The internet is widely used for health information and support, often by vulnerable people. Internet-based research raises both familiar and new ethical problems for researchers and ethics committees. While guidelines for internet-based research are available, it is unclear to what extent ethics committees use these. Experience of gaining research ethics approval for a UK study (SharpTalk), involving internet-based discussion groups with young people who self-harm and health professionals is described. During ethical review, unsurprisingly, concerns were raised about the vulnerability of (...) potential participants. These were dominated by the issue of anonymity, which also affected participant safety and consent. These ethical problems are discussed, and our solutions, which included: participant usernames specific to the study, a closed website, private messaging facilities, a direct contact email to researchers, information about forum rules displayed on the website, a ‘report’ button for participants, links to online support, and a discussion room for forum moderators. This experience with SharpTalk suggests that an approach to ethics, which recognises the relational aspects of research with vulnerable people, is particularly useful for internet-based health research. The solutions presented here can act as guidance for researchers developing proposals and for ethics committees reviewing them. (shrink)

Abstract This paper explores gender and mental health with particular reference to the emerging philosophical field of critical realism. This philosophy suggests a shared ontology and epistemology for the natural and social sciences. Until recently, most of the debate surrounding gender and mental health has been guided either implicitly or explicitly within a positivist or constructivist philosophy. With this in mind, key areas of critical realism are explored in relation to gender and mental health, and contrasted with the positions of (...) positivism and constructivism. It is argued that critical realism offers an alternative philosophical framework for the exploration of gender issues within mental health care. (shrink)

Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so particularly where psychopathology is seen as the extreme end of a dimension that includes normality. Depression is an example of such a psychiatric disorder. Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions.

Context The attitudes of medical professionals towards physician assisted dying have been widely discussed. Less explored is the level of agreement among physicians on the possibility of ‘rational suicide’—a considered suicide act made by a sound mind and a precondition of assisted dying legislation. Objective To assess attitudes towards rational suicide in a representative sample of senior doctors in England and Wales. Methods A postal survey was conducted of 1000 consultants and general practitioners randomly selected from a commercially available database. (...) The main outcome of interest was level of agreement with a statement about rational suicide. Results The corrected participation rate was 50%; 363 questionnaires were analysed. Overall 72% of doctors agreed with the possibility of rational suicide, 17% disagreed, and 11% were neutral. Doctors who identified themselves as being more religious were more likely to disagree. Some doctors who disagreed with legalisation of physician assisted suicide nevertheless agreed with the concept of rational suicide. Conclusions Most senior doctors in England and Wales feel that rational suicide is possible. There was no association with specialty. Strong religious belief was associated with disagreement, although levels of agreement were still high in people reporting the strongest religious belief. Most doctors who were opposed to physician assisted suicide believed that rational suicide was possible, suggesting that some medical opposition is best explained by other factors such as concerns of assessment and protection of vulnerable patients. (shrink)

We report on an interview-based study of decision-making capacity in two classes of patients suffering from depression. Developing a method of second-person hermeneutic phenomenology, we articulate the distinctive combination of temporal agility and temporal inability characteristic of the experience of severely depressed patients. We argue that a cluster of decision-specific temporal abilities is a critical element of decision-making capacity, and we show that loss of these abilities is a risk factor distinguishing severely depressed patients from mildly/moderately depressed patients. We explore (...) the legal and clinical consequences of this result. (shrink)

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico-legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. The terrain (...) can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority. (shrink)

Just as humans can draw conclusions responsibly or irresponsibly, so too can computers. Machine learning systems that have been trained on data sets that include irresponsible judgments are likely to yield irresponsible predictions as outputs. In this paper I focus on a particular kind of inference a computer system might make: identification of the intentions with which a person acted on the basis of photographic evidence. Such inferences are liable to be morally objectionable, because of a way in which they (...) are presumptuous. After elaborating this moral concern, I explore the possibility that carefully procuring the training data for image recognition systems could ensure that the systems avoid the problem. The lesson of this paper extends beyond just the particular case of image recognition systems and the challenge of responsibly identifying a person’s intentions. Reflection on this particular case demonstrates the importance (as well as the difficulty) of evaluating machine learning systems and their training data from the standpoint of moral considerations that are not encompassed by ordinary assessments of predictive accuracy. (shrink)

