ABSTRACT:Psychedelic substances have great promise for the treatment of many conditions, and they are the subject of intensive research. As with other medical treatments, both research and clinical use of psychedelics depend on our ability to ensure informed consent by patients and research participants. However, some have argued that informed consent for psychedelic use may be impossible, because psychedelic experiences can be transformative in the sense articulated by L. A. Paul (2014). For Paul, transformative experiences involve either the acquisition of (...) knowledge that cannot be obtained in any other way or changes in the self. Either of these characteristics may appear to undermine informed consent. This article argues, however, that there is limited evidence that psychedelic experiences are transformative in Paul's sense, and that they may not differ in their transformative features from other common medical experiences for which informed consent is clearly possible. Further, even if psychedelic experiences can be transformative, informed consent is still possible. Because psychedelic experiences are importantly different in several respects from other medical experiences, this article closes with recommendations for how these differences should be reflected in informed consent processes. (shrink)

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending (...) their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons’ mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge. (shrink)

Suffering is widely assumed to have particular moral significance, and is of special relevance in medicine. There are, however, many theories about the nature of suffering that seem mutually incompatible. I suggest that there are three overall kinds of view about what suffering is: value‐based theories, including the theory famously expounded by Eric Cassell, which as a group suggest that suffering is something like a state of distress related to threats to things that a person cares about; feeling‐based theories, which (...) equate suffering with aversive feelings or sensations like pain; and objective theories, which suggest that suffering is the absence of objective flourishing. Rather than argue that one or another of these kinds of theory most accurately captures the nature of suffering, I allow that the term is ambiguous and thus that it may have at least three different kinds. I further argue, however, that when we think about suffering as potentially justifying end‐of‐life interventions, especially for cognitively typical adults, we are interested mainly in value‐based suffering. This is because the moral significance of value‐based suffering for persons with decision‐making capacity generally outweighs that of the other types; those other types of suffering achieve overriding moral significance only if they also constitute, or contribute to, value‐based suffering. (shrink)

There is currently much concern over the use of pharmaceuticals and other biomedical techniques to enhance athletic performance—a practice we might refer to as doping. Many justifications of anti-doping efforts claim that doping involves a serious moral transgression. In this article, I review a number of arguments in support of that claim, but show that they are not conclusive, suggesting that we do not have good reasons for thinking that doping is wrong.

There has been much debate about whether the concept of disease articulated in Boorse’s biostatistical theory is value-neutral or value-laden. Here, I want to examine whether this debate matters. I suggest that there are two basic respects in which value-ladenness might be important: it could threaten either scientific legitimacy or moral permissibility. I argue that value-ladenness does not threaten the scientific legitimacy of our disease-concept because the concept makes little difference to the formulation and testing of scientific hypotheses. Likewise, even (...) if our disease-concept is value-laden, this does not show it is morally impermissible. To determine its permissibility, we must regard it as a tool to structure social institutions. Seen in that way, whether our disease-concept is morally permissible is a consequentialist matter and depends exquisitely on unanswered empirical questions. (shrink)

One of the most widely accepted views in bioethics is that paternalistic interference in others’ self-regarding decisions is justified only if those decisions are not autonomous. Typically, a decision is autonomous if and only if it satisfies certain psychological criteria. Namely, it must be competent and also voluntary. This latter criterion means, roughly, that the agent herself decided without being controlled or unduly influenced by other persons or impersonal forces, in light her own values.The modern locus classicus of this idea (...) is undoubtedly Beauchamp and Childress ; they claim we have a duty to respect autonomous agents. (shrink)

Rationale: Deep brain stimulation (DBS) of the hippocampus is proposed for enhancement of memory impaired by injury or disease. Many pre-clinical DBS paradigms can be addressed in epilepsy patients undergoing intracranial monitoring for seizure localization, since they already have electrodes implanted in brain areas of interest. Even though epilepsy is usually not a memory disorder targeted by DBS, the studies can nevertheless model other memory-impacting disorders, such as Traumatic Brain Injury (TBI). Methods: Human patients undergoing Phase II invasive monitoring for (...) intractable epilepsy were implanted with depth electrodes capable of recording neurophysiological signals. Subjects performed a delayed-match-to-sample (DMS) memory task while hippocampal ensembles from CA1 and CA3 cell layers were recorded to estimate a multi-input, multi-output (MIMO) model of CA3-to-CA1 neural encoding and a memory decoding model (MDM) to decode memory information from CA3 and CA1 neuronal signals. After model estimation, subjects again performed the DMS task while either MIMO-based or MDM-based patterned stimulation was delivered to CA1 electrode sites during the encoding phase of the DMS trials. Each subject was sorted (post hoc) by prior experience of repeated and/or mild-to-moderate brain injury (RMBI), TBI, or no history (control) and scored for percentage successful delayed recognition (DR) recall on stimulated vs. non-stimulated DMS trials. The subject’s medical history was unknown to the experimenters until after individual subject memory retention results were scored. Results: When examined compared to control subjects, both TBI and RMBI subjects showed increased memory retention in response to both MIMO and MDM-based hippocampal stimulation. Furthermore, effects of stimulation were also greater in subjects who were evaluated as having pre-existing mild-to-moderate memory impairment. Conclusion: These results show that hippocampal stimulation for memory facilitation was more beneficial for subjects who had previously suffered a brain injury (other than epilepsy), compared to control (epilepsy) subjects who had not suffered a brain injury. This study demonstrates that the epilepsy/intracranial recording model can be extended to test the ability of DBS to restore memory function in subjects who previously suffered a brain injury other than epilepsy, and support further investigation into the beneficial effect of DBS in TBI patients. (shrink)

