Maintaining accurate and precise temporal perception under conditions of stress is important. Studies in animal models and clinic patients have suggested that time perception can change under chronic stress. Little is known, however, about the relationship between chronic stress and time perception in healthy individuals. Here, a sample of 62 healthy young men completed Cohen’s Perceived Stress Scale (PSS) as a measure of chronic stress levels, while time perception was measured using a temporal bisection task. This task used short (400 (...) ms) and long (1600 ms) visual signals as anchor durations. Participants were presented with a range of intermediate probe durations and were required to judge whether the durations were more similar to the short or the long anchor. Results showed that chronic stress was negatively related to temporal sensitivity indexed by the Weber ratio. However, there was no significant correlation between chronic stress and subjective duration indexed by the bisection point. These results demonstrate that higher chronic stress is associated with lower temporal sensitivity and thus provide evidence for a link between chronic stress and time perception in healthy adults. (shrink)

Living with a chronic condition represents a strenuous experience that often could be lived as a sequence of waiting and crisis times. Therapeutic path incidents could represent however a catalysts and revelatory time, useful to patients to discover their own resources. A qualitative study according to the phenomenological hermeneutic perspective was conducted to understand the kind of skills expressed by the patients during a difficult episode, and the characteristics that identify patients who can overcome them better. From September 2019 to (...) August 2020 twenty-three patients followed-up in four Hospital Units of Northeastern of Italy were enrolled. All the patients described an episode linked whit their pathological condition; they mentioned mainly supportive, reactive, or behavioral strategies and an acceptance attitude. The sample characteristics may explain the recurring acceptance attitude; however, the younger individuals, those with a higher level of education and those who faced precedent negative life experiences seem to better overcome challenging events. It can’t be taken for granted that patients possess all the skills necessary to overcome the frequent challenging episodes they have to face; for this reason, healthcare professionals should assess their learning and reactive attitude in order to tailor for them therapeutic education paths. (shrink)

Chronic pain affects a large part of the population causing functional disability, being often associated with coexisting psychological disorders, such as depression and anxiety, besides cognitive deficits, and sleep disturbance. The world elderly population has been growing over the last decades and the negative consequences of chronic pain for these individuals represent a current clinical challenge. The main painful complaints in the elderly are related to neurodegenerative and musculoskeletal conditions, peripheral vascular diseases, arthritis, and osteoarthritis, contributing toward poorly life quality, (...) social isolation, impaired physical activity, and dependence to carry out daily activities. Organ dysfunction and other existing diseases can significantly affect the perception and responses to chronic pain in this group. It has been proposed that elderly people have an altered pain experience, with changes in pain processing mechanisms, which might be associated with the degeneration of circuits that modulate the descending inhibitory pathways of pain. Aging has also been linked to an increase in the pain threshold, a decline of painful sensations, and a decrease in pain tolerance. Still, elderly patients with chronic pain show an increased risk for dementia and cognitive impairment. The present review article is aimed to provide the state-of-art of pre-clinical and clinical research about chronic pain in elderly, emphasizing the altered mechanisms, comorbidities, challenges, and potential therapeutic alternatives. (shrink)

Some theorists have argued that we should understand the notion of free will from a functional perspective: free will just is our ability to choose effectively and adaptively in an ever-changing environment. Although far from what many philosophers normally mean by free will, those who adopt this biological-evolutionary perspective can clearly define and defend a notion of personal responsibility. One consequenceof this point of view is that addicts become responsible for their actions, for at each choice point, there is a (...) real sense in which the addict could have elected not to use or abuse. As a result, it has been argued that addiction is not a disease, that addictive behavior is voluntary, and that sometimes it is even rational. This paper defends a different way of thinking about addiction, one that aligns it with other complex chronic illnesses. The perspective put forth here suggests that these discussions about responsibility and free will represent an over-simplified and neuropsychologically inaccurate portrait of basic human capacities for behavioral choice. (shrink)

