very beginning. PPP has maintained this transdisciplinary inclusive spirit over the years, and its editorial and advisory boards remain richly representative, but the challenge of ensuring continued participation of clinicians is not insubstantial. After all, the point is not token participation, but a robust and transformative interdisciplinary engagement. Clinicians have much to contribute to philosophical debates, however, such capacity for dialogue requires sustained cultivation (Aftab & Waterman, 2021), and forces in medical education have led to a situation where comparatively fewer psychiatrists have the interest or the ability to engage in such rigorous dialogue with philosophers. Philosophy of mental health has grown and specialized exponentially since the mid-90s. Keeping up with this literature is difficult even for philosophers, it is no small feat for full-time clinicians.This means that PPP and its affiliate organizations have a responsibility to take a more active role in supporting educational initiatives to ensure that future generations of psychiatric clinicians are able to contribute to philosophical debates, and that philosophy of psychiatry does not become divorced from clinical and practical concerns. My advice to clinicians based on my experience would be two-fold: first, it is essential to acquire a basic familiarity with the philosophy of psychiatry literature. Aftab and Waterman (2021) offer a sample list of reading recommendations. At the time of this writing, the International Network for Philosophy and Psychiatry is also undertaking efforts to develop curricula aimed at clinicians. Second, it is important to find ways to interact with others in the philosophy of psychiatry community. Formal avenues to do so include the annual meetings of the Association for the Advancement of Philosophy and Psychiatry and the Philosophy Special Interest Group of the Royal College of Psychiatrists, among others. There are also various online communities active on social media that many find helpful.In recent years, we have seen an unprecedented enthusiasm and support for inclusion of lived experience in mental health care. This is a welcome and much needed development, but we are only just beginning to scratch the surface of [End Page 5] how to philosophically navigate this inclusion. Frameworks such as standpoint epistemology and epistemic justice offer us starting points (Knox, 2022), but much remains to be worked out (Aftab, 2022). There are notable philosophical challenges, such as ascertaining the limits of lived experience, and the biases and errors to which it is vulnerable; the application of scientific method and philosophical criticism to lived experience; methods to resolve disagreements when different forms of lived experience contradict each other; handling discrepancies between knowledge from lived experience and knowledge from other sources be handled; and analyzing the intersection of politics of lived experience with other differentials of power. I anticipate that these topics will be of central importance to the field and to the journal in the coming years.It is also vital that philosophy of psychiatry engage with the sociopolitical dimensions of madness (Kalathil & Jones, 2016). The failure of philosophy to do so in a meaningful way has already been articulated powerfully by commentators such as Nev Jones (2022). An important aspect of acknowledging philosophy's failures in this regard comes from the notion of "elite capture," recently popularized by Olúfẹ́mi O. Táíwò (2022). It refers to how progressive philosophical ideas such as standpoint epistemology are co-opted by the "elite" to serve their own ends. Discussions on social media have already begun to point out that concepts in philosophy of psychiatry such as "epistemic injustice" show signs of elite capture by the psychiatric establishment, resulting in token participation but no systemic changes. Philosophy of psychiatry needs to tackle its own vulnerability to co-option. This will require creative forms of philosophizing and engagement with... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.4 (2002) 381-382 [Access article in PDF] The Borderlands of Psychiatry and Theology Stephen Sykes Keywords: psychiatry, theology, spirituality. THE DISCUSSION OF THE TERMS we use to speak of experiences on the boundaries between spirituality and mental disorder is very important. Jackson and Fulford (1997) have gone a long way to avoid flattening the concepts into a single conceptual scheme, too far (...) for some of their critics like Littlewood (1997) and Storr (1997), but not far enough for Bratton and Marzanski (2002), who eventually accuse them of "anthropocentric psychologism." They want to preserve theological categories intact, mainly because this is how the subjects themselves see their experiences, but also because there is, they hold, additional explanatory value in such a language schema. As evidence they point to unremarkable attitudes and practices, which are nonetheless demonstrably part of the Christian way of life.The borderlands between theology and psychiatry are not alone in witnessing this dispute. A similar conflict has arisen in the discussion of public policy. In politics, people of religious conviction or representatives of faith communities have sometimes been told either to hold their tongues (because "not many people believe these things nowadays" or because "it's wrong to impose your beliefs on other people") or to formulate their proposals in nonreligious language. It is far from obvious that this is not a sophisticated form of discrimination, nonetheless objectionable for its being practiced by nonreligious people. The creation of genuine equality of access to the space for public discussion of political proposals is not at all easy.I have personal experience of the analogous difficulty in psychiatric practice. In a discussion of the overinvolvement of carers for a person with mental health problems self-sacrificing behavior was used with a negative connotation. But, as in the case of Carol, how were these actions to be construed—were they normal for a Christian or psychopathological? My personal response is that it is correct to say that a boundary exists between ordinary Christian spiritual experience (the kind that religious believers would immediately recognize as part of their religious lives) and disturbed or distorted perceptions that are the result of mental illness and can be mitigated by appropriate treatment. But the fact that a boundary exists in principle does not necessarily imply that it is always easy to draw the distinction in practice. Typically the cases that cause the most difficulty lie on the borderlands. Although on the face of it, it looks attractive to demonstrate the security of the criteria by making discriminations in precisely this area (and the point of the cases in Jackson and Fulford is precisely that they raise these complexities), in [End Page 381] fact it may be that such instances require both languages. In this case, Bratton and Marzanski are correct to argue for the retention of a theological frame of reference. The strength of their argument lies precisely in the support that fellow members of the respective faith communities are able to give to the people who, despite their manifest illnesses, persist in religiously justifiable courses of action.The paper raises one very important matter that bedevils a lot of the current literature, namely how spirituality is to be understood. In my view, there is a lot of purely arbitrary definition of this term, whose meaning has developed rapidly under specific social conditions (Sykes 2000a). In medicine, it functions best when it is taken to be a reminder that a patient may have had contact with a specific religious tradition that has contributed or still contributes to her worldview. In modern Western society, account has to be taken both of residual religiosities or fallback positions, and of new religions, as well as of traditional religious groupings. In the case of mental illness, it may be very important for a medical practitioner to be aware of the impact of these religious promptings on the formulation of the narrative identity of an individual—no easy task (Sykes 2000b).The generality of spirituality ought not to deflect the professional from attending to the particular tradition or traditions which have... (shrink)