Critics of medical aid in dying (MAID) often argue that it is impermissible because background social conditions are insufficiently good for some persons who would utilize it. I provide a critical evaluation of this view. I suggest that receiving MAID is a sort of “hard choice,” in that death is prima facie bad for the individual and only promotes that person’s interests in special circumstances. Those raising this objection to MAID are, I argue, concerned primarily about the effects of injustice (...) on hard choices. I show, however, that MAID and other hard choices are not always invalidated by injustice and that what matters is whether the injustice can be remediated given certain constraints. Injustice invalidates a hard choice when it can, reasonably, be remedied in a way that makes a person’s life go better. I consider the implications of this view for law and policy regarding MAID. (shrink)

Background Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with (...) persons with lived experience of mental illness.Methods We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.Results A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.Conclusions Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk. (shrink)

I am grateful for the insightful comments that have been furnished by Drs. Gala, Moseley, and Perring following their reading of my paper. Happily, I find myself in the position of being able to accept many of their criticisms, which identify many of the limitations of my argument as I see them. In only a few cases do I feel that their remarks are misplaced.The first concern raised by Moseley and Gala is that the paper gives the regrettable impression that (...) persons with anorexia nervosa generally have few cognitive deficits and primarily experience problems in valuing. But as is widely known, this is false: many persons with AN reason poorly and suffer perceptual distortions. I did not. (shrink)

Clinical research is difficult. It confronts massive heterogeneity in its participants, who are real people bumping around the world in complex ways. Clinical research in psychology is doubly difficult, since it tries systematically to study conditions that are inherently difficult to systematize. In their thoughtful and closely argued article, Truijens et al. emphasize these difficulties, and describe a novel challenge to psychotherapy research: that the support for many evidence-based therapies is weaker than previously recognized because it relies on patient-reported outcome (...) measures that often yield invalid results. Despite the initial plausibility of their position, however, their... (shrink)

The American Journal of Bioethics, Volume 11, Issue 8, Page 21-22, August 2011.

If you developed Alzheimer disease, would you want to go all the way to the end of what might be a decade‐long course? Some would; some wouldn't. Options open to those who choose to die sooner are often inadequate. Do‐not‐resuscitate orders and advance directives depend on others' cooperation. Preemptive suicide may mean giving up years of life one would count as good. Do‐it‐yourself methods can fail. What we now ask of family and clinicians caring for persons with dementia, and of (...) patients given no better option than to go on with lives they may not want, is unacceptable. To explore how one might better control one's own dying and avoid burdening others with overwhelming care and morally painful choices, we propose a thought experiment: an advance directive implant that would enable persons with early dementia, while competent, to arrange their own deaths without the subsequent intervention of anyone else. (shrink)

In his carefully documented article, “From reciprocity to autonomy in physician-assisted death: an ethical analysis of the Dutch Supreme Court ruling in the Albert Heringa case,” Berand Florijn (20...

The question of how to handle incidental findings has sparked a heated debate among neuroimaging researchers and medical ethicists, a debate whose urgency stems largely from the recent explosion in the number of imaging studies being conducted and in the sheer volume of scans being acquired. Perhaps the point of greatest controversy within this debate is whether the magnetic resonance imaging scans of all research participants should be reviewed in an active search for pathology and, moreover, whether this search should (...) be performed by a radiologist. Resistance to routine readings performed by radiologists, as opposed to selective review of those scans on which investigators have spotted a possible IF, has been fueled in part by the obvious and enormous cost — financial and logistical — of engaging radiologists to read massive numbers of scans. This cost would be especially burdensome, even prohibitive, to investigators who are not affiliated with a medical center, because of their limited access to radiologists and other medical expertise. (shrink)

We weigh the presumed benefts of routinely searching all research scans for incidental fndings against its substantial risks, including false-positive and false-negative fndings, and the possibility of triggering unnecessary, costly evaluations and perhaps harmful treatments. We argue that routinely searching for IFs may not maximize benefts and minimize risks to participants.

Volume 19, Issue 10, October 2019, Page W14-W17.

