Background How often does refractory suffering, which is suffering due to symptoms that cannot be adequately controlled, occur at the end of life in modern palliative care? What are the causes of such refractory suffering? Should euthanasia be offered for refractory suffering at the end of life? We sought to shed light on these questions through interviews with palliative care specialists. Methods Semi-structured interviews with six nurses and six doctors working in palliative care in five Norwegian hospitals. Transcripts were analysed (...) with systematic text condensation, a qualitative analysis framework. Results Informants find that refractory suffering is rare, and that with palliative sedation satisfactory symptom control can nearly always be achieved at the end of life. However, the process of reaching adequate symptom control can be protracted, and there can be significant suffering in the meantime. Both somatic, psychological, social and existential factors can contribute to refractory suffering and potentiate each other. However, informants also place significant weight on factors pertaining to the organization of palliative care services as contributing to insufficient symptom control. Conclusions If refractory suffering is indeed rare, then this arguably weakens a common prima facie argument for the legalization of assisted dying. However, the process of reaching adequate symptom control can be protracted and involve significant suffering. The experiences of palliative care clinicians constitute important empirical premises for the assisted dying debate. The study points to several areas in which palliative care can be improved. (shrink)

Deep brain stimulation is a well-accepted treatment for movement disorders and is currently explored as a treatment option for various neurological and psychiatric disorders. Several case studies suggest that DBS may, in some patients, influence mental states critical to personality to such an extent that it affects an individual’s personal identity, i.e. the experience of psychological continuity, of persisting through time as the same person. Without questioning the usefulness of DBS as a treatment option for various serious and treatment (...) refractory conditions, the potential of disruptions of psychological continuity raises a number of ethical and legal questions. An important question is that of legal responsibility if DBS induced changes in a patient’s personality result in damage caused by undesirable or even deviant behavior. Disruptions in psychological continuity can in some cases also have an effect on an individual’s mental competence. This capacity is necessary in order to obtain informed consent to start, continue or stop treatment, and it is therefore not only important from an ethical point of view but also has legal consequences. Taking the existing literature and the Dutch legal system as a starting point, the present paper discusses the implications of DBS induced disruptions in psychological continuity for a patient’s responsibility for action and competence of decision and raises a number of questions that need further research. (shrink)

Between‐trial effects in Stroop‐like interference tasks are linked to differences in the amount of cognitive control. Trials following an incongruent trial show less interference, an effect suggested to result from the increased control caused by the incongruent previous trial (known as the Gratton effect). In this study, we show that cognitive control not only results in a different amount of interference but also in a different locus of the interference. That is, the stage of the task that shows the most (...) interference changes as a function of the preceding trial. Using computational cognitive modeling, we explain these effects by a difference in the amount of processing of the irrelevant dimension of the stimulus. (shrink)

This article discusses how sequential sampling models can be integrated in a cognitive architecture. The new theory Retrieval by Accumulating Evidence in an Architecture (RACE/A) combines the level of detail typically provided by sequential sampling models with the level of task complexity typically provided by cognitive architectures. We will use RACE/A to model data from two variants of a picture–word interference task in a psychological refractory period design. These models will demonstrate how RACE/A enables interactions between sequential sampling and (...) long-term declarative learning, and between sequential sampling and task control. In a traditional sequential sampling model, the onset of the process within the task is unclear, as is the number of sampling processes. RACE/A provides a theoretical basis for estimating the onset of sequential sampling processes during task execution and allows for easy modeling of multiple sequential sampling processes within a task. (shrink)

Visual stimuli that are made invisible by masking can affect motor responses to a subsequent target stimulus. When a prime is followed by a mask which is followed by a target stimulus, an inverse priming effect has been found: Responses are slow and frequently incorrect when prime and target stimuli are congruent, but fast and accurate when prime and target stimuli are incongruent. To functionally localize the origins of inverse priming effects, we applied the psychological refractory period paradigm which (...) distinguishes a perceptual level, a central bottleneck, and a level of motor execution. Two dual-task experiments were run with the PRP-paradigm to localize the inverse priming effect relative to the central bottleneck. Together, results of the Effect-Absorption and the Effect-Propagation Procedure suggest that inverse priming effects are generated by perceptual mechanisms. We suggest two perceptual mechanisms as the source of inverse priming effects. (shrink)