The following article is a response to the position paper of the Hastings Center, "Ethical Challenges of Chronic Illness", a product of their three year project on Ethics and Chronic Care. The authors of this paper, three prominent bioethicists, Daniel Callahan, Arthur Caplan, and Bruce Jennings, argue that there should be a different ethic for acute and chronic care. In pressing this distinction they provide philosophical grounds for limiting medical care for the elderly and chronically ill. We give a critical (...) survey of their position and reject it as well as any attempt to characterize the physician-patient relationship as a commercial contract. We emphasize, as central features of good medical practice, a commitment to be the patient's agent and a determination to acquire and be guided by knowledge. These commitments may sometimes conflict with efforts to have the physician serve as an instrument of social and economic policies limiting medical care. Keywords: acute, agent, autonomy, chronic, knowledge, obligations, rights CiteULike Connotea Del.icio.us What's this? (shrink)

(2013). Pain, Chronic Pain, and Sickle Cell Chronic Pain. The American Journal of Bioethics: Vol. 13, No. 4, pp. 14-16. doi: 10.1080/15265161.2013.768859.

The article maintains that chronic fatigue syndrome can be properly understood only by taking an integrated perspective in which evolutionary, developmental and ecological aspects are considered. The integrative approach, supplemented by a complexity theory and psychoneuroimmunological research, is capable of explaining why there are so few structural aberrations to be found in chronic fatigue syndrome and why specific treatment is so difficult to establish. A major outcome of the investigation, that all individuals with chronic fatigue syndrome are diseased in their (...) own way, emphasises the need to study the development of personalised life histories. It also highlights an ethical dimension; personalised disease defies essentialist thinking on patient management. Another major outcome, which follows from the developmental systems perspective, is the dissolution of ontological mind-body dualism. This in turn allows for a methodological complementation of the biological and phenomenological approaches to knowledge. New research strategies that may help to resolve chronic fatigue syndrome, grounded in the revised perspective on individual development, are suggested. (shrink)

Pains that persist long after damaged tissue hasrecovered remain a perplexing phenomenon. Theseso-called chronic pains serve no useful function foran organism and, given its disabling effects, mighteven be considered maladaptive. However, a remarkablesimilarity exists between the neural bases thatunderlie the hallmark symptoms of chronic pain andthose that subserve learning and memory. Bothphenomena, wind-up in the pain literature andlong-term potentiation (LTP) in the learning andmemory literature, are forms of neuroplasticity inwhich increased neural activity leads to a longlasting increase in the excitability (...) of neuronsthrough structural modifications at pre- andpost-synaptic sites. Moreover, the synapticmodifications of wind-up and LTP share a commonmechanism: a glutamate N -methyl-D-aspartate(NMDA) receptor interaction that initiates a calciummediated biochemical cascade that ultimately enhancessignal processing at the -amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid (AMPA) receptor. This paper arguesthat chronic pain, which has no adaptive value, canbe accounted for in terms of the highly adaptivephenomenon of activity-dependent neural plasticity;hence, some cases of chronic pain can beconceptualized as a memory trace in spinal neurons. (shrink)

Globally, chronic disease and conditions such as diabetes, cardiovascular disease, depression and cancer are the leading causes of morbidity and mortality. Why, then, are public health efforts and programs aimed at preventing chronic disease so difficult to implement and maintain? Also, why is primary care—the key medical specialty for helping persons with chronic disease manage their illnesses—in decline? Public health suffers from its often being socially controversial, personally intrusive, irritating to many powerful corporate interests, and structurally designed to be largely (...) invisible and, as a result, taken for granted. Primary care struggles from low reimbursements, relative to specialists, excessive paperwork and time demands that are unattractive to medical students. Our paper concludes with a discussion of why the need for more aggressive public health and redesigned primary care is great, will grow substantially in the near future, and yet will continue to struggle with funding and public popularity. (shrink)

