Volume 20, Issue 3, March 2020, Page 35-37.

Volume 20, Issue 7, July 2020, Page 77-80.

Volume 20, Issue 9, September 2020, Page 18-20.

Advance care planning allows patients to articulate preferences for their medical treatment, lifestyle, and surrogate decision-makers in order to anticipate and mitigate their potential loss of decision-making capacity. Written advance directives are often emphasized in this regard. While these directives contain important information, there are several barriers to consider: veracity and accuracy of surrogate decision-makers in making choices consistent with the substituted judgement standard, state-to-state variability in regulations, literacy issues, lack of access to legal resources, lack of understanding of medical (...) options, and cultural disparities. Given these issues, it is vital to increase the use of patient and healthcare provider conversations as an advance care planning tool and to increase integration of such discourse into advance care planning policy as adjuncts and complements to written advance directives. This paper reviews current legislation about written advance directives and dissects how documentation of spoken interactions might be integrated and considered. We discuss specific institutional policy changes required to facilitate implementation. Finally, we explore the ethical issues surrounding the increased usage and recognition of clinician–patient conversations in advance care planning. (shrink)

Clinicians have an obligation to ensure that patients with adequate capacity can make autonomous decisions. Thus, patients who choose to forego treatment and leave hospitals “against medical advice” are typically allowed to do so. But what happens when they require clinicians’ assistance to physically leave? Is it incumbent upon clinicians to not only respect and fulfill patients’ requests with which they disagree, but to physically assist in their fulfillment? We attempt to develop an ethical framework wherein clinicians can honor patients’ (...) wishes without necessarily sacrificing their own moral position. (shrink)

A thirty-year-old single mother with recurrent, metastatic, treatment-refractory cancer presents to the emergency room with severe difficulty breathing due to an obstructive tumor in her neck, compounded by progressive disease in her lungs and a new pulmonary embolism. She cannot be safely intubated and would require an emergent awake tracheotomy. Even if the airway can be successfully secured surgically, the likelihood that she will be able to be weaned from mechanical ventilation is very low. The surgeon, a young mother too, (...) appreciates the patient's desire for more time with her toddler. But the surgeon knows the significant risk of surgery, the massive responsibility she would accept in trying to get the patient through it, and the emotional toll of an intraoperative death on surgical staff. And she can imagine the second-guessing that will come during the inevitable morbidity and mortality conference if the patient should die in the perioperative window. Yet the surgeon does not want to take the “easy” way out; after all, critically ill patients undergo aggressive resuscitation all the time. What should she do? (shrink)

IntroductionDespite the need for trained physician ethicists, fellowships in clinical ethics are limited and primarily offered to thosewho have completed a graduate degree. The standardization of credentialing for clinical ethics consultants (CECs) and the restructuring of undergraduate medical education allow innovative models to train CECs that can provide an expanded opportunity for formal ethics training at an earlier stage.MethodsAt the University of Michigan Medical School we developed, implemented, and evaluated a pre-doctoral clinical ethics fellowship program from 2017 to 2019 for (...) senior medical students, designed to meet established competencies for CECs. Consultation notes from the beginning and end of the fellowship program were randomly selected for each fellow and independently rated by two faculty ethicists who used the validated Ethics Consultation Quality Assessment Tool (ECQAT).1 Inter rater reliability and trends in scores over time were calculated.ResultsThree students successfully completed the fellowship at the University of Michigan Medical School, conducted at least 50 formal ethics consultations, and spent approximately 40 hours a week on service for a minimum of six months. All students finished the fellowship with teaching and policy development experience, first-authored peer-reviewed manuscripts, and national presentations. The fellows demonstrated improvement in their ECQAT overall holistic rating score; all ended their fellowship with a holistic score of adequate or above. There was 92 percent agreement between raters withrespect to the acceptability of the fellows’ ethics consult notes. Two fellows have taken and passed the Healthcare Ethics Consultant-Certification (HEC-C) exam offered by the American Society for Bioethics and Humanities (ASBH).ConclusionsIntegration of a pre-doctoral fellowship model that meets professional certification standards for clinical ethics consultation creates an opportunity for medical students to become trained CECs early in their career. (shrink)

