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)

The application of machine learning in health care holds great promise for improving care. Indeed, our own team is collaborating with experts in machine learning and statistical modeling to bu...

BackgroundDeep brain stimulation is approved for treating refractory obsessive-compulsive disorder in adults under the US Food and Drug Administration Humanitarian Device Exemption, and studies hav...

The ongoing debate within neuroethics concerning the degree to which neuromodulation such as deep brain stimulation (DBS) changes the personality, identity, and agency (PIA) of patients has paid relatively little attention to the perspectives of prospective patients. Even less attention has been given to pediatric populations. To understand patients’ views about identity changes due to DBS in obsessive-compulsive disorder (OCD), the authors conducted and analyzed semistructured interviews with adolescent patients with OCD and their parents/caregivers. Patients were asked about projected impacts (...) to PIA generally due to DBS. All patient respondents and half of caregivers reported that DBS would impact patient self-identity in significant ways. For example, many patients expressed how DBS could positively impact identity by allowing them to explore their identities free from OCD. Others voiced concerns that DBS-related resolution of OCD might negatively impact patient agency and authenticity. Half of patients expressed that DBS may positively facilitate social access through relieving symptoms, while half indicated that DBS could increase social stigma. These views give insights into how to approach decision-making and informed consent if DBS for OCD becomes available for adolescents. They also offer insights into adolescent experiences of disability identity and “normalcy” in the context of OCD. (shrink)

IntroductionDeep brain stimulation (DBS) is utilized to treat pediatric refractory dystonia and its use in pediatric patients is expected to grow. One important question concerns the impact of hope and unrealistic optimism on decision-making, especially in “last resort” intervention scenarios such as DBS for refractory conditions.ObjectiveThis study examined stakeholder experiences and perspectives on hope and unrealistic optimism in the context of decision-making about DBS for childhood dystonia and provides insights for clinicians seeking to implement effective communication strategies.Materials and MethodsSemi-structured interviews (...) with clinicians (n = 29) and caregivers (n = 44) were conducted, transcribed, and coded.ResultsUsing thematic content analysis, four major themes from clinician interviews and five major themes from caregiver interviews related to hopes and expectations were identified. Clinicians expressed concerns about caregiver false hopes (86%, 25/29) and desperation (68.9%, 20/29) in light of DBS being a last resort. As a result, 68.9% of clinicians (20/29) expressed that they intentionally tried to lower caregiver expectations about DBS outcomes. Clinicians also expressed concern that, on the flip side, unrealistic pessimism drives away some patients who might otherwise benefit from DBS (34.5%, 10/29). Caregivers viewed DBS as the last option that they had to try (61.3%, 27/44), and 73% of caregivers (32/44) viewed themselves as having high hopes but reasonable expectations. Fewer than half (43%, 19/44) expressed that they struggled setting outcome expectations due to the uncertainty of DBS, and 50% of post-DBS caregivers (14/28) expressed some negative feelings post treatment due to unmet expectations. 43% of caregivers (19/44) had experiences with clinicians who tried to set low expectations about the potential benefits of DBS.ConclusionThoughtful clinician-stakeholder discussion is needed to ensure realistic outcome expectations. (shrink)

Learning and memory are inextricably intertwined. The capacity for learning presupposes an ability to retain the knowledge acquired through experience, while memory stores the background knowledge against which new learning takes place. During the dark years of radical behaviorism, when the concept of memory was deemed too mentalistic to be a proper subject of scientific study, research on human memory took the form of research on verbal learning (Anderson, 2000; Schwartz & Reisberg, 1991).

Conscious recollection appears to be governed by seven principles: elaboration, organization, time‐dependency, cue‐dependency, encoding specificity, schematic processing, and reconstruction. However, these same principles may not apply to unconscious, or implicit, memory. Implicit memory is most commonly reflected in priming effects which occur in the absence of conscious recollection. Dissociations between explicit and implicit memory have been observed in patients suffering various sorts of brain damage, in other forms of amnesia, in behavioral performance of neurologically intact subjects, and in brain‐imaging studies (...) of memory. The most popular interpretation of these dissociations holds that explicit and implicit memory are mediated by separate and independent brain systems. However, there are also compelling interpretations in terms of dual processes operating on the contents of a single memory system. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead to experiences (...) of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

Among philosophical questions about human agency, one can distinguish in a rough and ready way between those that arise in philosophy of mind and those that arise in ethics. In philosophy of mind, one central aim has been to account for the place of agents in a world whose operations are supposedly ‘physical’. In ethics, one central aim has been to account for the connexion between ethical species of normativity and the distinctive deliberative and practical capacities of human beings. Ethics (...) then is involved with questions of moral psychology whose answers admit a kind of richness in the life of human beings from which the philosophy of mind may ordinarily prescind. Philosophy of mind, insofar as it treats the phenomenon of agency as one facet of the phenomenon of mentality, has been more concerned with how there can be ‘mental causation’ than with any details of a story of human motivation or of the place of evaluative commitments within such a story. (shrink)