ABSTRACT I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments. INTRODUCTION In contrast to the classic model of randomized-control trials, often with a large number of (...) subjects enrolled, precision medicine attempts to optimize therapeutic outcomes by focusing on the individual.[i] A recent publication highlights the strengths and weakness of both traditional evidence-based medicine and precision medicine.[ii] Plus, it outlines a tension in the shift from evidence-based medicine’s inductive reasoning style (the collection of data to postulate general theories) to precision medicine’s abductive reasoning style (the generation of an idea from the limited data available).[iii] The paper’s main example is the application of precision medicine for the treatment of cancer.[iv] I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. As the name suggests, brain-computer interfaces are a significant advancement in neurotechnology that directly connects someone’s brain to external or implanted devices.[v] Among the various kinds of brain-computer interfaces, adaptive deep brain stimulation devices require numerous personalized adjustments to their settings during the implantation and computation stages in order to provide adequate relief to patients with treatment-resistant disorders. What makes these devices unique is how adaptive deep brain stimulation integrates a sensory component to initiate the stimulation. While not commonly at the level of sophistication as self-supervising or generative large language models,[vi] they currently allow for a semi-autonomous form of neuromodulation. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments.[vii] ANALYSIS I. The State of Precision Medicine in Oncology and the Epistemological Shift While a thorough overview of precision medicine for the treatment of cancer is beyond the scope of this article, its practice can be roughly summarized as identifying clinically significant characteristics a patient possesses (e.g., genetic traits) to land on a specialized treatment option that, theoretically, should benefit the patient the most.[viii] However, in such a practice of stratification patients fall into smaller and smaller populations and the quality of evidence that can be applied to anyone outside these decreases in turn.[ix] As inductive logic helps to articulate, the greater the number of patients that respond to a particular therapy the higher the probability of its efficacy. By straying from this logical framework, precision medicine opens the treatment of cancer to more uncertainty about the validity of these approaches to the resulting disease subcategories.[x] Thus, while contemporary medical practices explicitly describe some treatments as “personalized”, they ought not be viewed as inherently better founded than other therapies.[xi] A relevant contemporary case of precision medicine out of Norway focuses on the care of a patient with cancer between the ventricles of the heart and esophagus, which had failed to respond to the standard regimen of therapies over four years.[xii] In a last-ditch effort, the patient elected to pay out-of-pocket for an experimental immunotherapy (nivolumab) at a private hospital. He experienced marked improvements and a reduction in the size of the tumor. Understandably, the patient tried to pursue further rounds of nivolumab at a public hospital. However, the hospital initially declined to pay for it given the “lack of evidence from randomised clinical trials for this drug relating to this [patient’s] condition.”[xiii] In rebuttal to this claim, the patient countered that he was actually similar to a subpopulation of patients who responded in “open‐label, single arm, phase 2 studies on another immune therapy drug” (pembrolizumab).[xiv] Given this interpretation of the prior studies and the patient’s response, further rounds of nivolumab were approved. Had the patient not had improvements in the tumor’s size following a round of nivolumab, then pembrolizumab’s prior empirical evidence in isolation would have been insufficient, inductively speaking, to justify his continued use of nivolumab.[xv] The case demonstrates a shift in reasoning from the traditional induction to abduction. The phenomenon of ‘cancer improvement’ is considered causally linked to nivolumab and its underlying physiological mechanisms.[xvi] However, “the weakness of abductions is that there may always be some other better, unknown explanation for an effect. The patient may for example belong to a special subgroup that spontaneously improves, or the change may be a placebo effect. This does not mean, however, that abductive inferences cannot be strong or reasonable, in the sense that they can make a conclusion probable.”[xvii] To demonstrate the limitations of relying on the abductive standard in isolation, commentators have pointed out that side effects in precision medicine are hard to rule out as being related to the initial intervention itself unless trends from a group of patients are taken into consideration.[xviii] As artificial intelligence (AI) assists the development of precision medicine for oncology, this uncertainty ought to be taken into consideration. The implementation of AI has been crucial to the development of precision medicine by providing a way to combine large patient datasets or a single patient with a large number of unique variables with machine learning to recommend matches based on statistics and probability of success upon which practitioners can base medical recommendations.[xix] The AI is usually not establishing a causal relationship[xx] – it is predicting. So, as AI bleeds into medical devices, like brain-computer interfaces, the same cautions about using abductive reasoning alone should be carried over. II. Responsive Neurostimulation, AI, and Personalized Medicine Like precision medicine in cancer treatment, computer-brain interface technology similarly focuses on the individual patient through personalized settings. In order to properly expose the intersection of AI, precision medicine, abductive reasoning, and implantable neurotechnologies, the descriptions of adaptive deep brain stimulation systems need to deepen.[xxi] As a broad summary of adaptive deep brain stimulation, to provide a patient with the therapeutic stimulation, a neural signal, typically referred to as a local field potential,[xxii] must first be detected and then interpreted by the device. The main adaptive deep brain stimulation device with premarket approval, the NeuroPace Responsive Neurostimulation system, is used to treat epilepsy by detecting and storing “programmer-defined phenomena.”[xxiii] Providers can optimize the detection settings of the device to align with the patient’s unique electrographic seizures as well as personalize the reacting stimulation’s parameters.[xxiv] The provider adjusts the technology based on trial and error. One day machine learning algorithms will be able to regularly aid this process in myriad ways, such as by identifying the specific stimulation settings a patient may respond to ahead of time based on their electrophysiological signatures.[xxv] Either way, with AI or programmers, adaptive neurostimulation technologies are individualized and therefore operate in line with precision medicine rather than standard treatments based on large clinical trials. Contemporary neurostimulation devices are not usually sophisticated enough to be prominent in AI discussions where the topics of neural networks, deep learning, generative models, and self-attention dominate the conversation. However, implantable high-density electrocorticography arrays (a much more sensitive version than adaptive deep brain stimulation systems use) have been used in combination with neural networks to help patients with neurologic deficits from a prior stroke “speak” through a virtual avatar.[xxvi] In some experimental situations, algorithms are optimizing stimulation parameters with increasing levels of independence.[xxvii] An example of neurostimulation that is analogous to the use of nivolumab in Norway surrounds a patient in the United States who was experiencing both treatment-resistant OCD and temporal lobe epilepsy.[xxviii]Given the refractory nature of her epilepsy, implantation of an adaptive deep brain stimulation system was indicated. As a form of experimental therapy, her treatment-resistant OCD was also indicated for the off-label use of an adaptive deep brain stimulation set-up. Another deep brain stimulation lead, other than the one implanted for epilepsy, was placed in the patient’s right nucleus accumbens and ventral pallidum region given the correlation these nuclei had with OCD symptoms in prior research. Following this, the patient underwent “1) ambulatory, patient-initiated magnet-swipe storage of data during moments of obsessive thoughts; (2) lab-based, naturalistic provocation of OCD-related distress (naturalistic provocation task); and (3) lab-based, VR [virtual reality] provocation of OCD-related distress (VR provocation task).”[xxix] Such signals were used to identify when to deliver the therapeutic stimulation in order to counter the OCD symptoms. Thankfully, following the procedure and calibration the patient exhibited marked improvements in their OCD symptoms and recently shared her results publicly.[xxx] In both cases, there is a similar level of abductive justification for the efficacy of the delivered therapy. In the case study in which the patient was treated with adaptive deep brain stimulation, they at least had their neural activity tested in various settings to determine the optimum parameters for treatment to avoid them being based on guesswork. Additionally, the adaptive deep brain stimulation lead was already placed before the calibration trials were conducted, meaning that the patient had already taken on the bulk of the procedural risk before the efficacy could be determined. Such an efficacy test could have been replicated in the first patient’s cancer treatment, had it been biopsied and tested against the remaining immunotherapies in vitro. Yet, in the case of cancer with few options, one previous dose of a drug that appeared to work on the patient may justify further doses. However, as the Norwegian case presents, corroboration with known responses to a similar drug (from a clinical trial) could be helpful to validate the treatment strategy. (It should be noted that both patients were resigned to these last resort options regardless of the efficacy of treatment.) There are some elements of inductive logic seen with adaptive deep brain stimulation research in general. For example, abductively the focus could be that patient X’s stimulation parameters are different from patient Y’s and patient Z’s. In contrast, when grouped as subjects who obtained personalized stimulation, patients X, Y, and Z demonstrate an inductive aspect to this approach’s safety and/or efficacy. The OCD case holds plenty of abductive characteristics in line with precision medicine’s approach to treating cancer and as more individuals try the method, there will be additional data. With the gradual integration of AI into brain-computer interfaces in the name of efficacy, this reliance on abduction will continue, if not grow, over time. Moving forward, if a responsive deep brain stimulation treatment is novel and individualized (like the dose of nivolumab) and there is some other suggestion of efficacy (like clinical similarities to other patients in the literature), then it may justify insurance coverage for the investigative intervention, absent other unrelated reasons to deny it. III. Ethical Implications and Next Steps While AI’s use in oncology and neurology is not yet as prominent as its use in other fields (e.g., radiology), it appears to be on the horizon for both.[xxxi] AI can be found in both the functioning of the neurotechnologies as well as the implementation of precision medicine. The increasing use of AI may serve to further individualize both oncologic and neurological therapies. Given these implications and the handful of publications cited in this article, it is important to have a nuanced evaluation of how these treatments, which heavily rely on abductive justification, ought to be managed. The just use an abductive approach may be difficult as AI infused precision medicine is further pursued. At baseline, such technology relies on a level of advanced technology literacy among the general public and could exclude populations who lack access to basic technological infrastructure or know-how from participation.[xxxii] Even among nations with adequate infrastructure, as more patients seek out implantable neurotechnologies, which require robust healthcare resources, the market will favor patient populations that can afford this complex care.[xxxiii] If patients already have the means to pay for an initial dose/use of a precision medicine product out of pocket, should insurance providers be required to cover subsequent treatments?[xxxiv] That is, if a first dose of a cancer drug or a deep brain stimulator over its initial battery life is successful, patients may feel justified in having the costs of further treatments covered. The Norwegian patient’s experience implies there is a precedent for the idea that some public insurance companies ought to cover successful cancer therapies, however, insurance companies may not all see themselves as obligated to cover neurotechnologies that rely on personalized settings or that are based on precision/abductive research more than on clinical trials. CONCLUSION The fact that the cases outlined above rely on abductive style of reasoning implies that there may not be as strong a justification for coverage by insurance, as they are both experimental and individualized, when compared to the more traditional large clinical trials in which groups have the same or a standardized protocol (settings/doses). If a study is examining the efficacy of a treatment with a large cohort of patients or with different experimental groups/phases, insurance companies may conclude that the resulting symptom improvements are more likely to be coming from the devices themselves. A preference for inductive justification may take priority when ruling in favor of funding someone’s continued use of an implantable neurostimulator. There are further nuances to this discussion surrounding the classifications of these interventions as research versus clinical care that warrant future exploration, since such a distinction is more of a scale[xxxv] than binary and could have significant impacts on the “right-to-try” approach to experimental therapies in the United States.[xxxvi] Namely, given the inherent limitations of conducting large cohort trials for deep brain stimulation interventions on patients with neuropsychiatric disorders, surgically innovative frameworks that blend abductive and inductive methodologies, like with sham stimulation phases, have traditionally been used.[xxxvii] Similarly, for adaptive brain-computer interface systems, if there are no large clinical trials and instead only publications that demonstrate that something similar worked for someone else, then, in addition to the evidence that the first treatment/dose worked for the patient in question, the balance of reasoning would be valid and arguably justify insurance coverage. As precision approaches to neurotechnology become more common, frameworks for evaluating efficacy will be crucial both for insurance coverage and for clinical decision making. ACKNOWLEDGEMENT This article was originally written as an assignment for Dr. Francis Shen’s “Bioethics & AI” course at Harvard’s Center for Bioethics. I would like to thank Dr. Shen for his comments as well as my colleagues in the Lázaro-Muñoz Lab for their feedback. - [i] Jonathan Kimmelman and Ian Tannock, “The Paradox of Precision Medicine,” Nature Reviews. Clinical Oncology 15, no. 6 (June 2018): 341–42, https://doi.org/10.1038/s41571-018-0016-0. [ii] Henrik Vogt and Bjørn Hofmann, “How Precision Medicine Changes Medical Epistemology: A Formative Case from Norway,” Journal of Evaluation in Clinical Practice 28, no. 6 (December 2022): 1205–12, https://doi.org/10.1111/jep.13649. [iii] David Barrett and Ahtisham Younas, “Induction, Deduction and Abduction,” Evidence-Based Nursing 27, no. 1 (January 1, 2024): 6–7, https://doi.org/10.1136/ebnurs-2023-103873. [iv] Vogt and Hofmann, “How Precision Medicine Changes Medical Epistemology,” 1208. [v] Wireko Andrew Awuah et al., “Bridging Minds and Machines: The Recent Advances of Brain-Computer Interfaces in Neurological and Neurosurgical Applications,” World Neurosurgery, May 22, 2024, S1878-8750(24)00867-2, https://doi.org/10.1016/j.wneu.2024.05.104. [vi] Mark Riedl, “A Very Gentle Introduction to Large Language Models without the Hype,” Medium (blog), May 25, 2023, https://mark-riedl.medium.com/a-very-gentle-introduction-to-large-language-models-without-the-hype-5 f67941fa59e. [vii] David E. Burdette and Barbara E. Swartz, “Chapter 4 - Responsive Neurostimulation,” in Neurostimulation for Epilepsy, ed. Vikram R. Rao (Academic Press, 2023), 97–132, https://doi.org/10.1016/B978-0-323-91702-5.00002-5. [viii] Kimmelman and Tannock, 2018. [ix] Kimmelman and Tannock, 2018. [x] Simon Lohse, “Mapping Uncertainty in Precision Medicine: A Systematic Scoping Review,” Journal of Evaluation in Clinical Practice 29, no. 3 (April 2023): 554–64, https://doi.org/10.1111/jep.13789. [xi] Kimmelman and Tannock, “The Paradox of Precision Medicine.” [xii] Vogt and Hofmann, 1206. [xiii] Vogt and Hofmann, 1206. [xiv] Vogt and Hofmann, 1206. [xv] Vogt and Hofmann, 1207. [xvi] Vogt and Hofmann, 1207. [xvii] Vogt and Hofmann, 1207. [xviii] Vogt and Hofmann, 1210. [xix] Mehar Sahu et al., “Chapter Three - Artificial Intelligence and Machine Learning in Precision Medicine: A Paradigm Shift in Big Data Analysis,” in Progress in Molecular Biology and Translational Science, ed. David B. Teplow, vol. 190, 1 vols., Precision Medicine (Academic Press, 2022), 57–100, https://doi.org/10.1016/bs.pmbts.2022.03.002. [xx] Stefan Feuerriegel et al., “Causal Machine Learning for Predicting Treatment Outcomes,” Nature Medicine 30, no. 4 (April 2024): 958–68, https://doi.org/10.1038/s41591-024-02902-1. [xxi] Sunderland Baker et al., “Ethical Considerations in Closed Loop Deep Brain Stimulation,” Deep Brain Stimulation 3 (October 1, 2023): 8–15, https://doi.org/10.1016/j.jdbs.2023.11.001. [xxii] David Haslacher et al., “AI for Brain-Computer Interfaces,” 2024, 7, https://doi.org/10.1016/bs.dnb.2024.02.003. [xxiii] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 103–4; “Premarket Approval (PMA),” https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100026. [xxiv] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 104. [xxv] Burdette and Swartz, 126. [xxvi] Sean L. Metzger et al., “A High-Performance Neuroprosthesis for Speech Decoding and Avatar Control,” Nature 620, no. 7976 (August 2023): 1037–46, https://doi.org/10.1038/s41586-023-06443-4. [xxvii] Hao Fang and Yuxiao Yang, “Predictive Neuromodulation of Cingulo-Frontal Neural Dynamics in Major Depressive Disorder Using a Brain-Computer Interface System: A Simulation Study,” Frontiers in Computational Neuroscience 17 (March 6, 2023), https://doi.org/10.3389/fncom.2023.1119685; Mahsa Malekmohammadi et al., “Kinematic Adaptive Deep Brain Stimulation for Resting Tremor in Parkinson’s Disease,” Movement Disorders 31, no. 3 (2016): 426–28, https://doi.org/10.1002/mds.26482. [xxviii] Young-Hoon Nho et al., “Responsive Deep Brain Stimulation Guided by Ventral Striatal Electrophysiology of Obsession Durably Ameliorates Compulsion,” Neuron 0, no. 0 (October 20, 2023), https://doi.org/10.1016/j.neuron.2023.09.034. [xxix] Nho et al. [xxx] Nho et al.; Erik Robinson, “Brain Implant at OHSU Successfully Controls Both Seizures and OCD,” OHSU News, accessed March 3, 2024, https://news.ohsu.edu/2023/10/25/brain-implant-at-ohsu-successfully-controls-both-seizures-and-ocd. [xxxi] Awuah et al., “Bridging Minds and Machines”; Haslacher et al., “AI for Brain-Computer Interfaces.” [xxxii] Awuah et al., “Bridging Minds and Machines.” [xxxiii] Sara Green, Barbara Prainsack, and Maya Sabatello, “The Roots of (in)Equity in Precision Medicine: Gaps in the Discourse,” Personalized Medicine 21, no. 1 (January 2024): 5–9, https://doi.org/10.2217/pme-2023-0097. [xxxiv] Green, Prainsack, and Sabatello, 7. [xxxv] Robyn Bluhm and Kirstin Borgerson, “An Epistemic Argument for Research-Practice Integration in Medicine,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 43, no. 4 (July 9, 2018): 469–84, https://doi.org/10.1093/jmp/jhy009. [xxxvi] Vijay Mahant, “‘Right-to-Try’ Experimental Drugs: An Overview,” Journal of Translational Medicine 18 (June 23, 2020): 253, https://doi.org/10.1186/s12967-020-02427-4. [xxxvii] Michael S. Okun et al., “Deep Brain Stimulation in the Internal Capsule and Nucleus Accumbens Region: Responses Observed during Active and Sham Programming,” Journal of Neurology, Neurosurgery & Psychiatry 78, no. 3 (March 1, 2007): 310–14, https://doi.org/10.1136/jnnp.2006.095315. (shrink)