Visual stimuli that are made invisible by a following mask can nonetheless affect motor responses. To localize the origin of these target priming effects we used the psychological refractory period paradigm. Participants classified tones as high or low, and responded to the position of a visual target that was preceded by a prime. The stimulus onset asynchrony between both tasks varied. In Experiment 1 the tone task was followed by the position task and SOA dependent target priming effects were (...) observed. When the visual position task preceded the tone task in Experiment 2, with short SOA the priming effect propagated entirely to the tone task yielding faster responses to tones on visually congruent trials and delayed responses to tones on visually incongruent trials. Together, results suggest that target priming effects arise from processing before and at the level of the central bottleneck such as sensory analysis and response selection. (shrink)

The agent portrayed in much philosophy of action is, let's face it, a square. He does nothing intentionally unless he regards it or its consequences as desirable. The reason is that he acts intentionally only when he acts out of a desire for some anticipated outcome; and in desiring that outcome, he must regard it as having some value. All of his intentional actions are therefore directed at outcomes regarded sub specie boni: under the guise of the good. This agent (...) is conceived as being capable of intentional action—and hence as being an agent—only by virtue of being a pursuer of value. I want to question whether this conception of agency can be correct. Surely, so general a capacity as agency cannot entail so narrow a cast of mind. Our moral psychology has characterized, not the generic agent, but a particular species of agent, and a particularly bland species of agent, at that. It has characterized the earnest agent while ignoring those agents who are disaffected, refractory, silly, satanic, or punk. I hope for a moral psychology that has room for the whole motley crew. I shall begin by examining why some philosophers have thought that the attitudes motivating intentional actions involve judgments of value. I shall then argue that their conception of these attitudes is incorrect. Finally, I shall argue that practical reason should not be conceived as a faculty for pursuing value. (shrink)

One of the more refractory problems in contemporary discussions of consciousness is the problem of determining what a mental state's being conscious consists in. This paper defends the thesis that a mental state is conscious if and only if it has a certain reflexive character, i.e., if and only if it has a structure that includes an awareness of itself. Since this thesis finds one of its clearest expressions in the work of Brentano, it is his treatment of the thesis (...) on which I initially focus, though I subsequently bring in Sartre where he addresses himself to an important point not considered by Brentano. As part of this investigation, the paper also, more specifically, aims to exhibit as perspicuously as possible the relationship between self-awareness and the phenomenal, or 'what-it- is-like', dimension of conscious experience. I attempt to show, in particular, that the phenomenal character of at least perceptual consciousness can be fully explained in terms of self-awareness, i.e., in terms of a low-level or 'implicit' self-awareness that is built into every conscious perceptual state. (shrink)

One of the topics that often comes up in ethical discussions of deep brain stimulation (DBS) is the question of what impact DBS has, or might have, on the patient’s self. This is often understood as a question of whether DBS poses a “threat” to personal identity, which is typically understood as having to do with psychological and/or narrative continuity over time. In this article, we argue that the discussion of whether DBS is a “threat” to continuity over time (...) is too narrow. There are other questions concerning DBS and the self that are overlooked in discussions exclusively focusing on psychological and/or narrative continuity. For example, it is also important to investigate whether DBS might sometimes have a positive (e.g. a rehabilitating) effect on the patient’s self. To widen the discussion of DBS, so as to make it encompass a broader range of considerations that bear on DBS’s impact on the self, we identify six features of the commonly used concept of a person’s “true self”. We apply these six features to the relation between DBS and the self. And we end with a brief discussion of the role DBS might play in treating otherwise treatment-refractory anorexia nervosa. This further highlights the importance of discussing both continuity over time and the notion of the true self. (shrink)