For the past two decades, agricultural workers in regions of Central America have reported an epidemic of chronic kidney disease of undetermined etiology (CKDu) that is not associated with established risk factors of chronic kidney disease. Several hypotheses have emerged, but the etiology of CKDu remains elusive and controversial. The aim of this literature review was to describe the potential risk factors of CKDu in Mesoamerica and implications for the U.S. agricultural worker population. PubMed and CINAHL databases were searched for (...) articles published between 2000 and 2018 that examined CKDu in Mesoamerica; 29 original studies were included in this review. CKDu is a multifactorial disease that is often asymptomatic with hallmark characteristics of elevated serum creatinine and blood urea nitrogen (BUN), low glomerular filtration rate, electrolyte abnormalities, and non-nephrotic proteinuria. Reducing the global prevalence of CKDu will require more robust studies on causal mechanisms and on interventions that can reduce morbidity and mortality in vulnerable populations. (shrink)

This article studies the phenomenology of chronic illness in light of phenomenology’s insights into ecstatic temporality and freedom. It shows how a chronic illness can, in lived experience, manifest itself as a disturbance of our usual relation to ecstatic temporality and thence as a disturbance of freedom. This suggests that ecstatic temporality is related to another sort of time—“provisional time”—that is in turn rooted in the body. The article draws on Merleau-Ponty’s Phenomenology of Perception and Heidegger’s Being and Time , (...) shedding light on the latter’s concept of ecstatic temporality. It also discusses implications for self-management of chronic illness, especially in children. (shrink)

While the biomedical model is still theleading paradigm within modern medicine and healthcare, and people with generalised chronicmusculoskeletal pain are frequent users of health careservices, their diagnoses are rated as having thelowest prestige among health care personnel. Anepistemological framework for understanding relationsbetween body, emotions, mind and meaning is presented.An approach based on a phenomenological epistemologyis discussed as a supplement to actions based on thebiomedical model.Within the phenomenological frame of understanding,the body is viewed as a subject and carrier ofmeaning, and therefore (...) chronic pain can be interpretedas a rational reaction to the totality of a person'slife situation. Search for possible hidden individualmeanings in painful muscles presupposes meeting healthpersonnel who view the person within a holistic frameof reference. (shrink)

This study explored the social determinants of chronic pain management among people who use drugs, focusing on the ethical notions shaping care‐giving and the social contexts in which they operate. It draws on qualitative data from interviews with people who were currently using drugs and had chronic pain, recruited in Uyo, Nigeria. Narratives show how pain‐related disability adversely impacted participants' livelihoods by hampering their ability to perform daily tasks. They also show how care‐giving, informed by the ethical duty of care (...) in nursing/healthcare professions and traditions of informal care, shaped the experience and meanings of chronic pain and helped participants overcome barriers to healthcare. Care‐giving was situationally undermined by the ethics of justice where chronic pain was seen as retribution for moral deviance and participants were deemed undeserving of care. The study contributes to the literature on chronic pain management among people who use drugs by showing how stigma undermines professional and informal care ethics through reframing chronic pain as retribution and care as something to be earned, rather than an ethical duty. It concludes by reflecting on the implications for nursing and healthcare practice and calling for interventions to tackle stigma and improve pain management for these persons. (shrink)

This paper offers an evolutionary account of chronic pain. Chronic pain is a maladaptive by-product of pain mechanisms and neural plasticity, both of which are highly adaptive. This account shows how evolutionary psychology can be integrated with Flanagan's natural method, and in a way that avoids the usual charges of panglossian adaptationism and an uncritical commitment to a modular picture of the mind. Evolutionary psychology is most promising when it adopts a bottom-up research strategy that focuses on basic affective and (...) motivational systems (as opposed to higher cognitive functions) that are phylogenetically deep. (shrink)

