The article aims at studying the economic processes of developing national market of resort services in a historical perspective. The theoretical conceptualization of the market of resort services has been conducted, the basic economic backgrounds of its formation has been defined basing on a comprehensive assessment of researches of Ukrainian and foreign scientists. The article has analyzed the institutional framework of a resort services market in the realities of a mixed model of the national economy. The issues (...) of financial security of resort treatment and rehabilitation in the conditions of a market and anti-market of Ukrainehave been studied. The problem of economic inefficiency of planning and distribution system to ensure the proper level of reproduction of human capital has been outlined. It has been established that the spa and resort sector of Ukraine is characterized by the transformation of the economy reflecting the changes of public vectors of a state-formationthat affect differently entrepreneurship, private and state property, principles and ways of funding spa treatment and rehabilitation of the population. The results of the study enable to formulate the basic economic conditions of formation of the national market of spa and resort services: a significant level of economic utilization of natural recreational resources, development of infrastructure for spa treatment and rehabilitation of people; revival of institutional norms of sanatorium and resort business on the principles of private property, entrepreneurship and competition. Further research should be conducted as to develop anti-crisis trends in a governmental regulation of the national market of resort services in Ukraine, transformation of quasi-marketsystem of spa and resort services into a socially oriented system of market relations that meet the demands of a modern Ukrainian society. (shrink)

У статті досліджено рекреаційне господарство Галичини другої половини XIX - першої третини ХХ ст. Комплексно охарактеризовано основні галузі, що становили основу рекреації та туризму, проаналізовано динаміку відпочиваючих, систему оплати оздоровлення та санаторно-курортне господарство, систему гірських притулків краю загалом. Показано, що туризм і відпочинок були важливим джерелом доходів мешканців Галичини, що дозволило краю отримати належне ставлення як із боку держави, так і з боку справжніх поціновувачів та любителів природи й етнографічних особливостей. Констатовано, що саме в цей період було побудовано розвинуту туристичну (...) та оздоровчу інфраструктуру, яка мала набагато більші масштаби, ніж у сучасних Україні та Польщі. (shrink)

It has been debated for quite some time among bioethicists and others whether or not the distinction between therapy and research in healthcare can and should be maintained. This paper tries to clarify what the disagreement is about, and argues that the distinction can be maintained in most, if not all, situations. However, even if it can be maintained, it does not necessarily follow that it should. It is argued here that there are good reasons to maintain the distinction both (...) for the sake of protecting research interests and the sake of patient safety. In addition, recognizing the distinction provides a barrier against unreasonable prioritization between patients. However, there may be situations, such as innovative last-resort treatment, in which regulatory requirements from both therapy and research should be considered. (shrink)

From the mid nineteenth to mid twentieth century sanatoria loomed large in the popular consciousness as the space for the treatment of tuberculosis (TB). A review of the historiography of sanatoria at the beginning of this paper shows that the nursing contribution to the care of TB patients is at best ignored and at worst attracts negative comment. Added to this TB nursing was not viewed as prestigious by contemporaries, leading to problems attracting recruits. Using a case study approach (...) based on surviving archival material, this paper sets out to provide a glimpse of the work of TB nurses in a rural sanatorium at Westwood, Queensland, Australia. For the nurses geographical isolation was compounded by professional stagnation, which created a working environment influenced by friction and discord among the staff. It reveals how despite this, nurses coped with working in hostile conditions, to make the long stay of their patients, separated from their families and familiar life style more bearable. (shrink)

Many participants in debates about the morality of assisted dying maintain that individuals may only turn to assisted dying as a ‘last resort’, i.e., that a patient ought to be eligible for assisted dying only after she has exhausted certain treatment or care options. Here I argue that this last resort condition is unjustified, that it is in fact wrong to require patients to exhaust a prescribed slate of treatment or care options before being eligible for (...) assisted dying. The last resort condition effectively pits one right of patients, their right to refuse medical treatment or interventions, against another patient right acknowledged by advocates of assisted dying, the right to die. Drawing on an analogy with the legal notion of an unconstitutional condition, I argue that the last resort condition unjustly demands that an arguably more fundamental right—the right to refuse medical treatment or intervention—be foregone in order to acquire a less fundamental right—the right to die. I then address three rationales for the last resort condition and find that they subject individuals to arbitrarily stringent standards for exercising the right to die, standards to which those who seek to end their lives by voluntarily ending life-sustaining treatments are not subject. Subjecting those who seek assisted dying to the last resort condition therefore wrongfully infringes on their right to refuse medical treatment or interventions. (shrink)