Eight focus groups were conducted in four public hospitals in Madrid to explore healthcare professionals’ perceptions of advance directives in order to improve the understanding of their lack of success among physicians and patients. A purposive sample of sixty healthcare professionals discussed ADs and reasons for their infrequent use. Three main themes were identified: perceptions about their meaning, appraisals of their use in clinical practice, and decision-making about them. Healthcare professionals perceived a lack of clarity about their definition and implementation. (...) There is insufficient awareness of their efficacy in improving the quality of clinical relationships and decision-making, and they are often perceived only as a bureaucratic procedure. Advance directives are not integrated in the clinical practice of Madrid’s healthcare specialist services because their application is exceedingly complex, because of insufficient education about them, and because of lack of procedural clarity. Consequently, healthcare professionals are not aware of how ADs could improve clinical decision-making, of when and for whom their use is appropriate, and of who has responsibility for providing ADs-related information to patients. These circumstances contribute to patients’ lack of interest in completing these documents and to physicians’ sceptical views about their usefulness. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Past, Present—and Future Perfect?Taking Psychiatry Beyond Its Single Message MythologiesK. W. M. Fulford (bio)I am grateful to John Sadler and his colleagues for their generous invitation to contribute to this collection marking Philosophy, Psychiatry, & Psychology (PPP)'s thirtieth birthday. True to our editorial tradition of "no nonsense" publishing, the "ask" was a reflection on PPP's past, present and future, limited to 500 words. In fact, one word (...) does it for me—collegiality.Collegiality was our watch word from the start. I still treasure a group photo taken at an early pre-meeting of the Association for the Advancement of Philosophy and Psychiatry (AAPP) convened by Michael Schwartz at his home in 1992, when, among other initiatives, PPP was conceived through transferring our then-nascent journal proposal from a small British publishing house to its current international publisher, the Johns Hopkins University Press. Michael and I had met earlier by phone when he had called the Royal College of Psychiatrists in London to enquire about its recently launched Philosophy Group and (by mere chance) I happened to be standing next to the person who took the call! PPP, with John and myself its founder editors, was subsequently born as, and has remained, a joint venture between our two groups: and Peter Zachar's recent initiative in building closer links with the International Network for Philosophy and Psychiatry (INPP) has taken us an important step towards the vision shared by Michael, John and myself that PPP should grow to reflect and represent a global open society of philosophy and mental health.As a pointer to the future, this global open society was no mere utopian vision but a joint commitment to what we conceived as a necessary ambition. Contemporary disenchantment with the repeated failures of translation of current narrowly empirical models of psychiatry, points to the truth of our German colleague, Paul Hoff's, characterization of the history of psychiatry as a history of serial collapses into single message mythologies. This disenchantment might seem to offer an opportunity for colonial expansion of philosophy into psychiatry (a re-assertion, perhaps, of phenomenology?). But PPP was born out of the "decade of the brain" and has remained throughout an ally of, not competitor to, the neurosciences. [End Page 3] So, while it is true that, with Peter's initiative, and with editorial and other innovations introduced by John, PPP is actively extending its reach (to new areas of philosophy, and to new voices, informed notably by experience as well as by training), this expansion remains a collegial not colonial enlargement of the field. I need hardly point to the challenges presented by the inclusive ambitions of such enlargement (not least to maintaining the highest standards of editorial and peer review). But PPP's collegiality provides the foundation for the work needed to deliver on these challenges. Even if imperfectly realized, this collegiality will help to take us beyond the single message mythologies by which our discipline has too long been hobbled. [End Page 4]K. W. M. Fulford K.W.M. (Bill) Fulford is a Fellow of St Catherine's College and Member of the Philosophy Faculty, University of Oxford; Emeritus Professor of Philosophy and Mental Health, University of Warwick Medical School; and Founder Director of the Collaborating Centre for Values-based Practice, St Catherine's College, Oxford (valuesbasedpractice.org).Copyright © 2023 Johns Hopkins University Press... (shrink)