Stress is prevalent in our daily life, and people often make moral decision-making in a stressful state. Several studies have indicated the influence of acute stress on moral decision-making and behavior. The present study extended the investigation to chronic stress, and employed a new approach, the CNI model, to add new insights regarding the mechanism underlying the association between chronic stress and moral decision-making. A total of 197 undergraduates completed the Perceived Stress Scale and made moral decision-making on a series (...) of deliberately designed moral dilemmas. The results indicated that the high-stress group (one standard deviation above the mean) preferred more deontological options than the low-stress group (one standard deviation below the mean). Process-dissociation analysis revealed that the two groups had differences on deontological inclinations but not on utilitarian inclinations. And CNI model analyses suggested that the high-stress group showed a stronger general preference for inaction than the low-stress group did, but there were no significant differences in sensitivity to consequences or sensitivity to moral norms between the two groups. Finally, the implications of our findings were discussed. (shrink)

Chronic diseases are the main disease burden worldwide, leading to premature deaths and poor individual and population health outcomes. Although modern medicine has made significant progress in developing effective treatments, only around 50% of people follow long-term treatment recommendations in high-income countries and presumably even less in low-income and middle-income countries.1 Health outcomes for chronic diseases follow a social gradient across socioeconomic groups, suggesting that the 50% adherence rate distributes unequally across social groups, affecting those who live in disadvantage the (...) most despite universal health coverage.2 Bioethicists have largely ignored inequalities that arise from differences in adherence to long-term treatments and the importance of the ethical dimension of chronicity for clinical practice. As I discuss in detail elsewhere, the concept of ‘chronic disease’ lacks a successful and agreed definition, failing to be structured in a traditional way and allowing for a disjunctive group of diseases to fall under the concept.3 Still, the main element that helps distinguish ‘chronic diseases’ from all other diseases is their long duration, so the noun chronicity can help demarcate and identify the nature of ‘chronic disease’. Drawing on conceptual analysis and phenomenological research on illness that highlight the tension between the cyclical and static elements of chronic disease, I have argued that chronicity has a phenomenological sense beyond its …. (shrink)

With an increasing number of individuals living with chronic illness and pain, integrative approaches offering self-management support are needed. This book proposes a multi-layered framework integrating the body/self/environment that cultivates wholeness as an authentic embodied presence in alignment with a reflexive self.

Embodied knowledge in chronic illness and injury When people experience chronic illness or serious injury, changes occur not just within their physical bodies but also in their embodiments, that is, how they view the world through their bodies. For such patients, dualistic (mind–body) notions of the body as object and the mind as subject can devalue experiences that are necessary for healing and for managing everyday problems related to their illness or injury. Nurses need to be able to guide people (...) with illness or injury to new levels of wellness, but may lack appropriate theoretical conceptualizations. Philosophies that underlie embodied knowledge — in particular, philosophies of Merleau‐Ponty and Polanyi — were explored yielding two new ways to understand the body. The body as ‘silent partner’ fosters an appreciation of the body's own subjectivity that can be enhanced in nursing care through sensitivity, listening, and creative coaching. Nurses can assist their patients to identify new and positive understandings of what their bodies mean to them after bodily changes. The body as ‘informant’ holds much promise for solving some of the everyday problems that people with chronic illness or injury experience. By using phenomenological and other naturalistic methods, researchers and patients can find clues to solving such problems, clues that are known through daily living but hidden beneath conscious awareness. As a result, some of the practical know‐how of the body as ‘informant’ can be transformed into testable nursing interventions. (shrink)

The nosological status of the putative clinical entity of compensation neurosis and the relationship of chronic pain complaints to compensation are explored. It is concluded that, using the traditional criteria of diagnostic validity, there is no support for the view that a specific type of psychiatric disorder related to compensation or litigation can be demonstrated. Although it has been generally considered that chronic pain complaints reflect an underlying disease state, recent evidence has shown that in the medico-legal setting the nature (...) of the compensation system and the level of available benefits have a marked influence on both the rate of chronic pain complaints and the duration of pain related work incapacity. (shrink)