In Japan, most residents with Hansen’s disease live in dedicated sanatoria because of an established quarantine policy, even after being cured of the primary disease. They suffer from secondary diseases and are advancing in age, and advance care planning is increasingly crucial for them to live their lives with dignity in a sanatorium. In this study, we have three aims: to understand how to promote communication about their wishes for medical treatment, care, and recuperation; to identify required assistance; (...) and to explore how to promote ACP in a sanatorium. This study is a qualitative research conducted through semi-structured interviews. The study included 57 ex-Hansen’s disease patients and 66 staff from 10 facilities. Ex-Hansen’s disease patients were expected to consider ACP, but this was in the context of uncertainty about whether a sanatorium would close and whether there would be doctors to manage their needs. They reported being confused when staff rushed to confirm their advance directives, feeling that they were not provided with enough information before being approached. Barriers to promoting ACP were found to be insufficient of team-based care and information sharing, ex-Hansen’s disease patients’ weak interest in their end of life, and their conservative thoughts. We believe that ACP can be achieved by listening to the wishes of recovered patients through regular home care visits by nurses and everyday support by care workers. Furthermore, multidisciplinary coordination is urgently needed for promoting ACP. (shrink)

In the late nineteenth and early twentieth century, the Peruvian Andes ranked as a key international destination for those afflicted with one of the world’s most deadly diseases, tuberculosis. Physicians, scientists, policy makers, and patients believed that high-elevation mountain climates worldwide would help cure the disease. Historical processes driving the creation of Andean health resorts, which are understudied in the historiography, uncover an important story in the history of tuberculosis, and also reveal how global health initiatives and disease treatment (...) played out within the global South, where national forces and local environmental conditions influenced the trajectory of science and medicine. Jauja, Peru, became an internationally recognized health resort for tuberculosis treatment not only through science and medicine but also through national political integration campaigns, transportation initiatives, economic development agendas, social relations, cultural perspectives of the Andean landscape, and the impact of the physical environment. This historical case about the evolution of Jauja reveals how science and medicine are shaped by distinct spatial forces that illuminate a geography of science in the postcolonial setting, as well as the ways in which climate is culturally constructed in specific sites, by different peoples, and at distinct points in time. (shrink)

Deep brain stimulation interventions are novel devices being investigated for the management of severe treatment-resistant psychiatric illnesses. These interventions require the invasive implantation of high-frequency neurostimulatory probes intracranially aiming to provide symptom relief in treatment-resistant disorders including obsessive-compulsive disorder and anorexia nervosa. In the scientific literature, these neurostimulatory interventions are commonly described as reversible and to be used as a last resort option for psychiatric patients. However, the ‘last resort’ status of these interventions is rarely expanded (...) upon. Contrastingly, usages of DBS devices for neurological symptoms have paved the way for established safety and efficacy standards when used earlier in a disease’s timeline. As DBS treatments for these neurological diseases progress to have earlier indications, there is a parallel ethical concern that early implementation may one day become prescribed for psychiatric illnesses. The purpose of this article is to build off contemporary understandings of reversible neurostimulatory interventions to examine and provide clarifications on the ‘last resort’ status of DBS to better address its ethically charged use in psychiatric neurosurgery. To do this, evaluative differences between DBS treatments will be discussed to demonstrate how patient autonomy would be a paramount guiding principle when one day implementing these devices at various points along a psychiatric disease’s timeline. In presenting the clarification of ‘last resort’ status, the ethical tensions of early DBS interventions will be better understood to assist in providing psychiatric patients with more quality of life years in line with their values. (shrink)