The U.S. federal government provides two tracks for eligible patients to obtain access outside clinical trials to investigational interventions currently under study for potential clinical benefits: the Food and Drug Administration’s expanded access pathway and the pathway created by the more recent Right to Try Act. In this issue of the Hastings Center Report, with a critical focus on patients, industry, and the research enterprise, Kelly Folkers and colleagues frame the inherent challenges that these pathways are meant to solve and (...) have also inadvertently created. But an additional key focus is how the relevant situations should be managed at the bedside and how the system risks both inefficient and inequitable access to options at the institutional level. Although either pathway could be helpful to patients, the challenges of having the pathways coexist are greater than the sum of their parts. Individual clinicians represent the front line of the regulatory and eligibility challenges of expanded access and right to try, making clinical education a critical component of a comprehensive approach to using them well. But it is medical institutions that must take the lead on supporting access to investigational options in the most equitable and effective manner possible. (shrink)

The following demarcates the sense of the human person in Orthodox-Catholic bioethics from the family of senses proper to secular bioethics and philosophy. The radically different sources of knowledge about the senses proper to each discipline suggest that the importation of philosophical and secular psychological distinctions and analyses into true Christianity's concern with the human person, is fundamentally misguided. This suggestion is confirmed by examination of the articles of Crosby, Glannon, Hoswepian, and Meador and Shuman.