The idea that the self is inextricably intertwined with the rest of the world—the “oneness hypothesis”—can be found in many of the world’s philosophical and religious traditions. Oneness provides ways to imagine and achieve a more expansive conception of the self as fundamentally connected with other people, creatures, and things. Such views present profound challenges to Western hyperindividualism and its excessive concern with self-interest and tendency toward self-centered behavior. This anthology presents a wide-ranging, interdisciplinary exploration of the nature and implications (...) of the oneness hypothesis. While fundamentally inspired by East and South Asian traditions, in which such a view often is critical to philosophical approach, this collection draws upon religion, psychology, and Western philosophy, as well as sociology, evolutionary theory, and cognitive neuroscience. Contributors trace the oneness hypothesis through the works of East Asian and Western thinkers and traditions, including Confucianism. Mohism, Daoism, Buddhism, Platonism, Zhuangzi, Kant, James, and Dewey. They intervene in debates over ethics, cultural difference, identity, group solidarity, and the positive and negative implications of metaphors of organic unity. Challenging dominant traditional views that presume the proper scope of the mind stops at the boundaries of the skin and skull, The Oneness Hypothesis shows that a more relational conception of the self is not only consistent with contemporary science but has the potential to lead to greater happiness and well-being for both individuals and the larger wholes of which they are parts. (shrink)

Copyright © 2015 by the Society of Criti. Objective: Global lung stress varies considerably with low tidal volume ventilation for acute respiratory distress syndrome. High stress despite low tidal volumes may worsen lung injury and increase risk of death. No widely available parameter exists to assess global lung stress. We aimed to determine whether the volume delivered during a recruitment maneuver is inversely associated with lung stress and mortality in acute respiratory distress syndrome. Design: Substudy of an acute respiratory distress (...) syndrome clinical trial on esophageal pressure-guided positive end-expiratory pressure titration. Setting: U.S. academic medical center. Patients: Forty-two patients with acute respiratory distress syndrome in whom airflow, airway pressure, and esophageal pressure were recorded during the recruitment maneuver. Interventions: A single recruitment maneuver was performed before initiating protocol-directed ventilator management. Recruitment maneuvers consisted of a 30-second breath hold at 40 cm H2O airway pressure under heavy sedation or paralysis. VRM was calculated by integrating the flow-time waveform during the maneuver. End-inspiratory stress was defined as the transpulmonary pressure during end-inspiratory pause of a tidal breath and tidal stress as the transpulmonary pressure difference between end-inspiratory and end-expiratory pauses. Measurements and Main Results: VRM ranged between 7.4 and 34.7 mL/kg predicted body weight. Lower VRM predicted high end-inspiratory and tidal lung stress. After adjusting for Pao2/Fio2 and either driving pressure, tidal volume, or plateau pressure and positive end-expiratory pressure, VRM remained independently associated with both end-inspiratory and tidal stress. In unadjusted analysis, low VRM predicted increased risk of death. VRM remained significantly associated with mortality after adjusting for study arm. Conclusions: Low VRM independently predicts high lung stress and may predict risk of death in patients with acute respiratory distress syndrome. (shrink)

ABSTRACTTime-consciousness has long been a focus of research in phenomenology and phenomenological psychology. We advance and extend this tradition of research by focusing on the character of temporal experience under conditions of mania. Symptom scales and diagnostic criteria for mania are peppered with temporally inflected language: increased rate of speech, racing thoughts, flight-of-ideas, hyperactivity. But what is the underlying structure of temporal experience in manic episodes? We tackle this question using a strategically hybrid approach. We recover and reconstruct three hypotheses (...) regarding manic temporality that were advanced and modeled by two pioneers of clinical phenomenology: Eugène Minkowski and Ludwig Binswanger. We then test, critique, and refine these hypotheses using heterophenomenological methods in an interview-based study of persons with a history of bipolar and a current diagnosis of acute mania. Our conclusions support a central hypothesis due to Minkowski... (shrink)

Assessment of decision-making capacity can be difficult in acquired brain injury particularly with the syndrome of organic personality disorder. Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be (...) present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: necessary for DMC, threatened by ABI, and assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined. (shrink)

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

Hume introduced important innovations concerning the theory of ideas. The two most important are the distinction between impressions and ideas, and the use he made of the principles of association in explaining mental phenomena. Hume divided the perceptions of the mind into two classes. The members of one class, impressions, he held to have a greater degree of force and vivacity than the members of the other class, ideas. He also supposed that ideas are causally dependent copies of impressions. And, (...) unlike Locke and others, Hume makes positive use of the principle of association, both of the association of ideas, and, in a more limited way, of the association of impressions. Such associations are central to his explanations of causal reasoning, belief, the indirect passions (pride and humility, love and hatred), and sympathy. These views about impressions and ideas and the principles of association form the core of Hume’s science of human nature. Relying on them, he attempts a rigorously empirical investigation of human nature. The resulting system is a remarkable but complex achievement. (shrink)

Thanks to Barton Palmer and John McMillan for these thoughtful commentaries. We found much to agree with and it is striking how so many of the issues relating to decision-making capacity assessment find resonances outside of an English jurisdiction. California and New Zealand are clearly grappling with a very similar set of issues and the commentaries speak to the international nature of these discussions.We will pick up on some main points the commentaries raise.As Palmer notes, DMC law is vulnerable to (...) the criticism that it does not attend to the authenticity of a decision. In ordinary language, this is the idea that someone is deciding while “not their self” or that it is the “illness speaking.” There is a... (shrink)

The first book-length treatment in English of Habermas’s theory of social evolution and progress.