Ecologists are challenged by the need to bridge and synthesize different approaches and theories to obtain a coherent understanding of ecosystems in a changing world. Both food web theory and regime shift theory shine light on mechanisms that confer stability to ecosystems, but from different angles. Empirical food web models are developed to analyze how equilibria in real multi-trophic ecosystems are shaped by species interactions, and often include linear functional response terms for simple estimation of interaction strengths from observations. Models (...) of regime shifts focus on qualitative changes of equilibrium points in a slowly changing environment, and typically include non-linear functional response terms. Currently, it is unclear how the stability of an empirical food web model, expressed as the rate of system recovery after a small perturbation, relates to the vulnerability of the ecosystem to collapse. Here, we conduct structural sensitivity analyses of classical consumer-resource models in equilibrium along an environmental gradient. Specifically, we change non-proportional interaction terms into proportional ones, while maintaining the equilibrium biomass densities and material flux rates, to analyze how alternative model formulations shape the stability properties of the equilibria. The results reveal no consistent relationship between the stability of the original models and the proportionalized versions, even though they describe the same biomass values and material flows. We use these findings to critically discuss whether stability analysis of observed equilibria by empirical food web models can provide insight into regime shift dynamics, and highlight the challenge of bridging alternative modelling approaches in ecology and beyond. (shrink)

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging (...) treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

Mandatory vaccination against COVID-19 is a highly controversial issue, and many members of the public oppose it on the grounds that they should be free to determine what happens to their own body. Opinion has generally favored parental authority with respect to vaccination of children, but less attention has been paid to the ethical complexities of how to respond when mature minors refuse vaccination that is requested by their parents. We present a case in which a mature minor, who was (...) psychiatrically hospitalized, refused vaccination that had been requested by her parents, which led to significant moral distress for her caregivers. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

Hoerl & McCormack's dual systems framework provides a new avenue toward the scientific investigation of temporal cognition. However, some shortcomings of the model should be considered. These issues include their reliance on a somewhat vague consideration of “systems” rather than specific computational processes. Moreover, the model does not consider the subjective nature of temporal experience or the role of consciousness in temporal cognition.

Two interpretations of the precautionary principle are considered. According to the normative interpretation, the precautionary principle should be characterised in terms of what it urges doctors and other decision makers to do. According to the epistemic interpretation, the precautionary principle should be characterised in terms of what it urges us to believe. This paper recommends against the use of the precautionary principle as a decision rule in medical decision making, based on an impossibility theorem presented in Peterson . However, (...) the main point of the paper is an argument to the effect that decision theoretical problems associated with the precautionary principle can be overcome by paying greater attention to its epistemic dimension. Three epistemic principles inherent in a precautionary approach to medical risk analysis are characterised and defended. (shrink)

In Australia and other countries, certain groups of women have traditionally been denied access to assisted reproductive technologies . These typically are single heterosexual women, lesbians, poor women, and those whose ability to rear children is questioned, particularly women with certain disabilities or who are older. The arguments used to justify selection of women for ARTs are most often based on issues such as scarcity of resources, and absence of infertility , or on social concerns: that it “goes against nature”; (...) particular women might not make good mothers; unconventional families are not socially acceptable; or that children of older mothers might be orphaned at an early age. The social, medical, legal, and ethical reasoning that has traditionally promoted this lack of equity in access to ARTs, and whether the criteria used for client deselection are ethically appropriate in any particular case, are explored by this review. In addition, the issues of distribution and just “gatekeeping” practices associated with these sensitive medical services are examined. (shrink)

Event-related potentials to hierarchical stimuli have been compared for global/local target trials, but the pattern of results across studies is mixed with respect to understanding how ERPs differ with local and global bias. There are reliable interindividual differences in attentional breadth biases. This study addresses two questions. Can these interindividual differences in attentional breadth be predicted by interindividual ERP differences to hierarchical stimuli? Can attentional breadth changes over time within participants be predicted by ERPs changes over time when viewing hierarchical (...) stimuli? Here, we estimated attentional breadth and isolated ERPs in response to Navon letter stimuli presented at two time points. We found that interindividual differences in ERPs at Time 1 did not predict attentional breadth differences across individuals at Time 1. However, individual differences in changes to P1, N1, and P3 ERPs to hierarchical stimuli from Time 1 to Time 2 were associated with individual differences in changes in attentional breadth from Time 1 to Time 2. These results suggest that attentional breadth changes within individuals over time are reflected in changes in ERP responses to hierarchical stimuli such that smaller N1s and larger P3s accompany a shift to processing the newly prioritized level, suggesting that the preferred level required less perceptual processing and elicited more attention. (shrink)

Peoples’ perceptions of healthy eating are influenced by the cultural context in which they occur. Despite this general acceptance by health practitioners and social scientists, studies suggest that there remains a relative homogeneity around peoples’ perceptions that informs a hegemonic discourse around healthy eating. People often describe healthy eating in terms of learned information from sources that reflect societies’ norms and values, such as the Canada Food Guide and the ubiquitous phrase “fruits and vegetables”. Past research has examined how built (...) environments shape people’s access to healthy living options, such as distribution of grocers versus convenience stores and fast food restaurants. Often overlooked is an in-depth understanding of how social contexts interact with built environments, molding peoples’ perceptions of healthy eating. This paper reports on perceptions of healthy eating in four communities across Alberta, Canada. A photovoice methodology was employed to elicit perceptions of healthy eating with 35 participants. This study illustrates how participants’ photographs and their stories convey multiple meanings about healthy eating within their own lives and communities. Findings suggest that a ‘local’ context is an important part of the discourse centered around the promotion of healthy eating practices in these and potential other communities. (shrink)