The author reviews the arguments made by Mark Hanson, James Keenan, S.J., and Joel Shuman in this issue. In the first section, she argues that they offer a significant contribution toward an understanding of the inner logic of a new trend in contemporary medicine, genetic engineering. However, she criticizes the authors for relying excessively on procedural guidelines and for failing to bring the practical realities of medicine and technology to bear on theory. She argues that more concrete guidelines, which (...) are ultimately grounded in a Christian conception of the person and on the commandment to love, are necessary. Writing from the Roman Catholic perspective, the author argues that the distinction between genetic enhancement and gene therapy is essential, despite the criticisms which have been offered of this distinction. Understanding this distinction will be critical for identifying as licit only those forms of genetic manipulation which respect the dignity of the human person. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 193-194 [Access article in PDF] A Comment on Christopher Ciocchetti:"The Responsibility of the Psychopathic Offender" Daniel W. Shuman Questions of responsibility for serious harm are complex and potentially divisive. The way in which we frame these questions and the criteria by which we assess answers to them are colored, in part, by the lens though which we view them. I am a (...) law professor whose writings includes issues relating to criminal responsibility of person with mentally disabilities and I come to this commentary from that perspective. For me questions of moral responsibility raise psychological and philosophical, as well as legal, questions.Ciocchetti's (2003) paper addressees the criminal responsibility of the psychopathic offender. Not sure quite what the author meant by this label, I began to try to understand the concept of psychopathic offender by picking up my DSM-IV-TR and found no reference to such a diagnostic category. Absent a handy reference in the DSM, I looked in the paper for some other definition or recognition of the category of psychopathic offender and found no satisfactory grounding in any body of sound research. Left with the author's unsupported assertions that such a category of persons exists and that they behave in ways the author asks me to accept without support, my lawyer instincts cautioned me to proceed carefully. The psychopathic offender the author describes might well exist, but I am not persuaded of that, nor would be my legal colleagues, absent proof.Next, to the author's thesis that "[t]he offender must have the capacities necessary to understand relationships to justify holding that offender responsible" (p. 176) and that because psychopaths lack this capacity they should not be held criminally responsible. Is the author proposing a new test for criminal responsibility? Certainly no test for criminal nonresponsibility based on mental disability (i.e., insanity defense) in Anglo-American jurisprudence, or any other with which I am familiar, makes status (i.e., a diagnostic category) exculpatory for criminal responsibility. Rather, every test addresses the impact of a mental illness or disorder on the cognitive or volitional capacity of the offender at the time of the offense. The author offers no reason to reject the approach taken for the last several hundred years [End Page 193] by Anglo-American jurisprudence. Moreover, to the extent that status or diagnostic category is relevant in the insanity defense in Anglo-American jurisprudence, character or personality disorders (the genus to which I take it that psychopathy belongs) are often specifically excluded from consideration. For example, the Texas Penal Code (Tex. Penal Code Ann. § 8.01 (Vernon 1994)) states that:It is an affirmative defense to prosecution that, at the time of the conduct charged, the actor, as a result of a severe mental disease or defect, did not know that his conduct was wrong. The term "mental disease or defect" does not include an abnormality manifested only by repeated criminal or otherwise antisocial conduct.The federal Insanity Defense Reform Act raises the same issue: The government relies on the legislative history of 18 U.S.C. § 17, which states: "The concept of severity was added to emphasize that non-psychotic behavior disorders or neuroses such as an 'inadequate personality,' 'immature personality,' or a pattern of 'antisocial tendencies' do not constitute the defense.".... The government argues that because Dr. Lorenz would have testified that Salava was not psychotic but suffered from antisocial personality disorder, his testimony was not relevant to either prong of the insanity defense under the statute.... As a general matter, the government's point is well-taken. It seems clear that Congress intended by its inclusion of the modifier "severe" to place certain "disorders" outside the purview of the insanity defense altogether. United States v. Salava, 978 F.2d 320, 323 (7th Cir. 1992) Nowhere in the paper does Chiochetti acknowledge or address these societal judgments of moral responsibility that have already rejected a far more modest version of his proposal in categorically ruling out character or personality disorders from inclusion as... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Multiple Personality and Moral Responsibility”Daniel W. Shuman (bio)Stephen Braude’s essay, “Multiple Personality and Moral Responsibility,” discusses a number of important issues about the moral and legal responsibility of persons diagnosed with multiple personality disorder (MPD), known in DSM-IV as Dissociative Identity Disorder (DID). One issue that is fundamental to this debate, which Braude does not address, however, is the empirical reality underlying the debate. Does MPD/DID (...) exist? A prerequisite to a debate about the legal consequences of MPD/DID is legally sufficient proof of its existence and its behavioral consequences.Proof that MPD/DID exists, its impact on legal standards of responsibility, and that the defendant suffers from it, must come from expert testimony; it is not part of the common knowledge or experience of the typical judge or juror. Courts are, however, increasingly, unwilling to assume that because an expert has impressive qualifications, he or she will necessarily present scientifically valid evidence. Particularly in cases of psychiatric and psychological evidence, courts that once looked solely at the expert’s qualifications to determine the admissibility for expert scientific evidence, now understand that the expert’s qualifications are a necessary but not a sufficient condition for the presentation of accurate expert testimony. Courts increasingly want to know how experts know what they claim to know and whether their methods of knowing meet the hallmarks of good science.Thus, from a legal standpoint, a prerequisite to admissibility of the evidence that serves as a basis for a discussion of the legal implications of MPD/DID is rigorous scientific proof of its existence. Proof of the existence of MPD/DID has not, however, been the subject of rigorous scientific research, but instead has consisted of non-falsifiable clinical experience where the risk of iatrogenesis (i.e., hypnosis and suggestion) is ever present. While these clinical observations and opinions may ultimately be proven valid by subsequent research, there is simply no way to know whether that is so in the absence of rigorous scientific research. If proof of the existence of MPD/DID is clinically but not scientifically grounded, legal rules based upon it are suspect. Moreover, claims of MPD/DID often arise in a legal context where there are significant benefits to be gained from receiving the diagnosis which heightens the importance of rigorous scientific scrutiny.Diagnostic validity and reliability matters in different ways in the forensic context than it does in the therapeutic context. These contextual differences [End Page 59] are reflected in disparate standards for scrutinizing each. There is no threshold requirement, for example, that a psychotherapist prove that a diagnostic category is valid or that a psychotherapeutic treatment used for a person suffering from it is generally recognized as safe and effective before using it; however, there is a threshold requirement of rigorous scientific scrutiny before admission of this information in evidence. If a therapist’s diagnostic hypothesis that there are two personality states influencing a patient’s behavior is not borne out, it can be revised in later sessions. Even if MPD/DID does not exist, treatment that assumes it does may nonetheless be effective because therapeutic outcome is more closely tied to the nature of the therapist-patient relationship than the content of therapy, or because multiple personality states is an effective therapeutic metaphor. Moreover, if the patient is not satisfied that the diagnosis or treatment rendered is helpful, the patient can leave therapy or seek another therapist.In contrast, judicial determinations are a one-shot determination which cannot be revisited in light of subsequently acquired knowledge. The defendant/patient is not free to change courts, or withdraw from the legal proceedings. Thus, it would be entirely appropriate for psychiatrists and psychologists to treat patients presenting symptoms of what they label MPD/DID and for courts to reject exculpatory evidence from psychiatrists and psychologists of that disorder.Related ArticlesFeature Article: Multiple Personality and Moral ResponsibilityCommentary: Commentary by ClarkCommentary: Commentary by ShumanDaniel W. Shuman Daniel W. Shuman, Professor of Law, Southern Methodist University, Dallas, TX 75235, USA.Copyright © 1996 The Johns Hopkins University Press... (shrink)