In spite of the labours of Sedlmayer,1 Ehwald2 and Palmer,3 it cannot be said that there exists a completely satisfactory edition of Ovid's Heroides. One or all of these editors sometimes leave a corrupted text, sometimes adhere too closely to a manuscript reading, and sometimes introduce untenable emendations. A new edition is called for, with revised collati ons of the known manuscripts, and an augmented apparatus criticus, exhibiting the large class of what I may term the ‘Vulgate’ manuscripts, which represents (...) a tradition different from, and probably later than that of our chief authority, the excellent but unfortunately incomplete eleventh-century Parisinus , which, like all primary manuscripts of this type, contains many readings or corruptions which should not on account of its mere authority be accepted slavishly. Light is often thrown on the text from less important sources, and the truth may be recovered from manuscripts of the ‘Vulgate’ family, where our better authority fails. In this connexion the study of my own manuscript has led me to some conclusions in certain passages which I venture to set forth as suggestions towards an improved constitution of the text of the Heroides. Though it is clear from the preceding investigation into its nature that O is no primary manuscript, but belongs rather to that large class which has passed through various stages of reproduction involving alterations due either to carelessness of copyists or, more rarely, to deliberate alteration, it presents at the same time a phenomenon not unusual with such manuscripts, inasmuch as it often supports the best tradition, and in some cases preserves a reading which yields the truth, or from which the truth can be elucidated. I have used the following symbols: P = Parisinus 8242 s. xi. E = Etonensis s. xi. G = Gueferbytanus s. xii. V = Schedae Vindobonenses s xii. O = my manuscript s. xiv. D = Dresdensis s. xiii. ω = all or the majonly of the ‘Vulgate’ manuscripts. ζ = some of these manuscripts. (shrink)

In spite of the labours of Sedlmayer,1 Ehwald2 and Palmer,3 it cannot be said that there exists a completely satisfactory edition of Ovid's Heroides. One or all of these editors sometimes leave a corrupted text, sometimes adhere too closely to a manuscript reading, and sometimes introduce untenable emendations. A new edition is called for, with revised collati ons of the known manuscripts, and an augmented apparatus criticus, exhibiting the large class of what I may term the ‘Vulgate’ manuscripts, which represents (...) a tradition different from, and probably later than that of our chief authority, the excellent but unfortunately incomplete eleventh-century Parisinus, which, like all primary manuscripts of this type, contains many readings or corruptions which should not on account of its mere authority be accepted slavishly. Light is often thrown on the text from less important sources, and the truth may be recovered from manuscripts of the ‘Vulgate’ family, where our better authority fails. In this connexion the study of my own manuscript has led me to some conclusions in certain passages which I venture to set forth as suggestions towards an improved constitution of the text of the Heroides. Though it is clear from the preceding investigation into its nature that O is no primary manuscript, but belongs rather to that large class which has passed through various stages of reproduction involving alterations due either to carelessness of copyists or, more rarely, to deliberate alteration, it presents at the same time a phenomenon not unusual with such manuscripts, inasmuch as it often supports the best tradition, and in some cases preserves a reading which yields the truth, or from which the truth can be elucidated. I have used the following symbols:P = Parisinus 8242 s. xi.E = Etonensis s. xi.G = Gueferbytanus s. xii.V = Schedae Vindobonenses s xii.O = my manuscript s. xiv.D = Dresdensis s. xiii.ω = all or the majonly of the ‘Vulgate’ manuscripts.ζ = some of these manuscripts. (shrink)

quam dolor hie umquam spatio euanescere possit,leniat aut odium tempus et hora meum.Here “spatio” means “lapse of time” : it is illustrated by A. A. II. 113forma bonum fragile est, quantumque accedit ad annos,fit minor et spatio carpitur ipsa suo.As regards the whole couplet, besides at this place, it is found also after line 40 in all the MSS. except the Galeanus Vaticanus and Phillipps MS. There, though it fits in with the context, it is not required: here it is (...) indispensable. It should therefore be omitted from the text after line 40, where its presence is due to that species of interpolation which consisted in the insertion of other portions of a writer's work kindred in meaning, on which see Mr. Hall's Companion to Classical Texts, p. 198. (shrink)