One of Edmund Husserl's theoretical priorities throughout his philosophical career was to understand the nature of perceptual experience. His analyses of perceptual experience had a profound impact on subsequent thinkers in the phenomenological tradition, such as Aron Gurwitsch and Maurice Merleau-Ponty. Naturally, his account of perception remains a topic of discussion among Husserl scholars. Despite the attention it has received over many decades, Husserl interpreters diverge considerably in how they understand his views and their relation to current debates in the (...) philosophy of perception. A case in point is Husserl's view on the relation between veridical perceptual experience and hallucination, which I will... (shrink)

Introduction -- Elucidating complexity theories -- Complexity in the natural sciences -- Complexity in social theory -- Towards transdisciplinarity -- Complexity in philosophy: complexification and the limits to knowledge -- Complexity in ethics -- Earth in the anthropocene -- Complexity and climate change -- American dreams, ecological nightmares and new visions -- Complexity and sustainability: wicked problems, gordian knots and synergistic solutions -- Conclusion.

This article is the second one in a series dealing with mental health ethics in Cuba. It reports on ethical dilemmas, resources and limitations to their resolution, and recommendations for action. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans experience dilemmas related to the interests of clients, their personal interests, and the interest of the state. These conflicts are related to power differentials among clients and professionals, professionals from various disciplines, and professionals and (...) organizational authorities. Resources to solve ethical dilemmas include government support, ethics committees, and collegial dialogue. Limitations include minimal training in ethics, lack of safe space to discuss professional disagreements, and little tolerance for criticism. Recommendations to address ethical dilemmas include better training, implementation of a code of ethics, and provision of safe space to discuss ethical dilemmas. The findings are discussed in light of the role of power in applied ethics. (shrink)

ABSTRACT:The primacy of shareholder demands in the traditional theory of the firm has typically excluded marginalised stakeholder voices. However, shareholders involved in social shareholder engagement (SSE) purport to bring these voices into corporate decision-making. In response to ethical concerns about the legitimacy of SSE, we use the lens of discourse ethics to provide a normative analysis at both action and constitutional levels. By specifying three normative questions, we extend the analysis of SSE to identify a political role for shareholders in (...) pursuit of the common good. We demonstrate the desirability for SSE to promote regulatory/institutional change to guarantee marginalised stakeholders a voice in corporate decisions that affect them. The theory of SSE we propose thus calls into question the stark separation of the political and economic spheres and reveals an underlying tension, often overlooked, within the responsible investment literature. (shrink)

The debate about what constitutes the discipline of ethics and who qualifies as an ethics consultant is linked unavoidably to a debate that is potentiated by the reality of a rapidly changing and high-stakes health care consultation marketplace. Who we are and what we can offer to the moral gesture that is medicine is shaped by our fundamental understanding of the place of expert knowledge in the transformation of social reality. The struggle for self-definition is particularly freighted since clinical ethics (...) consultation aspires to be more than academic contemplation. Two recent books (Ethics Consultation by John La Puma and David Schiedermayer and The Health Care Ethics Consultant: A Practical Guide, edited by Francoise Baylis) exemplify the two most popular but most widely divergent positions on these issues. We argue that while useful, neither book addresses fully the particular and distinct role of the professional ethicist. (shrink)

While classical phenomenology, as represented by Edmund Husserl’s work, resists certain forms of representationalism about perception, I argue that in its theory of horizons, it posits representations in the sense of content-bearing vehicles. As part of a phenomenological theory, this means that on the Husserlian view such representations are part of the phenomenal character of perceptual experience. I believe that, although the intuitions supporting this idea are correct, it is a mistake to maintain that there are such representations defining the (...) phenomenal character of low-level perception. What these representations are called on to explain, i.e., the phenomenal character of perceiving objects in their full presence, can be more parsimoniously explained by appealing to certain affective states or affect schemas that shape the intentional directedness of low-level perceptual experience and define its phenomenal character in a non-representational way. This revision of the Husserlian view, it is shown, also helps us understand the normative character of perception. (shrink)

When and why does it matter whether we can give an explicit justification for what we believe? This paper examines these questions in the light of recent empirical work on the social functions served by our capacity to reason, in particular, Mercier and Sperber’s argumentative theory of reasoning.

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper we present findings about clinical ethics from in depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the (...) research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics. (shrink)

Do we need a right to mental privacy? In an era of increasing sophistication in recording, interpreting, and directly intervening on our neural activity – not to mention efforts at combining neural...

