This paper describes the change of emphasis that occurred in the teaching of ethics to small groups of clinical students. Although the original focus of the course was on the analysis of ethical dilemmas associated with individual patients known to the students, it soon became evident that there were, for the students themselves, more fundamental ethical dilemmas in their new role as clinical students. These included worries about how to respond when patients asked questions which their consultants had previously deceived (...) them about, worries about inflicting pain on patients, as with intravenous cannulation, and the role of the medical student in the clinical team. We emphasise the need to explore student experiences as part of the process of ethics teaching. (shrink)

In his pioneering work of moral phenomenology, K. E. Løgstrup offered a phenomenological articulation of a central moment of ethical life: the experience in which “one finds oneself with the life of another more-or-less in one’s hands”. In such circumstances we encounter what Løgstrup calls simply the ethical demand. Løgstrup’s preferred formulation of the content of that demand is taken from the Bible: Love thy neighbor. This neighborly love is expressed in the form of spontaneous, selfless care for the other. (...) We shall have occasion in what follows to return to the content that Løgstrup associates with the ethical demand, but my primary focus here is not its content but its distinctive modality. Løgstrup specifies that modality in a fourfold analysis: the ethical demand is radical, silent, one-sided, and unfulfillable. My concern in what follows will be with the fourth element in this analysis – or what I shall refer to simply as Løgstrup’s unfulfillability thesis. My discussion addresses three specific questions: Is it coherent to suppose that the ethical demand is unfulfillable? Why does Løgstrup hold that the ethical demand is unfulfillable? What kind of response is appropriate in the face of an unfulfillable ethical demand? (shrink)

BackgroundFor many decades, the debate on children’s competence to give informed consent in medical settings concentrated on ethical and legal aspects, with little empirical underpinnings. Recently, data from empirical research became available to advance the discussion. It was shown that children’s competence to consent to clinical research could be accurately assessed by the modified MacArthur Competence Assessment Tool for Clinical Research. Age limits for children to be deemed competent to decide on research participation have been studied: generally children of 11.2 (...) years and above were decision-making competent, while children of 9.6 years and younger were not. Age was pointed out to be the key determining factor in children’s competence. In this article we reflect on policy implications of these findings, considering legal, ethical, developmental and clinical perspectives.DiscussionAlthough assessment of children’s competence has a normative character, ethics, law and clinical practice can benefit from research data. The findings may help to do justice to the capacities children possess and challenges they may face when deciding about treatment and research options. We discuss advantages and drawbacks of standardized competence assessment in children on a case-by-case basis compared to application of a fixed age limit, and conclude that a selective implementation of case-by-case competence assessment in specific populations is preferable. We recommend the implementation of age limits based on empirical evidence. Furthermore, we elaborate on a suitable model for informed consent involving children and parents that would do justice to developmental aspects of children and the specific characteristics of the parent-child dyad.SummaryPrevious research outcomes showed that children’s medical decision-making capacities could be operationalized into a standardized assessment instrument. Recommendations for policies include a dual consent procedure, including both child as well as parents, for children from the age of 12 until they reach majority. For children between 10 and 12 years of age, and in case of children older than 12 years in special research populations of mentally compromised patients, we suggest a case-by-case assessment of children’s competence to consent. Since such a dual consent procedure is fundamentally different from a procedure of parental permission and child assent, and would imply a considerable shift regarding some current legislations, practical implications are elaborated. (shrink)

For decades, the discussion on children’s competence to consent to medical issues has concentrated around normative concerns, with little progress in clinical practices. Decision-making competence is an important condition in the informed consent model. In pediatrics, clinicians need to strike a proper balance in order to both protect children’s interests when they are not fully able to do so themselves and to respect their autonomy when they are. Children’s competence to consent, however, is currently not assessed in a standardized way. (...) Moreover, the correlation between competence to give informed consent and age in children has never been systematically investigated, nor do we know which factors exactly contribute to children’s competence. (shrink)

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Biomedical Informatics: We Are What We Publish", written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the Elkin et al. paper. In subsequent issues the discussion can continue through letters to the editor.

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

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

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

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

Admitting to some departure from the Aristotelian classification, Jolivet divides human activities into three sorts: labor, play, and contemplation. He warns against the naturalizing effect of the Marxist notion of labor, defends play as the essentially superfluous, and argues for including art in his third category. A proper conception of human wisdom involves all three activities, although the speculative remains the highest, and the love of God is wisdom's fullest perfection. Based on a lecture series, the book is a clear, (...) rather non-technical, and contemporary re-working of some venerable ideas.--W. L. M. (shrink)

A severe critique of contemporary society as one in which there remains no significant class or group capable of radically opposing things as they are. Marcuse works on the assumption that advanced industrial society is indeed sick, much as some recent sociologists have depicted it to be. He sees evidence of alienation in political and cultural life, in the technical jargon of the bureaucracy, in the technological cult of "operationalism," and especially in contemporary analytic philosophy, which he sees as the (...) triumph of "one-dimensional thought." His conclusion is not optimistic: at this juncture in history, he believes, the only possible task for "critical philosophy" is to be negative.--W. L. M. (shrink)

Lakoff is writing the history of an idea, and he writes very professionally. He begins by identifying three basic approaches to the concept, which he later equates with liberalism, conservatism, and socialism. A chapter on pre-Reformation thought deals too briefly with Plato and Aristotle, and too insensitively with the Medievals. Thereafter, the development proceeds smoothly to the expected conclusion that each approach might well benefit from the others. Lakoff's exegeses and criticisms are satisfactorily subtle, though his basic classification schema is (...) not.—W. L. M. (shrink)

C. I. Lewis and Hans Reichenbach are the contemporaries selected for special study to support the thesis that a carefully redrawn Kantianism is still viable in logic and philosophy of science. The synthetic a priori is reinterpreted as the assumption that conceptual systems can be used to organize the data of sensuous awareness. The doctrine of the Ding-an-sich is defended.--W. L. M.

For Brun, the separation of men from existence, which expresses itself in various forms of anxiety, is the central concern of philosophy. While the separation of men from one another can be partly overcome by language and by modern technology's "conquests," the ontological separation cannot, the philosophic attitude of wonder can never be entirely replaced by nihil mirari. He takes issue with the philosophies of praxis which regard human action as the potential remedy for all separation. The thesis is defended (...) capably and passionately.--W. L. M. (shrink)

May discovered Diderot's copiously annotated copy of this anti-materialist tract by Hemsterhuis, known to many contemporaries as "the Dutch Plato"; this edition contains May's interesting introduction, a facsimile of the original text, and a transcription of all of Diderot's comments. The comments bear on infelicities of style as well as of thought, though the latter preponderate: the Lettre is not, alas, the product of a first-rate philosophical intellect. Diderot's strong objections to Hemsterhuis' crude theory of a moral organ can be (...) taken as complementing his Refutation of Helvetius, which dates from the same period.—W. L. M. (shrink)

White begins his inaugural lecture by explaining that philosophy is about explanations. He distinguishes between types of explanation and factors in explanation; he finds "reason," "cause," and, most controversially, "motive" to be examples of the former; and "feelings," "dispositions," "desires," and also "intentions" to be instances of the latter. Unfortunately he has no opportunity to elaborate on exactly what type of explanation a motive is.--W. L. M.