Psychedelic treatments, particularly 3,4-methylenedioxymethamphetamine (MDMA)-assisted and psilocybin-assisted therapies, have recently seen renewed interest in their clinical potential to treat various mental health conditions. Clinical trials for both MDMA-assisted and psilocybin-assisted therapies have shown to be highly efficacious for post-traumatic stress disorder and major depression. Recent research trials for psychedelic-assisted therapies (PAT) have demonstrated that although they are resource-intensive, their effects are rapid-acting, durable and cost-effective. These results have generated enthusiasm among researchers seeking to investigate psychedelic therapies in active-duty service members (...) of the US military, particularly those with treatment refractory mental health conditions. At the same time, psychedelics remain in early stages of clinical investigation, have not yet achieved regulatory approval for general clinical use and may confer unique psychological and neurobiological effects that could raise novel ethical considerations when treating active-duty service members. Should psychedelics achieve regulatory approval, military relevant considerations may include issues of access to these treatments, appropriate procedures for informed consent, confidentiality standards, and possible unanticipated mental health risks and other psychological sequelae. A service member’s deployability, as well as their ability to return to full military duty following PAT, may also be of unique concern. The authors argue that MDMA-assisted therapy currently represents a promising treatment that should be more rapidly investigated as a clinical therapy for service members while still taking a measured approach that accounts for the many military-specific uncertainties that remain. (shrink)

Psychogenic non epileptic seizures (PNES) are clinical events of psychological nature. Video-electroencephalography monitoring (V-EEGM) is a valuable method for the diagnosis of PNES and may be combined with provocative tests to induce seizures. The use of placebo in provocative tests for the diagnosis of PNES is controversial because of associated deception, and contrasts with the use of truly decreasing epileptogenic threshold techniques such as hyperventilation and photo stimulation. We present a clinical case of a pregnant woman with a past (...) history of refractory epilepsy, admitted in the obstetric department due to unremitting seizures. In this clinical context, non-deceiving provocative tests such as hyperventilation and photo stimulation could be potentially harmful, nevertheless, the use of intravenous saline injection presented as a safer alternative to diagnose PNES and hence obviate an urgent caesarean. This case illustrates a disproportionate risk of causing harm when telling the truth, in comparison with the benefit of avoiding such risk, although deceiving the patient. This is a clinical example of how considerations concerning the use of placebo must be evaluated in an individual basis. (shrink)

This paper studies the attempts (and failure) of Russian revolutionaries to mobilize the peasantry in the decade leading to the Soviet revolution of 1917. Peasants, who had been emancipated from serfdom only four decades earlier, in 1861, were still largely propertyless and poor. This would, at first glance, make them a ripe target for revolutionary activity. But peasants were largely refractory. We explain this lack of revolutionary spirit through two models. First, despite their lack of education and political awareness, the (...) peasants were rational in their refusal to participate in revolutionary activity; they engaged in a cost–benefit calculus which pushed them away from revolt and political organization. Second, based on the Wildavsky–Thompson cultural types, Russian peasants were largely fatalist: they believed they had no influence on the world, so it was not worth attempting to change it. This paper sheds light on some aspects of the Russian revolution, but also encourages further research in history and economic sociology on the interaction between culture and incentives. (shrink)

This eighth volume of the Collected Works of Jung comprises a collection of essays in which Jung struggles with the basic theoretical problems of his psychology. He brings an impressive erudition to his search for concepts, models and explanatory principles adequate to the refractory psychic phenomena with which he deals. In keeping with Jung's conviction that the psyche is "a thing of such infinite complexity that it can be observed and studied from a great many sides," the essays exhibit a (...) variety of approaches, from the relatively empirical to the frankly speculative. The essays span some forty years of Jung's reflection and, thanks to their arrangement in thematic groupings by the editors, present an interesting study in the refinement of his thought and statement.--J. M. W. (shrink)