BackgroundThe quality of ethics consults is notoriously difficult to measure. Survey-based assessments cannot capture nuances of consultations. To address this gap, we conducted interviews with health professionals who requested ethics consults during the initial phase of the COVID-19 pandemic.MethodHealthcare professionals requesting ethics consultation between March 2020 and May 2020 at a tertiary academic medical centre were eligible to participate. We asked participants to comment on the consults they called and thematically analysed responses to identify features associated with optimal quality consultations.ResultsOf (...) 14 healthcare providers, 8 (57%) were women and professions were as follows: 11 (79%) medical doctors, 1 (7%) social worker, 1 (7%) physician assistant and 1 (7%) nurse practitioner. Two aspects of quality emerged: satisfaction and value. Themes within the domain of satisfaction included: responsiveness of the ethics consultant, willingness to consult, institutional role of the ethics service and identifying areas for improvement. When describing value, respondents spoke of the intrapersonal and interpersonal worth of consultation.ConclusionParticipants were generally satisfied with ethics consultation services, similar to opinions of those found in pre-COVID-19 survey studies. Our qualitative approach allowed for a richer exploration of the value of ethics consultation during the pandemic and has implications for ethics consultation services more broadly. Ethics consultation—emphasising both the process and outcome—created valuable moral spaces, promoting thoughtful and ethical responses to dilemmas in patient care. Future assessments should incorporate patient and family/surrogate perspectives and explore the domain of education as an additional quality measure. (shrink)

I argue here that the ways we experience, think about, and treat pain are bound up with sociocultural and technological phenomena that shape our desires and expectations. I propose a way of imagining caring for and offering healing to those who suffer pain informed by the Christian theological tradition. This way does not aspire to replace the care and healing made possible by modern medicine, but rather to place it within the common life of a community of mutual love, hospitality, (...) and reciprocal care. (shrink)

In The Body of Compassion, Joel Shuman presents an important, new theological treatment of contemporary bioethics, weaving together personal experience, a critical treatise on contemporary bioethics, and an exploration of a Christian theological alternative.The author first draws the reader into a consideration of the current state of bioethics by relating the story of his grandfather, a hard-working family man who died a solitary death, unaccompanied by loved ones, in the unfamiliar and sterile world of a hospital. Troubled by the (...) way his grandfather died, Shuman takes the reader along as he explores how modern medicine has distanced itself from dealing with people as living beings beyond their immediate physicality. He examines how various approaches to bioethics over the past twenty years have tried to remedy this problem by prescribing certain standards for treatment and how each of these ultimately has fallen short due to the lack of “a teleological concern for the body”—i.e., to trying to understand what the body is actually for in a larger context. From this point, Shuman deftly moves to a discussion of the centrality of the body to Christianity, focusing on how baptism, participation in the liturgy, and the partaking of the Eucharist all serve to unite Christians as one in the body of Christ. For Christians, the author argues, the body does not just belong to the individual but rather is one with the community of the Church. With this in mind, Shuman proposes a new kind of bioethics for Christians, where care for the body of Christ becomes the model of how we should care for and receive care from each other.This fresh and thought-provoking book is sure to be of interest to ethicists, medical professionals, and everyone who is troubled by places where science and religion intersect and seem to conflict. (shrink)

Recent studies indicate that mammalian chromosomes contain discretecis‐acting loci that control replication timing, mitotic condensation, and stability of entire chromosomes. Disruption of the large non‐coding RNA gene ASAR6 results in late replication, an under‐condensed appearance during mitosis, and structural instability of human chromosome 6. Similarly, disruption of the mouse Xist gene in adult somatic cells results in a late replication and instability phenotype on the X chromosome. ASAR6 shares many characteristics with Xist, including random mono‐allelic expression and asynchronous replication timing. (...) Additional “chromosome engineering” studies indicate that certain chromosome rearrangements affecting many different chromosomes display this abnormal replication and instability phenotype. These observations suggest that all mammalian chromosomes contain “inactivation/stability centers” that control proper replication, condensation, and stability of individual chromosomes. Therefore, mammalian chromosomes contain four types ofcis‐acting elements, origins, telomeres, centromeres, and “inactivation/stability centers”, all functioning to ensure proper replication, condensation, segregation, and stability of individual chromosomes. (shrink)