In a book that challenges the most widely held ideas of why individuals engage in collective conflict, Russell Hardin offers a timely, crucial explanation of group action in its most destructive forms. Contrary to those observers who attribute group violence to irrationality, primordial instinct, or complex psychology, Hardin uncovers a systematic exploitation of self-interest in the underpinnings of group identification and collective violence. Using examples from Mafia vendettas to ethnic violence in places such as Bosnia and Rwanda, (...) he describes the social and economic circumstances that set this violence into motion. Hardin explains why hatred alone does not necessarily start wars but how leaders cultivate it to mobilize their people. He also reveals the thinking behind the preemptive strikes that contribute to much of the violence between groups, identifies the dangers of "particularist" communitarianism, and argues for government structures to prevent any ethnic or other group from having too much sway. Exploring conflict between groups such as Serbs and Croats, Hutu and Tutsi, Northern Irish Catholics and Protestants, Hardin vividly illustrates the danger that arises when individual and group interests merge. In these examples, groups of people have been governed by movements that managed to reflect their members' personal interests--mainly by striving for political and economic advances at the expense of other groups and by closing themselves off from society at large. The author concludes that we make a better and safer world if we design our social institutions to facilitate individual efforts to achieve personal goals than if we concentrate on the ethnic political makeup of our respective societies. (shrink)

Just over a decade ago, I began teaching medical students in the required preclinical course ethics and professionalism. The point of the course was to introduce basic ethical and professional norms through a small number of large group sessions, but mostly small group tutorials of 10 or 12 students engaging in weekly sessions combining readings from the literature and case scenarios highlighting real-life ethical tensions they either had, or would most likely, encounter in the future. The students wrote (...) perceptively and thoughtfully each week, and class was topical and lively. Some students went on to complete longer essays for a school-wide ethics competition and even to win. By all accounts a resounding... (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)

The paper examines Nikolas Rose's conception of the neuroscientific revolution in psychiatry. It has been repeatedly stated that the advances in neuroscience led to the radical transformation of psychiatry and that they will lead to further changes in mental health. Regardless of whether this transformation is considered as change for the better or for the worse, it is described as a radical move towards a completely new way of understanding and treating mental disorders. Rose's conception is remarkable since (...) it focuses not only on the very transformation of psychiatry, but also on the discourse of radical shift, on hopes, expectations and evaluations of these changes. This paper examines and summarizes key ideas of how the discourse of radical shift - which in fact refers to the future - influences the way psychiatry evolves. The author demonstrates that this discourse is controversial, since it is based on an ambivalent concept of the future. On the one hand, the neuroscientific revolution in psychiatry is said to establish a predictable, calculable and thus governable future in the field of mental health. On the other hand, the expected radical revolution in methods of treating and preventing mental disorders is considered as inconceivable from today's perspective. Yet, the latter is the condition of the former. This paradox forms an integral part of recent discussions on the neuroscientific revolution in psychiatry. (shrink)

Background Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees’ attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. Methods We used panel data in a longitudinal design study to measure (...) variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0–T1–T2). Mixed models were used to account for dependence of data in persons who participated more than once. Results In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. Conclusions This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since—despite the intrinsic value of participating in ERG or MCD—CES inherently aims, and should aim, at improving clinical practices. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Editorial changes at PPPWelcomes and ThanksJohn Z. Sadler, MDAfter 30 years of co-editing (with Bill Fulford) and editing Philosophy, Psychiatry, & Psychology, I thought it was time for me to step down, and last fall the Association for the Advancement of Philosophy and Psychiatry Executive Council assembled an international search team to select a new Editor-in-Chief. This thoughtful and efficient group, led by Robyn Bluhm, (...) completed the search and selection in a matter of a few months! All of us in the field are grateful to the search committee members for their congenial, disciplined, and fruitful work: Derek Bolton, David Crepaz-Keay, Anthony Fernandez, Brent Kious, Guilherme Messas, and Michael Wong. We are excited about the future of the journal with our new Editor-in-Chief, Professor Werdie van Staden. Briefly, Werdie is the Nelson Mandela Professor of Philosophy and Psychiatry and Director of the Centre for Ethics and Philosophy of the Health Sciences, the University of Pretoria, South Africa.Students, trainees, and early career scholars in our field often ask about how senior scholars found their way to, and through, the field of philosophy/psychiatry. The reading of Werdie's biography, in chronological order, would befuddle a reader trying to predict where he would end up by 2024. In the youth of his adulthood, Werdie was heading toward a career in music, collecting several degrees in music theory, composition, and performance. Indeed, music would occupy a big piece of his life over the decades. Dr. van Staden has continued his musical career as a composer of two symphonies, a concerto, as well as multiple choral and chamber works. He has performed as a flautist for the Pretoria Symphony Orchestra since 2006, and was the Principal for 8 years.However, he was also an individual directed toward service to his fellow human beings. He completed his MBChB medical degree in 1990 and went on to several degree qualifications in medicine, psychiatry, and philosophy. Most significant for us was his early experience with Bill Fulford's master's degree program in the Philosophy of Mental Health at the University of Warwick, later completing a doctoral degree. His Mandela Professorship at Pretoria was the first endowed Professorship in our philosophy/psychiatry multidisciplinary field. Since then his intellectual work has ranged over clinical and research ethics, philosophy of language and psychopathology, Ubuntu virtue theory, person-centered medicine, medical education, and many more areas, making him a most versatile scholar. Over the past three [End Page 91] decades he has functioned as a practicing clinician, a department chair, a clinical trialist, a partner to Bill Fulford in developing and disseminating the Values-Based Practice approach to clinical medicine, a leader in many professional organizations, an editor of the South African Journal of Psychiatry, not to overlook serving as an author, reviewer, and Senior Editor at PPP at various points since the journal's inception. His professional and intellectual activities and accomplishments are too numerous to recount; suffice to say we are delighted to have him bring his vision, creativity, and vigor to us by adding PPP to his to-do list!We congratulate and thank Professor Nancy Potter on her retirement from academia as well as one of our first Senior Editors of PPP. Nancy's path to philosophy/psychiatry was by way of work in the correctional system in her youth, followed by philosophical field work in the emergency psychiatry department at the University of Louisville Hospital, with her psychiatrist colleague Rafi El-Mallakh, MD. However, philosophy has been her first priority, with work in feminist theory, philosophy of peace, virtue theory, and standpoint/social epistemology over her career. Never satisfied with armchair philosophy, Dr. Potter has immersed herself in settings, traditions, and practices to understand them from inside as well as out. As a PPP Senior Editor, Nancy was instrumental in developing the service-user voice, as well as diversifying our authorship in many other ways. I will miss her even-tempered, yet rigorous editorial voice in the journal.My last appointment of a Senior Editor turned out to be one of Dr. van Staden's students. I welcome Dr. Mohammed Abouelleil Rashed as our newest... (shrink)

Self-diagnosis in psychiatry is where individuals diagnose themselves rather than rely upon official diagnosticians to supply a psychiatric diagnosis. The accuracy of self-diagnosis is a contested topic. In this paper, I outline what arguments are needed to see self-diagnosis as accurate and how different approaches to self-diagnosis require different arguments. I show how different arguments are required to justify accuracy for an autistic individual judging they are autistic compared to non-autistic individuals judging they are not autistic. Different arguments are (...) required if a self-diagnosing individual accepts or rejects official diagnostic criteria. Finally, different arguments are required depending upon whether diagnoses are seen as objective entities, the product of theoretical virtues or practically useful groupings. All these approaches require unique arguments to justify the accuracy of self-diagnosis. Identifying the required arguments for different approaches is a stepping stone toward establishing whether those arguments and which of those arguments can be successfully justified. (shrink)