The candid student of scientific method will recognize that biology is not entirely a physical science, while acknowledging that it owes its present state of development largely or mainly to physical conceptions and methods. It is clear that the constant features of vital organization and activity presuppose the physical constancies as basis. Nevertheless the living organism has proved in many ways refractory to a purely physical analysis. This is not merely because the higher organisms have their psychical side and that (...) psychological method differs from physical method; conceivably a properly unified science might apply equally to the physical and the psychical sides of nature. Nor is it entirely because vital behaviour is more individualized and less predictable than physical behaviour. It is rather that certain fundamental features of natural process, largely neglected by physics, are just those which are of chief importance in those flux-like entities which are living organisms. The traditional methods of physics, which analyze nature into combinations of invariant elements and processes, are ill-adapted to deal with the fluid, asymmetrical and largely indeterminate features of process as displayed so conspicuously in living organisms. This, put briefly, is the contention of L. L. Whyte, physicist and author of the recent remarkable book on the relations between physics and biology. In the present paper I propose first to consider especially those sections of the book which bear more particularly on the fundamental problems of biology; this part is paraphrase and commentary rather than summary, although never departing far from the subject of unitary principle as defined by Whyte. Later I shall consider some philosophical implications which seem important. For the details of Whyte's exposition the reader should refer to his book, which is notably clear, concise and critical in style and treatment, as well as comprehensive and fully realistic in its point of view. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Third Way: Social Disability and Person-Centered AssessmentChristopher Heginbotham (bio)Keywordsimpaired functioning, psychopathic, personality disorder, neurological damage, psychotherapyJohn Sadler’s Fascinating Paper identifies a significant problem with existing diagnostic classifications. But in doing so he raises further unresolved philosophical, nosological, and practical problems. Although he is undoubtedly right in showing that the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV (and International Classification of Diseases [ICD]-10) do not provide an adequate (...) categorization, he is I believe wrong to use the term “vice” to describe the cluster of wrongful acts.“Vice” conjures up images of Miami, drugbusting police, prostitution, and other activities that are characterized by one thing—by and large, these are actions undertaken knowingly, usually for financial gain. These are not the actions of people with impaired mental functioning as a result of mental disorder or neurological damage. It is of course true that human trafficking and enforced prostitution may mean women forced into prostitution against their will, but rarely are these women considered mentally disordered solely as a result of their prostitution. Yet it is capacitated, premeditated wrongdoing that is normally considered to be “vice.”By contrast, all the cases cited in the paper describe conditions that are almost certainly the result of some form of impaired functioning, either owing to early childhood experiences (Case A), familial culture and conditioning (Case B), or neurological damage (Case C). The common thread in these cases is impaired capacity—in Case A this could be described as due to psychopathic or personality disorder (I distinguish the two separately rather than describe the phenomenon as “psychopathic personality disorder”) as a result of multiple childhood traumas. Their presentation is not unexpected given the person’s history and, although the condition may have become refractory, it might be amenable to treatment with psychoanalytically oriented psychotherapy, given sufficient time and a nurturing environment (Bateman and Fonagy 2006, 2008; Cordess and Cox 1996; Levy 2008).The description of Case B leaves a lot of room for doubt and uncertainties. Did Ms A really try to smother her child? She confessed to one occasion, but was this under duress? Did she feel that if she agreed she would be treated more leniently? And if she was guilty, does it suggest “vice,” a premeditated act, or is there another explanation—attention [End Page 31] seeking because of low self-esteem or a personality disorder as a result of some abuse that had not been identified? Almost certainly from the description given this would not count, for me at any rate, as vice. Her actions may be odd, bizarre, or dangerous, but did they demonstrate a mens rea? Was Ms A making adequate evaluative judgments of her situation and that of her child? We know from clinical work with very damaged women in forensic mental health services that early physical, emotional, or sexual abuse leads in turn to women harming both themselves and their children (Bland et al. 1999; Cordess and Cox 1996; see also for example, Jeffcote and Watson 2004). Or perhaps, speculatively, her condition was Munchausen’s by proxy?Case C is horrendous but does not lend itself readily to the forms of psychiatric