I argue here that Weberian disenchantment is manifest in the triumph of instrumental reason and the expansion of analytic enquiry, which now dominates not simply those sciences upon which medicine depends, but medical practice itself. I suggest ways that analytic enquiry, also referred to here as anatomical reasoning, are part of a particular ideology—a way of seeing, speaking about, and inhabiting the world—that often fails to serve the health of patients because it is incapable of “seeing” them in the moral (...) sense described by Iris Murdoch and others. I use the work of James Elkins and Wendell Berry to call for the recovery of a way of seeing the human body as both other and more than an object of scientific enquiry and social control. (shrink)

Explores the impact of expert witnessing on the integrity of forensic scientific information. Complaints on the behavior of expert witnesses; Factors stimulating the susceptibility of experts to abandon their scientific integrity; Implications of the reliance of expert witnesses on ethics codes.

Even though boys and girls in childhood perform similarly in math and spatial thinking, after puberty fewer young women pursue majors that emphasize abilities such as science, technology, engineering, and math (STEM) in college. If postpubertal feminization contributes to a lower likelihood of choosing STEM majors, then young women who enter puberty early should be the least likely to pursue those majors later in their education. In this study, we investigate the association between age at menarche and the choice of (...) STEM major. We surveyed 150 undergraduate women from a variety of majors in a large, public university and created logistic regression models to estimate their likelihood of choosing a STEM major. We found that early-maturing girls are less likely to enter STEM majors. We posit that the earlier a young woman enters puberty, the earlier and more extensively she is affected by the “leaky pipeline.”. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Operating Through HatredAndrew G. Shuman“You’re not cutting my ***ing neck. The cancer is in my ***ing mouth.”While many patient encounters are memorable, Mr. K’s introduction to the head and [End Page 20] neck surgical oncology clinic is indelibly imprinted into the minds of all of the clinicians present on that certain autumn morning. This was, quite simply, a man who resonated hate. He was rude and disruptive. He (...) insisted on an expedited workup “without any waiting.” He questioned the ethnicity and nationality of his care providers. He told me, in no uncertain terms, that he did not appreciate my Jewish heritage—the swastika tattooed on his bicep underscored the point. He bragged about his recent incarceration for armed robbery. While my colleagues and I were tempted to simply refuse to assume his care, Mr. K had a bad problem—his recurrent tongue cancer required a major operation in order to offer him any hope for cure.Mr. K initially received an abbreviated course of radiation at an outside institution, which was limited by his non–compliance. While one might debate the wisdom of this decision in retrospect—in general, surgery is preferred for his type of tumor—the die was already cast. A heroic attempt at surgical salvage was now his only curative option. He previously sought care elsewhere... only to be fired by this original surgeon when Mr. K physically threatened him in the outpatient office during preoperative consultation. [It was the doctor’s fault for insulting him in the first place, Mr. K maintained... and no charges were filed.] We were, indeed, his last resort. Other than his recurrent cancer, Mr. K was robust; he was in his sixth decade, physically fit, and on the whole, fairly healthy. In the classic surgical lexicon, he was a reasonable surgical candidate. But was it reasonable to operate on such a person?I remember thinking, at the time, about our obligation to care for such an individual. Of course, being a medical professional carries with it many obligations, including a judicious assumption of personal risk. And, working in a tertiary care center begets the responsibility to assist referring clinicians in the management of difficult cases. Although professional obligations certainly have their limits, defining their bounds is decidedly more difficult. Paramount is creating an atmosphere of mutual trust and acceptance. Naturally, this was easier said than done in regard to Mr. K.Perhaps against our better judgment, we agreed to operate under the condition that he abide by strict behavioral ground rules, on our terms. We agreed upon the extent of the necessary operation (which indeed involved cutting his ***ing neck, much to his chagrin and reluctant acceptance). Mr. K promised to follow instructions for postoperative care. He assured us that he would not swear or yell (again). And, in the presence of hospital security, who reinforced our institutional policies regarding patient behavior, he guaranteed that he would not be verbally or physically violent or inappropriate, and would not make disparaging comments to other patients or staff. It seemed, at least, that we had an understanding.Needless to say, these rules were broken shortly after he awoke from surgery. I vividly remember being summoned from the OR when he threatened to murder his impressionable and terrified nurse a few days later, who would not acquiesce to his unreasonable demands. From that point onward, hospital security was deployed to his room regularly, and anything resembling a potential weapon was safeguarded. Any semblance of a mutual doctor–patient bond was shattered. At this point, everyone’s goal was simply to get Mr. K home.My visceral reactions to his behavior, while intense, were not unexpected, and fell in line with those of the entire team of clinicians caring for him. His antics brought his healthcare team together in collective unity (and condemnation). However, my surgical colleagues and I also felt somewhat guilty and responsible. While surgeons can choose to assume some degree of inherent personal danger in caring for a violent and angry patient, we also put the safety and soundness of the entire perioperative team in jeopardy, without necessarily seeking their input. But once we had decided to... (shrink)