Problem: Medical student mistreatment, as well as patient and staff mistreatment by all levels of medical trainees and faculty, is still prevalent in U.S. clinical training. Largely missing in interventions to reduce mistreatment is acknowledgement of the abuse of power produced by the hierarchical structure in which medicine is practiced. Approach: Beginning in 2001, Yale School of Medicine has held annual “Power Day” workshops for third year medical students and advanced practice nursing students, to define and analyse power dynamics within (...) the medical hierarchy and hidden curriculum using literature, guest speakers, and small groups. During rotations, medical students write narratives about the use of power witnessed in the wards. In response to student and small group leader feedback, workshop organizers have developed additional activities related to examining and changing the use of power in clinical teams. Outcome: Emerging narrative themes included the potential impact of small acts and students feeling “mute” and “complicit” in morally distressing situations. Small groups provided safe spaces for advice, support, and professional identity formation. By 2005, students recognized residents that used power positively with Power Day awards and alumni served as keynote speakers on the use of power in medicine. By 2010, departments including OB/GYN, surgery, psychiatry, and paediatrics, had added weekly team Power Hour discussions. Next Steps: The authors highlight barriers, benefits, and lessons learned. Barriers include the notion of clinical irrelevance and resistance to the word “power” due to perceived accusation of abuse. Benefits include promoting open dialogue about power, fostering inter-professional collaboration, rewarding positive role modelling by residents and faculty, and creating a network of trainee empowerment and leadership. Furthermore, faculty have started to ask that issues of power be addressed in a more transparent way at their level of the hierarchy as well. (shrink)

Background On December 2017 the Italian Parliament approved law n. 219/2017 “Provisions for informed consent and advance directives” regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person’s autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey among (...) physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law. Methods A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation). Results Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians’ opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered. Conclusions Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations. (shrink)

Teaching mathematics and improving mathematics competence are pending subjects within our educational system. The PEIM (Programa Evolutivo Instruccional para Matemáticas), a constructivist intervention program for the improvement of mathematical performance, affects the different agents involved in math learning, guaranteeing a significant improvement in students’ performance. The program is based on the following pillars: (a) students become the main agents of their learning by constructing their own knowledge; (b) the teacher must be the guide to facilitate and guarantee such a construction (...) by being a great connoisseur of the fundamental aspects of the development of the child’s mathematical thinking; (c) the mathematical contents must be sequenced in terms of the complexity and significance for the student as well as contextualized at all times; and (d) the classroom must have a constructivist climate highlighting cooperative work among students. The implementation of PEIM along with the empirical evaluation conducted in several centers in Madrid and Zaragoza (Spain) confirm how students improve their mathematical competence. Both first- and second-grade students in elementary education were far more effective in solving problems, highlighting the use of more advanced strategies in their resolution and a lower incidence of conceptual errors. Moreover, it was possible to verify how the students proving greater difficulty, experienced an evolution in learning similarly to those who did not present it. The program provides customized education to allow the teacher to know at all times how he should be more influential on the students’ learning through mathematical profiles. Both teaching practice and teachers were observed, being that of the experimental group more prone to analyzing processes and allowing the construction of knowledge by students, due to their psycho-developmental training. As a result, we found several improvements through the implementation of the program that may serve, for upcoming years, as a basis for the necessary changes in the teaching of mathematics. (shrink)

Carpendale & Lewis (C&L) rightly emphasise the central role of social interaction in the development of children's understanding of mind. Further support and justification for their theoretical focus are provided by research on advanced reasoning about socio-emotional and socio-motivational processes. Variability in social experience can explain both developmental change and within-age-group differences in such social understanding.

Language evolution, intended as an open problem in the evolutionary research programme, will be here analyzed from the theoretical perspective advanced by the supporters of the Extended Evolutionary Synthesis. Four factors and two associated concepts will be matched with a selection of critical examples concerning genus Homo evolution, relevant for the evolution of language, such as the evolution of hominin life-history traits, the enlargement of the social group, increased cooperation among individuals, behavioral change and innovations, heterochronic modifications leading to (...) increased synaptic plasticity. A particular form of niche construction will be considered in a multilevel framework. It will be argued that the four points mentioned above prove to be fundamental explanatory tools to understand how language might have emerged as a result of a gene-culture coevolutionary dynamics. (shrink)

In this theoretical paper, I analyze business groups’ corporate social responsibility. Building on economic thinking, I propose that the level and diversity of CSR investments of business groups evolve with the development of the country, as a result of the interaction of two drivers: the level of infrastructure deficiencies and the cost of negative externalities. I argue that in underdeveloped countries, business groups have high levels and low diversity of CSR investments, focusing on the social arena to compensate for infrastructure (...) deficiencies. As countries implement pro-market reforms and become emerging economies, the level of CSR investments diminishes as business groups can rely on external providers and the government for supporting infrastructure, but CSR diversity increases to address the growing costs of negative externalities in the environmental and economic arenas. As countries further develop to become advanced economies, business groups’ level and diversity of CSR investments increase to prevent the high costs of negative externalities in the social, environmental, and economic arenas proactively. (shrink)

In this paper, I address a question in social epistemology about the unity of a scientic community to- wards its inner groups (teams, labs...). I investigate the reasons why these groups might want to \go it alone", working among themselves and hiding their discoveries from other groups. I concentrate on the intermediate results of a longer project, where the first steps can help to achieve a more advanced result. I study to what extent the isolation of research groups might be (...) damaging to the epistemic progress of the whole community. In order to get an idea of the reason why scientists might not share their intermediate results with others, consider for example Schawlow and Townes in the summer of 1958 (the historical material is drawn from Broberg, 1991, chap. 3): together they had just designed the principle of functioning of what would be known as the laser, with the intention of constructing the rst laser, relying on their theoretical ideas. Should they have published their theoretical discovery, or rather taken advantage of their advance on possible oppo- nents and start the experimental work? They chose to publish their theoretical ideas in a scientic journal, and they also led a patent application. On the one hand, it was a valuable choice: the patent was granted and their paper was published, making them soon famous. Further- more, another scientist called Gould was to le a simi- lar patent application a few months later, in March 1959; it was refused, because of the priority of Schawlow and Townes. If the latter had not submitted their idea in 1958, the patent would certainly have been acknowl- edged to Gould. In this sense, publishing their intermediate result was a worthy strategy. On the other hand, history showed that their publication had also some drawbacks for them. Schawlow and Townes' publication triggered a race among many American laboratories for the rst experimental construction of the laser. In addition to bringing them competitors, their publication helped these competitors in crucial ways; so much so that it was another scientist, Maiman, and not Schawlow and Townes, who was able to build the rst working laser, in May 1960, and to publish the result. If Schawlow and Townes had not published their theoretical idea, there are chances that they would have been the first ones to build a laser. Their publication of the first theoretical result certainly prevented them from getting the second experimental one. In short, the best publishing strategy about an intermediate result is no easy question for a scientist. Consider now the whole community, concerned with the results available to all and with the pace of the epistemic progress. Schawlow and Townes' publication enabled the rst laser to be built quicker, as other teams could rely on their theoretical work. More generally, being able to reuse other's works seems to be a rm basis of scientic progress. Thus, for the whole community, it seems that there are only benets if intermediate results are published. As this is not necessarily the best strategy for those who reach these intermediate results, there might be a conflict between the interests of individuals and those of the whole community. The question Schawlow and Townes faced was whether they should make their discovery publicly known, or keep it for themselves to progress alone. This alternative can also arise for an entire lab, when competing with other labs on some long-run project: should it make its discoveries known to its opponents, or only share them internally among its members? At a higher level still, this question arises for what can be called scientic schools, which are groups of labs sharing some particular approach|methodological, experimental or interpre- tational, for example. At each level within the scientic community, there are competitive groups of scientists which may decide to go it alone and to prevent their results from being accessible to others. If they had good reasons for doing so, there would be dramatic consequences for the whole community: other groups would not be able to reuse their results, labour force would be wasted in achieving them again, and the progress of the eld would be slowered. 9 The aim of this paper is to investigate this risk of division: to assess the conditions under which it may oc- cur, its damage for the community, and to draw the limit of an acceptable pluralism. The reasoning with benets and drawbacks which has been sketched for Schawlow and Townes seems to be implicitly an informal economic argument. In order to clarify and to rene such an argument, I will investigate it in a rational decision framework, supposing some utility or preferences for the groups of scientists, and I will propose a formal model, in game theory. In social epistemology of science, formal models have been proposed for various questions (for example, Kitcher 1990, 1993, Goldman 2009, Strevens 2003, 2006, Weisberg and Muldoon, forthcoming, Zollman 2007, 2008, 2009, 2010), but not for the question of the division of the scientic community. I will concentrate on the normative aspect of the question, ignoring the descriptive and historical question of whether groups do go it alone or not. The model I propose is sequential: two groups are competing on a research program, which consists of several results which have to be obtained in order. The groups always carry out some research for the next result, which they reach with some probability per unit of time. When a group, say A, reaches a result, it can either make it public for the other group, or continue its research. After a result is made public, the competitor B can start from it so as to continue its own research. Thus, when A publishes it loses its lead, and its competitor will be able to compete with it in the near future. But it is also recognized as the rst to reach this step. I consider two dierent cases, one in which the number of steps is limited, another where the limit concerns the number of temporal intervals. In both cases, assuming that all steps are equally dicult and equally rewarding, it turns out that the best strategy for a group concerned with its own reward is to make public every step it takes. Thus, there is no risk that groups might separate: a scientist, whatever its group, will publish for all. Finally, I turn to more complex situations, where results have varying size or diculty: there, groups can indeed be better o going it alone. (shrink)