We propose that hyper‐inflammation (HYPi) is a ‘‘runaway’’ consequence of acute inflammation (ACUi) that arises more easily (and also abates less easily) in those who host a pre‐existing chronic inflammation (CHRi), because (i) most factors involved in generating an ACUi to limit viral proliferation are already present when there is an underlying CHRi, and also because (ii) anti‐inflammatory (AI) mechanisms for the abatement of ACUi (following containment of viral proliferation) are suppressed and desensitized where there is an underlying CHRi, with (...) this causing the ACUi to spiral into a HYPi. Stress, pollution, diet, and gut microbiomes (alterable in weeks through dietary changes) have an intimate and bidirectional cause‐effect relationship with CHRi. We propose that avoidance of CHRi‐promoting foods and adoption of CHRi‐suppressing foods could reduce susceptibility to HYPi, in Covid‐19 and in other viral diseases, such as influenza, which are characterized by episodic and unpredictable HYPi. (shrink)

Spermiogenesis is an important physiological process of mammalian fertilization. The germ cells are susceptible to the harmful effects of either psychological or physiological stress, which could induce male infertility. Our previous studies have found that chronic psychological stress could decrease sexual motivation. However, molecular mechanisms underlying male reproductive toxicity induced by chronic stress remain elusive. Recently, autophagy is proven to be involved in regulating the survival of germ cells, which is related to apoptosis. Herein, we established a chronic psychological stress (...) model and a chronic pain model (physiological stressor) to explore the roles of autophagy in germ cells. Thirty-two male Sprague-Dawley rats were randomly divided into four groups, including the control group, the chronic psychological stress group, the SNI-sham group, and the chronic pain stress group. After exposure to stress for 35 days, open field test and the unconditioned sexual motivation test were performed. Following the behavioral experiment, autophagy in the rat testis was detected by Western blot and immunohistochemistry. We found both chronic psychological stress and chronic pain stress reduced total travel distance, the frequency of central crossing and increased the sensitivity to mechanical pain. While chronic psychological stress, but not the chronic pain stress declined sexual motivation. Chronic psychological stress prompt the expression of LC3-II with the decreased expression of p62, indicating that chronic psychological stress induced autophagy in rat testis. However, there was no significant difference between the expression of LC3-II and p62 in male rats under chronic pain stress. Therefore, chronic psychological stress and chronic pain stress have common behavior changes, but due to its unpredictability, chronic psychological stress leads to a decline in sexual motivation in male rats and induced the autophagy in testicular tissues. (shrink)

Chronic pain patients often miss receiving acknowledgement for the multidimensional struggles they face with their specific conditions. People suffering from chronic pain experience a type ofinvisibilitythat is also borne by other chronically ill people and their respective medical conditions. However, chronic pain patients face both passive and active exclusion from social participation in activities like family interactions or workplace inclusion. Although such aspects are discussed in the debates lead by the bio-psycho-social model of pain, there seems to be a lack (...) of a distinct interest in assessing more specifically the social aspects regarding chronic pain. As a result, the social aspects have yet to be taken into a more thorough theoretical consideration of chronic pain and to be practically implemented to help affected patients. By addressing chronic pain patients’ struggle for recognition, this paper attempts to shed light on some of these social aspects. We base this attempt on a theoretical framework that combines patients’ statements with an adaptation of Axel Honneth’s social-philosophical work onrecognition. Thus, this paper tries to make a suggestion on how the bio-psycho-social model of pain can live up to its name by helping to address more adequately some of the more neglected aspects in chronic pain patients’ suffering than has been possible to date. (shrink)