This paper addresses sedation at the end of life. The use of sedation is often seen as a last resort for patients whose death is imminent and whose symptoms cannot be treated in any other way. This paper asks how to assess constellations, where patients want to hasten their death by refusing (further) life-sustaining treatment, or by voluntarily stopping eating and drinking (VSED), and wish this to be accompanied by sedation. We argue that sedation is ethically and legally (...) permissible not only as a last resort, but in principle. Furthermore, we see a clear obligation to sedate in cases of acute suffering of any kind, while in some other constellations individual physicians’ objections to supposedly premature or unnecessary sedation must be respected. Such possible reservations should, however, be reconsidered in light of the fundamental ethical and legal right to a self-determined death. In general, sedation practices should be less restrictive, and existing guidelines should be revised accordingly. -/- ----- Dieser Beitrag befasst sich mit Sedierungen von Patienten am Lebensende. In der Regel werden Sedierungen nur als ultima ratio vorgenommen, wenn die Betroffenen dem Tod bereits nahe sind und Leidenssymptome aufweisen, die anders nicht zu lindern sind. Doch wie sind Fälle zu beurteilen, in denen Patienten sich selbstbestimmt für einen Behandlungs- oder einen Flüssigkeits‑/Nahrungsverzicht entscheiden, um zu sterben, und dafür eine „Begleitsedierung“ erbitten oder erwarten – auch wenn dies aus medizinischer Sicht über eine Anwendung von Sedierung als letztes Mittel hinausgeht? Wir argumentieren hier dafür, dass Zusage wie Anwendung einer Begleitsedierung ethisch und rechtlich nicht nur als ultima ratio, sondern grundsätzlich zulässig sind. Eine klare Verpflichtung zu sedieren sehen wir darüber hinaus bei akutem Leiden jeder Art, während in einigen anderen Konstellationen Vorbehalte individueller Ärzte gegenüber vermeintlich verfrühten oder unnötigen Sedierungen respektiert werden müssen. Vor dem Hintergrund des ethischen und juridischen Grundrechts auf ein selbstbestimmtes Sterben plädieren wir allerdings dafür, auch solche Vorbehalte zu überdenken. Die medizinischen Leitlinien sollten entsprechend überarbeitet werden. (shrink)

This issue’s “Legal Briefing” column covers recent legal developments involving coerced treatment and involuntary confinement for contagious disease. Recent high profile court cases involving measles, tuberculosis, human immunodeficiency virus, and especially Ebola, have thrust this topic back into the bioethics and public spotlights. This has reignited debates over how best to balance individual liberty and public health. For example, the Presidential Commission for the Study of Bioethical Issues has officially requested public comments, held open hearings, and published a 90-page (...) report on “ethical considerations and implications” raised by “U.S. public policies that restrict association or movement (such as quarantine).” Broadly related articles have been published in previous issues of JCE. We categorize recent legal developments on coerced treatment and involuntary confinement into the following six categories: 1. Most Public Health Confinement Is Voluntary 2. Legal Requirements for Involuntary Confinement 3. New State Laws Authorizing Involuntary Confinement 4. Quarantine Must Be as Least Restrictive as Necessary 5. Isolation Is Justified Only as a Last Resort 6. Coerced Treatment after Persistent Noncompliance. (shrink)

As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a “last resort,” and a position statement from the American Academy of Hospice and Palliative Medicine describe it as “an intervention reserved for extreme situations.” Accordingly, patients must progress to unremitting pain and (...) suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of “last resort.”. (shrink)

Coronavirus disease 2019 (COVID-19) is a fast-developing viral pandemic spreading across the globe. Due to lack of availability of proven medicines against COVID-19, physicians have resorted to treatments through large trials of investigational drugs with poor evidence or those used for similar diseases. Large trials randomize 100–500+ patients at multiple hospitals in different countries to either receive these drugs or standard treatment. In order to expedite the process, some regulatory agencies had also given permission to use drugs approved for (...) other diseases, despite a lack of evidence of efficacy in COVID-19. In this review, we highlight the potential ethical issues that should be addressed during the use of investigational drugs with little prior evidence as a treatment options during a pandemic. We discuss the impact of design of randomized clinical trials using LOTUS trial as an example and that of off-label use of drugs like chloroquine/hydroxychloroquine (CQ/HQ) on the safety of patients during COVID-19. We conclude that the adaptive randomized clinical trial designs offer a flexible and efficient approach, enabling patients to quickly switch to successful treatments, while minimizing the number of patients on standard of care. Randomized clinical trial design should consider blinding of investigators and only representative patients who can provide consent should be included. We also conclude the emergency approvals of drugs should be carefully issued and off-label use should be restricted in pandemics. Streamlined regulatory guidelines for emergency drug use in a pandemic can also help in providing benefit and minimizing harm to patients in the future. (shrink)

OBJECTIVE: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of 'strong persuasion' in patient management. METHOD: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating disorder was (...) the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. RESULTS: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients. (shrink)