classification available. Indeed there is no easy way to describe such actions other than those of someone who is either incapable of understanding the nature and consequence of the actions that he has undertaken, or is simply “mad” in a folk sense. Prima facie this seems to be the result of permanent and little understood neurological damage. However, this case comes closest to the evil that is implied in the term “vice”; and might be diagnosed similarly to a celebrated English murderer, that of Peter Sutcliffe, the so-called Yorkshire Ripper. Sutcliffe was diagnosed as suffering from paranoid schizophrenia, although the jury at his trial found that he was fit to plead, and he was initially sent to prison, where he deteriorated. He is now, and has for some time, been in Broadmoor high secure hospital.The result of these comments is that I agree fully with John Sadler’s conclusions, but for rather different reasons. DSM-IV categories try and fail to offer a symptomatology for... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Adolf Meyer: Psychiatric AnarchistS. Nassir Ghaemi (bio)KeywordsMeyer, biopsychosocial model, Jaspers, pluralism, philosophy, psychiatryThey had weekly lunches in 1920s New York City: In one door stepped a stooped philosopher, with a mustache and a twinkle, perhaps ruminating on some recent Marxist theory; in the other door came the elegant Swiss physician, goateed and erudite. Every week, for a time, John Dewey (leader of American pragmatism) and Adolf Meyer (dean of (...) mid-twentieth century American psychiatry and long-time chair of the Johns Hopkins psychiatry department) lunched together and, somewhere in those conversations—one might imagine—the field of philosophy and psychiatry was born (Meyer 1948, 152).Yet pragmatism—as a proper school of philosophy—does not capture Meyer’s psychiatry. Rather, the core of his thinking, in my view, is to be found in a vague term that deserves analysis: eclecticism.EclecticismIt has been said that eclecticism is a vice in theory but a virtue in practice (Stone 1981), which highlights why so many are attracted to it. Deep down, practitioners just want to be free: They believe that their freedom of choice will tailor treatments best to patients and thus result in best outcomes. As a conceptual theory for psychiatry, eclecticism is a model that views any theory or method as potentially correct, but no theory or method as definitively incorrect. There is no way to avoid an “anything goes” practice with eclecticism: It is—to use a political analogy—an anarchism of mind.William James once remarked that the basis for all philosophies lies in the personalities of philosophers. So it was with Meyer’s eclecticism: congenial personally, he seemed congenitally incapable of disagreeing with any person. Any idea, even the most unusual, would receive a respectful hearing from Meyer. (Double brings out new, excellent documentary evidence of this extreme indecision in the drafts of Meyer’s unsent letters to the behaviorist John Watson.) Although quaint and commendable pedagogically, this excessive open mindedness left American psychiatry—so dependent on Meyer—prey to hard-headed biological radicals and psychoanalytic dogmatists. This is where his eclecticism failed us.Enabling Biological ExtremismMeyer played a key role in legitimizing extreme biological approaches. In addition to his interest in insulin coma (which Double mentions), Meyer enabled the popularization of colectomy and frontal [End Page 341] lobotomy. Psychiatric colectomy, developed by Henry Cotton, was based on the focal toxin theory of mental illness—the idea that mental illness was caused by toxins released by bacteria in the body, the specific locations of which where were the colon and rotted teeth. In one hundred case reports, with mostly short-term follow-up, published in his prominent text, The Defective Delinquent and Insane (Cotton 1921), Cotton laid out his case, which Meyer legitimized by writing a generous foreword. Meyer’s authority was powerful enough to render Cotton’s limited evidence base much more credible than it might otherwise have been. In the 1920s and 1930s, tens of thousands colectomies and full mouth teeth extractions were conducted in patients with mental illness. (Meyer himself sometimes recommended it).1The other biological extremist story is more famous. In a 1936 conference, with Meyer in attendance, the neurologist Walter Freeman presented, for the first time, cases of refractory schizophrenia treated with a new method: frontal lobotomy. Psychoanalyst attendees protested that Freeman was proposing nothing more than mutilation of the brain; yet Meyer intervened in favor of Free-man (“I am not antagonistic to this work, but find it very interesting” [El-Hai 2005]). Unfortunately, Freeman, like Cotton, was a dogmatist: Over time, he performed frontal lobotomy more and more extensively, not just as a treatment of last resort in the most ill schizophrenics (as in the first cases presented to Meyer), but later as a treatment of first resort for the mildest mood disorders. (By 1950 Freeman had personally conducted 2400 transorbital lobotomies, an “office procedure” that allowed him to lobotomize a patient in 15 minutes [El-Hai 2005]).2Lest my critique of Meyer in that era be seen as a Whiggish interpretation of history (the claim that we are so much smarter than those shrinks of the past; in fact I think... (shrink)