ABSTRACT Current attempts to understand unusually high rates of psychiatric illness in complex, chronic illnesses can be guilty of operating within an explanatory framework whereby there are two options. Either (a) that the psychiatric predicaments are secondary to the bodily condition, and (b) that they are primary. In this paper, I draw upon philosophical work on affect, contemporary empirical work, and qualitative first-person patient data to illustrate a much messier reality. I argue that affective experience is generally more complex in (...) such conditions, and that a variety of pre- and post-morbid causal factors dynamically interact such that the resultant psychiatric predicaments do not permit to classification as strictly primary or secondary to the bodily condition. Affective scaffolding, in my view, provides an apt theoretical framework for capturing this nuance. (shrink)

Chronic pain is one of the most disabling conditions globally, yet we are still missing a satisfying theoretical framework to guide research and clinical practice. This is highly relevant as research and practice are not taking place in a vacuum but are always shaped by a particular philosophy of pain, that is, a set of implicitly or explicitly prevailing assumptions about what chronic pain is and how it is to be addressed. In looking at recent history, we identify a promising (...) trend from neuro-centrism to the application of the biopsychosocial model. Unfortunately, due to its limited theoretical foundation, the biopsychosocial model is too often implemented in a reductionist, fragmented, and linear manner. In particular, it remains too vague concerning the relationship between involved biological, psychological, and social processes. Sanneke de Haan prominently labeled this the integration problem. In this paper, we introduce five different facets of the integration problem that every philosophy of pain needs to address: (i) ontological, (ii) conceptual, (iii) explanatory, (iv) methodologicalMethodological, and (v) therapeutic. We develop an enactive theory of chronic pain and outline how far it provides solutions to these different integration challenges. (shrink)

Chronic diseases represent the major illness burden of developed nations. A chronic disease databank system consists of parallel longitudinal data sets from diverse locations describing the courses of thousands of patients with chronic illness over many years. Illustrated by ARAMIS (The American Rheumatism Association Medical Information System), such data resources facilitate analysis of long term health outcomes and the factors associated with particular outcomes. A model for clinical investigation of contemporary disease is presented, based on the overwhelming prevalence of chronic (...) illness, the variability, complexity, and uniqueness of the individual patient course, the difficulties of traditional univariate reductionist approaches, and the time span required for study. In this model, data are systematically accrued and continually analyzed, and the data collected are gradually modified based upon evolving anticipation of future needs. The strategies underlying the development of ARAMIS are described, investigational results summarized, and future directions outlined. Keywords: ARAMIS, Chronic Disease Databanks, Prognosis, Health Outcomes CiteULike Connotea Del.icio.us What's this? (shrink)

Exercise may influence components of executive functioning, specifically cognitive control and action monitoring. We aimed to determine whether high level exercise improves the efficacy of cognitive control in response to differing levels of conflict. Fitter individuals were expected to demonstrate enhanced action monitoring and optimal levels of cognitive control in response to changing task demands. Participants were divided into the highly active or low-active group based on self-reported activity using the International Physical Activity Questionnaire. A modified flanker task was then (...) performed, in which the level of conflict was modulated by distance of distractors from the target and congruency of arrows. Electroencephalography was collected during 800 trials; trials were 80% congruent, 20% incongruent, 50% close, and 50% far. The error-related negativity and error positivity were extracted from the difference wave of correct and incorrect response locked epochs, the N2 from the difference wave of congruent and incongruent stimulus locked epochs and the P3 from stimulus locked epochs. The HA group showed a larger Pe amplitude compared to the low-active group. Close trials elicited a larger N2 amplitude than far trials in the HA group, but not the low-active group, the HA group also made fewer errors on far trials than on close trials. Finally, the P3 was smaller in the lowest conflict condition in the HA, but not the low-active group. These findings suggest that habitual, high levels of exercise may influence the endogenous processing involved in pre-response conflict detection and the post-error response. (shrink)

has been put forth by Rolston, which leads to respect for the irreversibly comatose by virtue of the residual biological (objective) life. By comparing objective and subjective life, he develops a naturalistic principle which he contrasts with the humanistic norm of contemporary medical ethics. He claims there are clinical applications which would necessarily follow. A critique of this viewpoint is presented here, which begins with an analysis of what might be of value in spontaneous objective life. A measure of the (...) moral worth of simple objective life is attempted by means of comparison with our attitudes toward animals. Finally, some of the clinical applications suggested by Rolston are reviewed. Except for euthanasia, there appear to be few clinical situations where the naturalistic principle helps in problem solving. Keywords: naturalistic principle, value of life, irreversibly comatose CiteULike Connotea Del.icio.us What's this? (shrink)