Between 1980 and 2010 California’s health care policy field shifted from a business-dominated, closed-door pattern of decision making to a more open political arena. Through this process, a wide-ranging and diversely resourced coalition advocating on behalf of beneficiaries became an accepted partner in policymaking. This article examines this transformation, considering its broader implications for the political dynamics of the public-private welfare state and the role of advocacy groups in defending beneficiary interests. We argue that multifaceted coalitions exploit three vulnerabilities of (...) the public-private welfare state, which presents openings for advancing public priorities: 1) diverse and shifting interests, which allow advocates to build broad coalitions that include labor and some providers 2) service gaps that, when publicized, can generate public outrage; and 3) the hybrid institutional form of the public-private welfare state, which can connect service delivery organizations with a broader pro-public coalition. (shrink)

Background: Frailty is a natural consequence of the aging process. With the increasing aging population in Mainland China, the quality of life and end-of-life care for frail older people need to be taken into consideration. Advance Care Planning has also been used worldwide in long-term facilities, hospitals and communities to improve the quality of end-of-life care, increase patient and family satisfaction, and reduce healthcare costs and hospital admissions in Western countries. However, it has not been practiced in China. Research objective: (...) This study aimed to evaluate the effectiveness of a modified Advance Care Planning intervention in certainty of end-of-life care, preferences for end-of-life care, quality of life concerns, and healthcare utilization among frail older people. Research design: This study used a quasi-experimental design, with a single-blind, control group, pretest and repeated posttest approach. Participants and research context: A convenience sample of 74 participates met the eligibility criteria in each nursing home. A total of 148 frail older people were recruited in two nursing homes in Zhejiang Province, China. Ethical considerations: The study received ethical approval from the Clinical Research Ethics Committee, the Faculty of Medicine, and The Chinese University of Hong Kong, CREC Ref. No: 2016.059. Findings: The results indicated the Advance Care Planning programme was effective at increasing autonomy in decision making on end-of-life care issues, decreasing decision-making conflicts over end-of-life care issues, and increasing their expression about end-of-life care. Discussion: This study promoted the participants’ autonomy and broke through the inherent custom of avoiding talking about death in China. Conclusion: The modified Advance Care Planning intervention is effective and recommended to support the frail older people in their end-of-life care decision in Chinese society. (shrink)

In this article, we expand the analytical and theoretical foundations of the study of knowledge commons in the context of more classical agrarian commons, such as seed commons. We show that it is possible to overcome a number of criticisms of earlier work by Ostrom (Governing the commons. The evolution of institutions for collective action, Cambridge University Press, Cambridge, 1990) on natural commons and its excludability/rivalry matrix in addressing the inclusive social practices of “commoning”, defined as a way of living (...) and acting for the preservation of the commons. Our empirical analysis emphasizes, using the most recent advances in the IAD/SES framework, the distributed and collaborative knowledge governance in a French peasant seed network as a key driver for reintroducing cultivated agrobiodiversity and on-farm seed conservation of ancient and landrace varieties. These inclusive peasant seed groups developed alternative peer-to-peer models of collaborative peasant-led community-based breeding and grassroots innovations in the search for more resilient population varieties. Our results highlight the various models of collective action within the network and discuss the organizational tradeoffs of opting out of peasant seed activities and recreating a shared collective knowledge base on the benefits of restoring cultivated agrobiodiversity. It helps us better understand how modern peasant seed groups function as epistemic communities which contributes to envisioning alternative agricultural systems. (shrink)

Essential Philosophy of Psychiatry is a concise introduction to the growing field of philosophy of psychiatry. Divided into three main aspects of psychiatric clinical judgement, values, meanings and facts, it examines the key debates about mental health care, and the philosophical ideas and tools needed to assess those debates, in six chapters. In addition to outlining the state of play, Essential Philosophy of Psychiatry presents a coherent and unified approach across the different debates, characterized by a rejection (...) of reductionism and an emphasis on the ineliminability of uncodified skilled judgement. The first part, Values, outlines the debate about whether diagnosis of mental illness is essentially value-laden and argues that the prospects for reducing illness or disease to plainly factual matters are poor. It also explains the important role of skilled contextual judgement, rather than a principles-based deduction, in ethical judgement. The second part, Meanings, examines the central role of understanding and a shared first person perspective, both against attempts to reduce meaning to basic information-processing mechanisms and to explain away the difficulties of understanding psychopathology in recent models of delusion. The third part, Facts, shows the importance of uncodified clinical judgements, both in assessing the validity of psychiatric taxonomy and in the application of Evidence Based Medicine. Despite advances in the codifaction of practice and operationalism of diagnosis, an element of judgement remains in the assessment both of what, at one level, is good evidence for diagnosis and treatment and what, at a higher level, is good evidence for the validity of classification overall. (shrink)

Accountability for developing, deploying, and using any emerging weapons system is affirmed as a guiding principle by the Group of Governmental Experts on Emerging Technologies in the Area of Lethal Autonomous Weapons Systems. Yet advances in emerging technologies present accountability challenges throughout the life cycle of a weapons system. Mindful of a lack of progress at the Convention on Certain Conventional Weapons since 2019, this essay argues for a mechanism capable of imputing accountability when individual agent accountability is exceeded, (...) forensic accountability unreliable, and aspects of political accountability fail. (shrink)

Psychiatry is increasingly dominated by the reductionist claim that mental illness is caused by neurobiological abnormalities such as chemical imbalances in the brain. Critical psychiatry does not believe that this is the whole story and proposes a more ethical foundation for practice. This book describes an original framework for renewing mental health services in alliance with people with mental health problems. It is an advance over the polarization created by the "anti-psychiatry" of the past.

Aureli advances a fresh, spirited and combative account of the idea of ‘autonomy’, connecting Italian architectural debates from the 1960s with the politics of class-autonomy that was being developed and advanced by workerist theorists such as Raniero Panzieri, Mario Tronti and Toni Negri. Aureli’s account focuses on Aldo Rossi’s architectural ideas and the project of the No-Stop City proposed by the young avant-garde group Archizoom. The Project of Autonomy is not simply envisaged as an historical exploration of the 1960s; (...) primarily, it is conceived as an intervention in current architectural theory, drawing on the author’s interest in Tronti’s politics to challenge the contemporary popularity of a broadly post-Negrian ‘autonomism’. This review questions aspects of Aureli’s reading of Rossi and Manfredo Tafuri. Furthermore, although Aureli’s discussion of Red Vienna opens up onto vital questions of strategies for social change, which remain pertinent to contemporary arguments over ‘enclaves’ or ‘zones’ of resistance, his antagonism towards Tafuri prevents his argument from either exploring or advancing the debate which he has initiated. (shrink)

Teaching the art of profession-related communication to students of non-linguistic study fields allows instructors to explain their students how to keep up the conversation using facts, data, concepts etc. specific to the area of their future profession. It activates the acquisition processes as well as increases students' motivation to study. The formation of oral monologue speaking skills in students of non-linguistic study fields is one of the tasks within the course of Foreign ( English) Language for Specific Purposes.This process is (...) associated with certain difficulties, which can inhibit learning and demotivated students to study. Among strategies and techniques aiding learning that can be used to improve performance and study outcomes during the course and can be implemented for the enhancement of speaking on occupation-related topics, the mind mapping technique is of specific relevance. It can serve as an interesting and useful tool serving to enhance quality of oral speaking skills in students majoring in Psychology as the representatives of non-linguistic study fields. The article analyses the carried out research concerning the facilitating impact of mind mapping on the oral speech performance of Psychology students. The study hypothesis implies that the use of the mind-mapping technique in the process of preparing for and presenting the talk in the study sessions enhances students' oral monologue speech performance. In order to check the hypothesis, we have conducted the experiment in Bohdan Khmelnytsky National University of Cherkasy at the Department of Psychology. The study involved 46 first-year students, including 34 female and 12 male participants. The respondents were randomly assigned to the experimental mind-mapping group of 23 students ( including 6 males) and the control group of 23 students ( including 6 males as well). The students in the experimental group were involved into the experiment using the mind-mapping technique during their study, and the students in the control group continued their study in the usual way. The hypothesis was confirmed. The mind map use stimulates activity of both brain hemispheres, thus making it easier for students to memorize thematic vocabulary, follow the logical sequence of the talk when speaking. The research findings have shown the effectiveness of implementing the mind-mapping technique into the university course teaching English for Specific Purposes to develop, advance and master students' professional communicative competence. Consistent use of mind maps will also promote the educational process efficiency and have positive effects on the general formation of competitive skilled specialists. (shrink)

The failure of psychiatry to validate its diagnostic constructs is often attributed to the prioritizing of reliability over validity in the structure and content of the Diagnostic and Statistical Manual of Mental Disorders. Here I argue that in fact what has retarded biomedical approaches to psychopathology is unwarranted optimism about diagnostic discrimination: the assumption that our diagnostic tests group patients together in ways that allow for relevant facts about mental disorder to be discovered. I consider the Research Domain (...) Criteria framework as a new paradigm for classifying objects of psychiatric research that solves some of the challenges brought on by this assumption. (shrink)