While life in general can be explained by the mechanisms of physics, chemistry and biology, to many scientists and philosophers it appears that when it comes to explaining consciousness, there is what the philosopher Joseph Levine called an “explanatory gap” between the physical brain and subjective experiences. Here we deduce the living and neural features behind primary consciousness within a naturalistic biological framework, identify which animal taxa have these features (the vertebrates, arthropods, and cephalopod molluscs), then reconstruct when consciousness first (...) evolved and consider its adaptive value. We theorize that consciousness is based on all the complex system features of life, plus the even more complex features of elaborate brains. We argue that the main reason why the explanatory gap between the brain and experience has been so refractory to scientific explanation is that it arises from both life and from varied and diverse brains and brain regions, so bridging the gap requires a complex, multifactorial account that includes the great diversity of consciousness, its personal nature that stems from embodied life, and the special neural features that make consciousness unique in nature. (shrink)

When we reach to pick up an object, our actions are effortlessly informed by the object’s spatial information, the position of our limbs, stored knowledge of the object’s material properties, and what we want to do with the object. A substantial body of evidence suggests that grasps are under the control of “automatic, unconscious” sensorimotor modules housed in the “dorsal stream” of the posterior parietal cortex. Visual online feedback has a strong effect on the hand’s in-flight grasp aperture. Previous work (...) of ours exploited this effect to show that grasps are refractory to cued expectations for visual feedback. Nonetheless, when we reach out to pretend to grasp an object (pantomime grasp), our actions are performed with greater cognitive effort and they engage structures outside of the dorsal stream, including the ventral stream. Here we ask whether our previous finding would extend to cued expectations for haptic feedback. Our method involved a mirror apparatus that allowed participants to see a “virtual” target cylinder as a reflection in the mirror at the start of all trials. On “haptic feedback” trials, participants reached behind the mirror to grasp a size-matched cylinder, spatially coincident with the virtual one. On “no-haptic feedback” trials, participants reached behind the mirror and grasped into “thin air” because no cylinder was present. To manipulate haptic expectation, we organized the haptic conditions into blocked, alternating, and randomized schedules with and without verbal cues about the availability of haptic feedback. Replicating earlier work, we found the strongest haptic effects with the blocked schedules and the weakest effects in the randomized uncued schedule. Crucially, the haptic effects in the cued randomized schedule was intermediate. An analysis of the influence of the upcoming and immediately preceding haptic feedback condition in the cued and uncued random schedules showed that cuing the upcoming haptic condition shifted the haptic influence on grip aperture from the immediately preceding trial to the upcoming trial. These findings indicate that, unlike cues to the availability of visual feedback, participants take advantage of cues to the availability of haptic feedback, flexibly engaging pantomime, and natural modes of grasping to optimize the movement. (shrink)

This article seeks to critically question the internal logic and coherence of ‘anti-doping’ through the case study of advantage-seeking practices in the sport of Brazilian Jui-Jitsu (BJJ). We provide an analysis of the recent controversy between high-profile fighters Gordon Ryan and Nicky Rod involving the relative morality of image and performance enhancing drug (IPED) use compared with ‘greasing’, whereby BJJ athletes apply substances, such as oil or lubricants, to the body to make it harder for opponents to establish a grip (...) or maintain control during grappling exchanges. We employ this case study to highlight the impasse between the World Anti-Doping Agency’s (WADA) ethical foundation of the ‘spirit of sport’ and the anti-doping industry’s ‘anti-policy’ stance. We then query why a host of non-chemical advantage-seeking practices are normalised and overlooked within the rigid and constrictive systems. Ultimately, we characterise WADA as a myopic compliance system that stifles moral debate around advantage-seeking in sport and is hamstrung by an ethical discord between anti-policy and the neo-Aristotelian ideal of the spirit of sport. We close with a call for a holistic ethical understanding of advantage-seeking in sport and the need to encourage stakeholders to ‘think institutionally’ in order to establish a malleable and reactive response to doping. (shrink)