Testimony is an invaluable source of knowledge. We rely on the reports of those around us for everything from the ingredients in our food and medicine to the identity of our family members. Recent years have seen an explosion of interest in the epistemology of testimony. Despite the multitude of views offered, a single thesis is nearly universally accepted: testimonial knowledge is acquired through the process of transmission from speaker to hearer. In this book, Jennifer Lackey shows that this (...) thesis is false and, hence, that the literature on testimony has been shaped at its core by a view that is fundamentally misguided. She then defends a detailed alternative to this conception of testimony: whereas the views currently dominant focus on the epistemic status of what speakers believe, Lackey advances a theory that instead centers on what speakers say. The upshot is that, strictly speaking, we do not learn from one another's beliefs - we learn from one another's words. Once this shift in focus is in place, Lackey goes on to argue that, though positive reasons are necessary for testimonial knowledge, testimony itself is an irreducible epistemic source. This leads to the development of a theory that gives proper credence to testimony's epistemologically dual nature: both the speaker and the hearer must make a positive epistemic contribution to testimonial knowledge. The resulting view not only reveals that testimony has the capacity to generate knowledge, but it also gives appropriate weight to our nature as both socially indebted and individually rational creatures. The approach found in this book will, then, represent a radical departure from the views currently dominating the epistemology of testimony, and thus is intended to reshape our understanding of the deep and ubiquitous reliance we have on the testimony of those around us. (shrink)

Background:The public domain of midwifery practice, represented by the educational and hospital institutions could be blamed for a subconscious ethical dilemma for midwifery practitioners. The result of such tension can be seen in complaints from maternity service users of dehumanised care. When expectations are not met, women report dehumanising experiences that carry long term consequences to both them and their child.Objectives:To revisit the ethical foundation of midwifery practice to reflect the feminist Ethic of Care and reframe what is valuable to (...) women and midwives during the childbirth experience.Research Design:A comprehensive literature review is presented from the midwifery and feminist ethics discourse.Ethical Considerations:Nil to report.Findings:Women are vulnerable during childbirth as they need care, yet they prioritise elements of relationship in their experience. The Ethic of Care approach equalises the relationship between the midwife and the woman, providing the space for relationship building and allowing midwives to meet the expectations of their accepted responsibility.Discussion:Some midwives manage to balance the demands of the institution with the needs of the woman. This is described as both an emotional and professionally challenging balancing act.Conclusion:Until there is a formal acknowledgement of the different ethical approach to midwifery practice from within the profession and the Institution, midwifery identity and practice will continue to be compromised. (shrink)

Hume said that to have a memory image of some individual, x, is to perceive a ‘faint copy’ of some prior perception of x. This classical view of memory images includes three distinct claims: Images and percepts are mental entities which serve as objects for a ‘direct’ or ‘non-inferential’ perception. A memory image of some individual, x, shares numerous properties with some prior perception of x.

Dispositionality is a modal notion of a certain sort. When an object is said to have a disposition, we typically understand this to mean that under certain circumstances, the object would behave in a certain way. For instance, a fragile object is disposed to break when dropped onto a concrete surface. It need not actually break - its being fragile has implications that, so to speak, point beyond the actual world. According to dispositionalism, all modal features of the world may (...) be accounted for in terms of its dispositional features. My aim in this paper is to assess the prospects for dispositionalism by examining the most promising theories. Sections 1 and 2 clarify the assumptions and desiderata of a successful dispositionalist theory of modality. Section 3 introduces the principles governing the dispositionalist theories that apparently meet the desiderata. Sections 4 through 6 show that dispositionalism nonetheless faces three problems: while dispositions help account for modal features of the world that are local, diachronic, or gradable, they cannot account for certain modal features of the world that are global, synchronic, or absolute. I end by discussing the costs of preserving dispositionalism. (shrink)

1. Lying -- 2. The problem of what is said -- 3. What is said -- 4. Is lying worse than merely misleading? -- 5. Some interesting cases.

Implicit memory refers to a change in task performance due to an earlier experience that is not consciously remembered. The topic of implicit memory has been studied from two quite different perspectives for the past 20 years. On the one hand, researchers interested in memory have set out to characterize the memory system underlying implicit memory, and see how they relate to those underlying other forms of memory. The alternative framework has considered implicit memory as a by-product of perceptual, conceptual, (...) or motor systems that learn. That is, on this view the systems that support implicit memory are heavily constrained by pressures other than memory per se. Both approaches have yielded results that have been valuable in helping us to understand the nature of implicit memory, but studied somewhat in isolation and with little collaboration. This volume is unique in explicitly contrasting these approaches, bringing together world class scientists from both camps in an attempt to forge a new approach to understanding one of the most exciting and important issues in psychology and neuroscience. Written for postgraduate students and researchers in cognitive psychology and cognitive neuroscience, this is a book that will have an important influence on the direction that future research in this field takes. (shrink)