Suzie loves to talk. A successful mid-thirties businesswoman, she is a self-described social butterfly—which made her diagnosis of tongue cancer even more devastating. She came to the clinic complaining of a lump in her throat, which in most young healthy people turns out to be benign and easily treated. But not for Suzie, who had a very rare salivary tumor arising in the back of her tongue. Its slow growth was both a blessing and a curse; such tumors do not (...) kill people quickly, but they typically require surgery. It would slowly and relentlessly grow until and unless we removed most of her tongue. In head and neck surgery, issues of appearance, identity, function, and communication are the foremost considerations when we decide when, and whether, to operate. As the adage goes, knowing when not to operate is the sine qua non of the wise surgeon. But the inverse is also true. (shrink)

The question of what, if anything, Christian theology as theology might contribute to ethical debates about appropriate uses of medical genetics has often been ignored. The answer is complex, and the author argues it is best characterized by an explanation of the analogous aspirations of the two: both have as their goal the perfection of the human being, both assert that the present disposition of the human body is on a fundamental level more often than not other than it ought (...) to be, and both aspire to transform the present state of the body toward a future state in which present imperfections no longer exist. Given these analogous concerns, it would seem that one of the primary moral contributions that Christianity can make to debates about medical genetics is to ask whether and to what extent the Christian vision of embodied human perfection is compatible with the vision of perfection offered by the sciences pertaining to medical genetics. The author pursues a discussion of this analogy and its implications in this essay. (shrink)

This paper compares the accounts of agency, morality, and law presumed by liberal political theory to the account offered by Thomas Aquinas. In Aquinas, law is among the several "principles of human acts" and is presumed always to have a constructive effect on the moral formation of those living under its aegis. One of its purposes, in other words, is to make women and men good. The liberal account, on the other hand, is relatively less attentive to the constructive effects (...) of law. This difference raises a question concerning the viability of the liberal assumption of a distinction between a morally neutral public law and a private morality. (shrink)

The attempt to arrive at some consensus on precisely what qualifies a human as a person represents one of the more persistently debated and widely significant issues in modern biomedical ethics. The attribution of personhood has been and continues to be a powerful tool in moral discourse. Biomedical and bioethical debates about personhood seem especially morally significant in late modernity given the recent trends in biomedical technology. Our attempts to formally articulate universally agreed upon criteria for personhood represent some of (...) the last vestiges of the hope that we can achieve substantial moral agreement in an otherwise morally fragmented world. In this essay, we argue that, from the perspective of certain strands of the Christian tradition, all bioethics grounded in attempts to develop formal, objective criteria by which we may designate a given individual a person are misguided. Criteria centering on the possession of reflective mental capacity, moreover, are for Christians especially problematic. We suggest that there are no morally neutral ways of designating personhood. (shrink)

Vaesen infers unique properties of mind from the appearance of specific cultural innovation – a correlation without causal direction. Shifts in habitat, population density, and group dynamics are the only independently verifiable incentives for changes in cultural practices. The transition from Acheulean to Late Stone Age technologies requires that we consider how population and social dynamics affect cultural innovation and mental function.