The study examined the development of Chinese as a second language learners’ formulaic knowledge through comparing the processing of Chinese idioms versus non-idiomatic formulaic sequences (FSs) by advanced-level learners (ALs), super-advanced learners (SLs), and native speakers (NSs). Using two phrase acceptability judgment tasks with and without think-aloud protocols, we collected data on participants’ processing accuracy, processing speed, and processing strategies of reading the two types of FSs. Four processing patterns emerged from the analyses of the datasets. First, learners’ processing accuracy (...) and speed increased along with their proficiency. Second, learners’ idiom processing ability was generally lower than that of non-idiom processing ability, but they demonstrated an improving trend as their proficiency level increased. Third, learners’ use of processing strategies did not change much as proficiency rose and demonstrated a categorical difference from NSs. Fourth, all three groups exhibited poorer productive idiom knowledge than productive non-idiom knowledge. The overall findings denote that second language learners’ formulaic knowledge can evolve beyond the lexical plateau as learners move from the advanced to a higher proficiency level, but the productive idiom knowledge can be a long-term problem. The findings provide implications for measuring and teaching Chinese formulaic knowledge at the higher-than-advanced stage. (shrink)

Coercion is still highly prevalent in contemporary psychiatry. Qualitative research indicates, however, that patients and psychiatric staff have different understandings of what they mean by ‘coercion’. Psychiatric staff primarily employ the concept as referring to instances of formal coercion regulated by law, such as involuntary hospital admission or treatment. Patients, on the other hand, use a broader concept, which also understands many instances of informal psychological pressure as coercive. We point out that the predominance of a narrow concept of (...) coercion in psychiatry can have negative consequences for patients, and argue that this difference in how the concept ‘coercion’ is used is both grounded in epistemic oppression and reinforces such oppression. Epistemic oppression, as defined by Dotson, refers to the persistent epistemic exclusion of members of marginalized groups from participation in practices of knowledge production. We first demonstrate how patients may experience inferential inertia when communicating their experiences of coercion. We then show that the resulting predominance of a narrow concept of coercion in psychiatry can be described as a case of hermeneutical injustice in a context shaped by institutional hermeneutical ignorance. We argue for a change in institutional practices in psychiatry that allows for the adequate consideration of patients’ perspectives on coercion. (shrink)

In this discussion paper we consider the influence of ethnicity, religiosity, spirituality and health literacy on Advance Care Planning for older people. Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of advance care planning by this group across a number of countries where advance care planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life decisions. Health literacy issues (...) have been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote advance care planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape advance care planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities and to promote older peoples’ ability to enact moral agency in making such decisions. (shrink)

"The Textbook of Yoga Psychology, written by noted Sanskrit scholar and yogi Ramamurti S. Mishra, M.D., combines his definitive translation with an inspiring interpretation of Patanjali's Yoga Sutras. Patanjali's ancient formulae for self-analysis make this text crucial to the proper understanding of the philosophy, psychology and practice of Yoga. An extensive Introduction provides a lucid and thorough examination of the Sankhya Yoga Philosophy from which the Yoga Sutras emerged. The accessibility of Dr. Mishra's translation of the Yoga Sutras has made (...) this the favorite among beginning Yoga students, while experienced yogis and novices both appreciate the clarity of his commentaries on each sutra. Dr. Mishra's interpretation is unique in placing this ancient work in a modern context, examining Yoga psychology in the light of recent advances in psychiatry, psychology and parapsychology." --. (shrink)

This paper examines the empirical aspect of the debates over group selection. I argue that specific narrow readings of the notion of ‘group’ result in a deficient experimentation of the group selection process. Criteria for empirical testability are presented and used to reexamine two well-known experiments of group selection. I argue that the former holds a narrow image of ‘group’ that does not distinguish group selection from selection at other levels; while the latter holds (...) a multifaceted image of ‘group’ that offers a way to achieve substantive progress in the debate. However, most supporters and opponent of group selection maintain a narrow and restricted image of ‘group’, which implicitly undermines informative details regarding population dynamics and population structure. These details may improve our understanding of the evolution of altruism and the evolution of sociality. To conclude, adopting a wide-ranging meaning of ‘group’ may empirically advance the group selection debates. (shrink)

Informed consent and confidentiality supposedly minimize harm for research participants in all qualitative research methodologies, inclusive of one-on-one unstructured interviews and focus groups. This is not the case for the latter. Confidentiality and informed consent uniquely manifest themselves as endemic ethical dilemmas for focus group researchers. The principle of caveat emptor (let the buyer beware) may be a more useful tool for those involved in focus group research: that is, let the researcher, the participants and the ethics committee (...) beware that the only ethical assurance that can be given to focus group participants is that there are few ethical assurances. These ethical dilemmas are not sufficiently realized in the literature, and if they are discussed, they are often dealt with within the focus group moderator’s preamble to the group discussion. This paper encourages the mandatory use of a participant information sheet sufficiently detailed to engender the participant’s active consent. Sufficient here means the participant must be made adequately aware of these endemic ethical dilemmas in advance, to allow them to consent to share responsibility for any ensuing harm. The focus group moderator is not their sole protector. (shrink)

This article seeks to understand the origins of the Soviet concept of ‘sluggish schizophrenia’, a diagnostic category that was used to imprison political dissidents in the post-WWII era. It focuses on the 1920s and 1930s, a period when Soviet psychiatrists attempted to find ways to diagnose schizophrenia at its earliest stages. The new Soviet state supported these efforts, funding new institutions where clinicians encountered types of patients they had not previously studied. Conceptual disagreements arose about what symptoms could be used (...) to diagnose schizophrenia, and how it could be differentiated from other ‘borderline’ mental disorders such as neurosis and psychopathy. Several research groups used their findings to propose new clinical concepts, including ‘mild schizophrenia’ and sluggish schizophrenia. By the early 1930s Soviet psychiatrists no longer shared a basic consensus about schizophrenia. At the same time, the priorities of the Soviet government under Joseph Stalin ceased to support preventative psychiatry. The result was a 1936 ‘discussion’ at which the concept of mild schizophrenia was criticized and sluggish schizophrenia was held up as a model for how the discipline should develop in the future. (shrink)

Our philosophical understanding of mental illness is being shaped by neuroscience. However, it has the paradoxical effect of igniting two radically opposed groups of philosophical views. On one side, skepticism and denialism assume that, lacking clear biological mechanisms and etiologies for most mental illnesses, we should infer they are constructions best explained by means of social factors. This is strongly associated with medical nihilism: it considers psychiatry more harmful than benign. On the other side of the divide, naturalism and (...) reductionism are on the look for failures in the biological functioning of the organism whenever a genuine mental illness occurs. Psychiatry as currently practiced, accordingly, exhibits the gaps of an ongoing research programme; a yet to be completed neuroscience would link mental illnesses with identifiable biological mechanisms. Both sides of this divide claim to be fostered by scientific discoveries and advances in neuroscience, when taken at face value. Against this background, we argue instead for a modest view. To that end, we draw attention to some nuances in the scientific realism debate. While contending that neuroscientific theories and models aim to provide true representations of their target systems, and can justifiably claim to have attained some, we argue that our confidence should not be placed beforehand in specific features of these scientific representations. Hence, it would be unwarranted to extract morals for psychiatry from posits (or their absence) in neuroscientific explanations of mental illnesses. To illustrate our position, we examine some recent discoveries in neuroscience concerning bipolar disorder. We conclude by linking our topic to a broader issue in the philosophy of medicine: insofar as psychiatry is a biomedical specialty, its classifications of health and disease are guided by pragmatic concerns, as well as by scientific discoveries. (shrink)

Given advances in the science of fertility preservation and the link between fertility choices and wellbeing, it is time to reframe our ethical thinking around fertility preservation procedures for children and young people with cancer. The current framing of fertility preservation as a possible offer may no longer be universally appropriate. There is an increasingly pressing need to discuss the ethics of failing to preserve fertility, particularly for patient groups for whom established techniques exist. I argue that the starting point (...) for deliberating about a particular patient should be a rebuttable presumption that fertility preservation ought to be attempted. Consideration of the harms applicable to that specific patient may then override this presumption. I outline the benefits of attempting fertility preservation; these justify a presumption in favour of the treatment. I then discuss the potential harms associated with fertility preservation procedures, which may justify failing to attempt fertility preservation in an individual patient's particular case. Moving from a framework of offer to one of rebuttable presumption in favour of fertility preservation would have significant implications for medical practice, healthcare organizations and the state. (shrink)

Objectives: To analyse and compare the surveys on German doctors and judges on end of life decision making regarding their attitudes on the advance directive and on the dying process.Design: The respondents were to indicate their agreement or disagreement to eight statements on the advance directive and to specify their personal view on the beginning of the dying process.Participants: 727 doctors in three federal states and 469 judges dealing with guardianship matters all over Germany.Main measurements: Comparisons of means, analyses of (...) variance, pivot tables and factor analyses .Results: Three attitude groups on advance directive were disclosed by the analysis: the decision model, which emphasises the binding character of a situational advance directive; the deliberation model, which puts more emphasis on the communicative aspect; and the delegation model, which regards the advance directive as a legal instrument. The answers regarding the beginning of the dying process were broadly distributed, but no marked difference was observed between the responding professions. The dying process was assumed by most participants to begin with a life expectancy of only a few days.Conclusions: A high degree of valuation for advance directive was seen in both German doctors and judges; most agreed to the binding character of the situational directive. Regarding the different individual concepts of the dying process, a cross-professional discourse on the contents of this term seems to be overdue. (shrink)