Marc Lewis argues that addiction is not a disease, it is instead a dysfunctional outcome of what plastic brains ordinarily do, given the adaptive processes of learning and development within environments where people are seeking happiness, or relief, or escape. They come to obsessively desire substances or activities that they believe will deliver happiness and so on, but this comes to corrupt the normal process of development when it escalates beyond a point of functionality. Such ‘deep learning’ emerges from consumptive (...) habits, or ‘motivated repetition’, and although addiction is bad, it ferments out of the ordinary stuff underpinning any neural habit. Lewis gives us a convincing story about the process that leads from ordinary controlled consumption through to quite heavy addictive consumption, but I claim that in some extreme cases the eventual state of deep learning tips over into clinically significant impairment and disorder. Addiction is an elastic concept, and although it develops through mild and moderate forms, the impairment we see in severe cases needs to be acknowledged. This impairment, I argue, consists in the chronic automatic consumption present in late stage addiction. In this condition, the desiring self largely drops out the picture, as the addicted individual begins to mindlessly consume. This impairment is clinically significant because the machinery of motivated rationality has become corrupted. To bolster this claim I compare what is going on in these extreme cases with what goes on in people who dissociate in cases of depersonalization disorder. (shrink)

In this article some of the presuppositions that underly the current ideas about decision making capacity, autonomy and independence are critically examined. The focus is on chronic disorders, especially on chronic physical disorders. First, it is argued that the concepts of decision making competence and autonomy, as they are usually applied to the problem of legal (in)competence in the mentally ill, need to be modified and adapted to the situation of the chronically (physically) ill. Second, it is argued that autonomy (...) and dependence must not be considered as two mutually exclusive categories. It is suggested that decision making may take on the form of a more or less conscious decision not to be involved in making all kinds of explicit and deliberate decisions. Elaborating on Agich's distinction between ideal and actual autonomy, the concept of Socratic autonomy is introduced. (shrink)

This paper starts by establishing a prima facie case that disadvantaged groups or individuals are more likely to get a chronic disease and are in a disadvantaged position to adhere to chronic treatment despite access through Universal Health Coverage. However, the main aim of this paper is to explore the normative implications of this claim by examining two different but intertwined argumentative lines that might contribute to a better understanding of the ethical challenges faced by chronic disease health policy. The (...) paper develops the argument that certain disadvantages which may predispose to illness might overlap with disadvantages that may hinder self-management, potentially becoming disadvantageous in handling chronic disease. If so, chronic diseases may be seen as disadvantages in themselves, describing a reproduction of disadvantage among the chronically ill and a vicious circle of disadvantage that could both predict and shed light on the catastrophic health outcomes among disadvantaged groups—or individuals—dealing with chronic disease. (shrink)