Background This study used a scenario- and discussion-based approach to teach preclinical medical students the socio-philosophical aspects of psychiatry and qualitatively evaluated the learning outcomes in a medical humanities course in Taiwan. Methods The seminar session focused on three hypothetical psychiatry cases. Students discussed the cases in groups and were guided by facilitators from multiple disciplines and professions. At the end of the semester, students submitted a narrative report comprising their reflections on the cases and discussions. The authors (...) utilized content analysis to categorize students’ narratives into three facets, namely, the philosophical, social and individual. Results In total 163 preclinical medical students participated in the class; 150 of them mentioned the scenario-based lesson in their reports; 33.3% of these reports discussed the case at the philosophical dimension (n = 50), 45.3% at the social dimension (n = 68), and 26.6% at the individual dimension (n = 40). Four major themes emerged: (1) a psychiatric diagnosis has far-reaching consequences for an individual’s life, (2) the social structure affects how patients experience psychiatric disorders, (3) students related personal experience or those of friends and family to understand psychiatric disorders, and (4) medical humanities are of particular importance in psychiatric education. Conclusions This study demonstrated that the scenario-based discussions led by a multidisciplinary team of facilitators can benefit medical students with limited clinical experience to contemplate the socio-philosophical aspects of psychiatry. The authors suggest that this pedagogical model during preclinical education should be encouraged. (shrink)

William Galston is a distinguished political philosopher whose work is informed by the experience of having also served from 1993–5 as President Clinton's Deputy Assistant for Domestic Policy. He is thus able to speak with an authority unique amongst political theorists about the implications of advancing certain moral and political values in practice. The foundational argument of this 2002 book is that liberalism is compatible with the value pluralism first espoused by Isaiah Berlin. William Galston defends a version of value (...) pluralism - liberal pluralism - and argues, against the contentions of John Gray and others, that it undergirds a kind of liberal politics that gives weight to the ability of individuals and groups to live their lives in accordance with their deepest beliefs about what gives meaning and purpose to life. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Bad, the Ugly, and the Need for a Position by PsychiatryLloyd A. Wells (bio)Keywordsvice, psychiatric education, psychiatry-law interface, medicalizationSadler’s paper is thought provoking and will resonate with many psychiatrists who deal with the interface of vice and psychiatric syndromes. This interface and the dilemmas it poses are perhaps most discussed by residents, who are dealing with the issue for the first time and who often debate what (...) is “psychiatric” about these cases. Many residents have their own informal systems of classifying vice, often with a divide between the criminal population and those perceived as avoiding work and responsibility. These unofficial classifications are usually judgmental and often pejorative, but the residents rarely get much help from faculty in this area. Indeed, many of the faculty have equally judgmental and pejorative views, which are neither systematized nor subject to systematic analysis.By clarifying the importance of the issue of the vice–mental disorder relationship (VMDR) to psychiatry, Sadler may move this topic to one that receives Socratic discourse in our training programs and serious consideration in the training of psychiatrists rather than an idiosyncratic lumping of these patients into the broad category of “patients I don’t like.”Sadler asks for comments in several categories: historical intractability, goals of psychiatry, taxonomy, implications for the criminal justice system, implications for the law, and ethical/political implications.Issues of historical intractability are long standing. In A Tour of the Whole Island of Great Britain, written in the early eighteenth century, Daniel Defoe (1724–1727) describes many asylums, often with the comment, “as it is a madhouse, so is it also a house of correction.” Some of the great public hospitals of the seventeenth and eighteenth centuries were built at least as much to get antisocial and homeless people off the streets as to provide care for the mentally ill. The moral treatment of France and Great Britain, which added much to the practice of psychiatry, clearly had punitive “treatments” for patients with vice-laden behaviors, and this was very explicit in the American moral model of treatment of the late nineteenth century with its obsessive need to prevent patients from masturbating. In the nineteenth and early twentieth centuries, there was great debate about the inclusion of Pritchard’s “moral insanity”—now sanitized into “personality disorders”—into the psychiatric domain, and Kraepelin referred to this group as “enemies of society.”Sadler next asks us to consider the goals of psychiatry in regard to “a proper VMDR.” He wonders [End Page 43] whether a strict medicalization account can be defended. I think it is clear from a large literature and from clinical experience that it cannot be defended —now. But it may become defensible in this century, which will pose enormous challenges to psychiatry, lawmakers, and the courts (vide infra). A strict moralization model is defended by many in society, including some psychiatrists, but has severe limitations and seems illogical. It is hard to make a case (though juries have done so) that, for example, a very delusional young woman with postpartum psychosis who murders her children because of the belief that far worse things than death will happen to them imminently if they live, fits the moralization approach. The Dahmer case is especially instructive. Although there was enormous “vice” (and perhaps “evil”), it is hard to make a case that a sane man would make temples out of the body parts of victims and would attempt to commune with the dead through them.He wonders whether a “mixed” version of medicalization/moralization can be developed and defended. I would argue for both a mixed approach and a “shared” approach. A middle adolescent with bipolar disorder burned his house to the ground. (Fortunately, he and family members were injured but not killed.) He was wildly manic at the time and set the fire because he wanted to prove that he was immortal and totally impervious to flames. He was delusional, extraordinarily impulsive, and completely without judgment, and it would be extraordinarily difficult to exclude the medical frame in any consideration of the vice involved. The vice, indeed, may be more involved in his decision while euthymic to stop taking... (shrink)

In this article we discuss the validity of previous preferences and advance directives in cases of severe mental illness.

BackgroundOne of the next frontiers in HIV research is focused on finding a cure. A new priority includes people with HIV (PWH) with non-AIDS terminal illnesses who are willing to donate their bodies at the end-of-life (EOL) to advance the search towards an HIV cure. We endeavored to understand perceptions of this research and to identify ethical and practical considerations relevant to implementing it.MethodsWe conducted 20 in-depth interviews and 3 virtual focus groups among four types of key stakeholders in the (...) United States (PWH, biomedical HIV cure researchers, HIV clinicians, and bioethicists) to obtain triangulated viewpoints because little was known about the ethics of this topic. Each group was queried as to ethical considerations, safeguards, and protections for conducting HIV cure-related research at the EOL to ensure this research remains acceptable.ResultsAll four key stakeholder groups generally supported HIV cure-related research conducted at the EOL because of the history of altruism within the PWH community and the potential for substantial scientific knowledge to be gained. Our informants expressed that: (1) Strong stakeholder and community involvement are integral to the ethical and effective implementation, as well as the social acceptability of this research; (2) PWH approaching the EOL should not inherently be considered a vulnerable class and their autonomy must be respected when choosing to participate in HIV cure-related research at the EOL; (3) Greater diversity among study participants, as well as multi-disciplinary research teams, is necessitated by HIV cure-related research at the EOL; (4) The sensitive nature of this research warrants robust oversight to ensure a favorable risk/benefit balance and to minimize the possibility of therapeutic misconception or undue influence; and (5) Research protocols should remain flexible to accommodate participants’ comfort and needs at the EOL.ConclusionBecause of the ethical issues presented by HIV cure-related research at the EOL, robust ethical safeguards are of utmost importance. The proposed ethical and practical considerations presented herein is a first step in determining the best way to maximize this research’s impact and social value. More much inquiry will need to be directed towards understanding context-specific and cultural considerations for implementing EOL HIV cure research in diverse settings. (shrink)

The aim of this article is to give more insight into what ethical challenges clinicians in mental healthcare experience and discuss with a Clinical Ethics Committee in psychiatry in the Region of Southern Denmark. Ethical considerations are an important part of the daily decision-making processes and thereby for the quality of care in mental healthcare. However, such ethical challenges have been given little systematic attention – both in research and in practices. A qualitative content analysis of 55 written case-reports (...) from the Clinical Ethics Committee. The Committee offers clinicians in mental healthcare structured ethical analyses of ethical challenges and makes a thorough written case-report. The ethical challenges are grouped into three overarching topics: 1. Clinicians and their relation to patients and relatives. 2. Clinicians and institutional aspects of mental healthcare 3. Clinicians and mental healthcare in a wider social context. Through presentation of illustrative examples the complexity of daily clinical life in mental healthcare becomes evident, as well as typical interests, values and arguments. This qualitative study indicates that difficult ethical challenges are an inherent part of mental healthcare that requires time, space and competence to be dealt with adequately. (shrink)

This paper examines the claim of G.W.F. Hegel that chemical thinking-the method of thinking employed in chemistry-marks a significant advance upon meCHANistic thinking-the method of thinking characteristic of physics. This is done in the context of Mancur Olson's theory of collective action and public goods. The analogy between the efficiency of a catalyst in bringing about chemical transformation and the function of leaders in free human society in developing latent groups to provide public goods is explored.