Advance care planning is a process that encourages people to identify their values, to reflect upon the meanings and consequences of serious illness, to define goals and preferences for future medical treatment and care, and to discuss these goals with family and health-care providers. Advance care planning is especially important for those who are chronically ill, as patients and their families face a variety of complex healthcare decisions. Participating in advance care planning has been associated with improved outcomes; yet, despite (...) over 25 years of public awareness campaigns, research, and interventions developed to increase participation, advance care planning completion rates for people with chronic illnesses are no different than those in the general public (approximately 25%). Advance care planning has traditionally used an individualistic approach to autonomy, which puts forward an understanding of agents as independent, rational and self-interested persons. Because this individualistic approach has been largely unsuccessful in improving advance care planning uptake, a re-examination of the philosophical underpinnings of this practice and an exploration of alternative frameworks is warranted. In offering this exploration, we briefly outline two current perspectives on autonomy: the individualistic view and the relational view as articulated by feminist philosophers. Using a critical examination of the theoretical and empirical work on this topic, we argue that the individualistic view of autonomy does not sufficiently capture the relational and social complexities of the decision-making process of advance care planning. To offer a counterpoint, we examine the relational view of autonomy and suggest that this perspective is better aligned with the process of advance care planning. Specifically, we demonstrate that a relational model of autonomy is well suited to exploring advance care planning for four main reasons: (1) it recognizes the importance of relationships, (2) it reflects the fluctuating nature of autonomy in chronic illness, (3) it recognizes vulnerability, and (4) it is consonant with empirical work examining the advance care planning process. (shrink)

The criminal law requires citizens to demonstrate ‘reasonable firmness’ in the face of temptations to violate its provisions. But what if individuals repeatedly face powerful temptations to offend, are not responsible for being in such predicaments, cannot escape them, and cannot alter or expunge their desires because they count as urgent on any plausible account of a decent human life? Should the criminal law make some sort of allowance for the chronically tempted? I argue that it should, because individuals in (...) such predicaments will have to exhibit exemplary if not extraordinary self-control. Intuitively, such self-control is more than the criminal law can reasonably demand of individuals. Also, there is empirical evidence that repeated acts of self-control wear down individuals. Numerous objections to the position I defend are addressed and its implications for the criminal law are briefly explored. (shrink)

Chronic diseases are recognized as a leadingcause of mortality, morbidity, health careutilization and cost. A constant tailoring ofcare to the actual needs of individualpatients, complexity and long duration are thedistinguishing features of chronic diseasemanagement.

Chronic diseases are major causes of health inequalities. Community nurses can potentially make large contributions to chronic illness prevention and management in Israel but may be obstructed by professional dominance of physicians. However, insufficient research exists about community nursing in Israel, and how it may differ from other countries. This study aims to document chronic disease‐related community nursing roles in Israel, identify changes and trends in community nursing roles that may increase social justice, and understand how the roles and trends (...) in community health nursing in Israel may differ from developments in other countries. In‐depth interviews were performed with 55 Israeli health system professionals, and 692 nurse care‐givers were asked open‐ended questions. Interview answers were analyzed to find themes and trends. The study found that community nurse roles in Israel have expanded, especially for chronic disease control. Commonalities exist with countries such as the United States and the UK, albeit with important differences. However, continued conflicts with physicians exist, which can limit nurses' contributions to reducing health inequalities. Community nurses' importance is growing. Enabling them to overcome professional dominance and improve chronic disease control can help reduce health inequalities in Israel and elsewhere. (shrink)

Chronic illness is a major cause of disability, especially in women. Therefore, any adequate feminist understanding of disability must encompass chronic illnesses. I argue that there are important differences between healthy disabled and unhealthy disabled people that are likely to affect such issues as treatment of impairment in disability and feminist politics, accommodation of disability in activism and employment, identification of persons as disabled, disability pride, and prevention and “cure” of disabilities.

Twenty years ago, the biopsychosocial model was proposed by George Engel to be the new paradigm for medicine and psychiatry. The model assumed a hierarchical structure of the biological, psychological and social system and simple interactions between the participating systems. This article holds the thesis that the original biopsychosocial model cannot depict psychiatry's reality and problems. The clinical validity of the biopsychosocial model has to be questioned. It is argued that psychiatric interventions can only stimulate but not determine their target (...) systems, because intervention and outcome are only loosely coupled. Thus, psychiatric interventions have in principle limited ranges which differ according to the type of intervention and according to the system to be stimulated. Psychosocial interventions face far more obstacles to be overcome than psychopharmacogical therapy. (shrink)