Introduction Deep brain stimulation (DBS) is approved under a humanitarian device exemption to manage treatment-resistant obsessive-compulsive disorder (TR-OCD) in adults. It is possible that DBS may be trialed or used clinically off-label in children and adolescents with TR-OCD in the future. DBS is already used to manage treatment-resistant childhood dystonia. Evidence suggests it is a safe and effective intervention for certain types of dystonia. Important questions remain unanswered about the use of DBS in children and adolescents with TR-OCD, (...) including whether mental health clinicians would refer pediatric patients for DBS, and who would be a good candidate for DBS.Objectives To explore mental health clinicians’ views on what clinical and psychosocial factors they would consider when determining which children with OCD would be good DBS candidates.Materials and Methods In depth, semi-structured interviews were conducted with n = 25 mental health clinicians who treat pediatric patients with OCD. The interviews were transcribed, coded, and analyzed using thematic content analysis. Three questions focused on key, clinical, and psychosocial factors for assessing candidacy were analyzed to explore respondent views on candidacy factors. Our analysis details nine overarching themes expressed by clinicians, namely the patient’s previous OCD treatment, OCD severity, motivation to commit to treatment, presence of comorbid conditions, family environment, education on DBS, quality of life, accessibility to treatment, and patient age and maturity.Conclusions Clinicians generally saw considering DBS treatment in youth as a last resort and only for very specific cases. DBS referral was predominantly viewed as acceptable for children with severe TR-OCD who have undertaken intensive, appropriate treatment without success, whose OCD has significantly reduced their quality of life, and who exhibit strong motivation to continue treatment given the right environment. Appropriate safeguards, eligibility criteria, and procedures should be discussed and identified before DBS for childhood TR-OCD becomes practice. (shrink)

Background Patients with unmet medical needs sometimes resort to non-standard treatment options, including the use of unapproved, investigational drugs in the context of clinical trials, compassionate use or named-patient programs. The views and experiences of patients with unmet medical needs regarding unapproved, investigational drugs have not yet been examined empirically. Methods In this qualitative study, exploratory interviews and focus groups were held with patients with chronic or life-threatening diseases, about topics related to non-standard treatment options, such as (...) the search for non-standard treatment options, patients’ views of the moral obligations of doctors, and the conditions under which they would or would not wish to use non-standard treatment options, including expanded access to unapproved, investigational drugs. Results Respondents had very little knowledge about and/or experience with existing opportunities for expanded access to investigational drugs, although some respondents were actively looking for non-standard treatment options. They had high expectations of their treating physicians, assuming them to be aware of non-standard treatment options, including clinical trials elsewhere and expanded access programs, and assuming that they would inform their patients about such options. Respondents carefully weighed the risks and potential benefits of pursuing expanded access, citing concerns related to the scientific evidence of the safety and efficacy of the drug, side effects, drug-drug interactions, and the maintaining of good quality of life. Respondents stressed the importance of education and assertiveness to obtain access to good-quality health care, and were willing to pay out of pocket for investigational drugs. Patients expressed concerns about equal access to new and/or non-standard treatment options. Conclusion When the end of a standard treatment trajectory comes into view, patients may prefer that treating physicians discuss non-standard treatment options with them, including opportunities for expanded access to unapproved, investigational drugs. Although our respondents had varying levels of understanding of expanded access programs, they seemed capable of making well-considered choices with regard to non-standard treatment options and had realistic expectations with regard to the safety and efficacy of such options. Dutch patients might be less likely to fall prey to false hope than often presumed. (shrink)

We anticipate a further decline of patients who eventually will become brain dead. The intensive care unit (ICU) is considered a last resort for patients with severe and multiple organ dysfunction. Patients with primary central nervous system failure constitute the largest group of patients in which life-sustaining treatment is withdrawn. Almost all these patients are unconscious at the moment physicians decide to withhold and withdraw life-sustaining measures. Sometimes, however competent ICU patients state that they do not want to (...) live anymore because of the severity of their illness or the poor prognosis and ask for withdrawal of life-sustaining measures like mechanical ventilation. Do we consider the unconscious patient as potential organ donor before withdrawal of mechanical ventilation? This is paradoxically rare in the case of the conscious ICU patient. Is it practically possible and ethically feasible to obtain consent for organ donation from this group of patients? (shrink)

Since the 1970s, animal advocacy groups have attempted to improve the treatment of non-human animals by influencing public opinion and lobbying for legislation that protects animals. Empirical assessments of these efforts have reported mixed results. Animal advocacy groups also use litigation as a means of improving the treatment of nonhuman animals, but there has been limited empirical testing of the effectiveness of animal advocacy litigation. To fill this gap in the literature, this study examines the 188 animal law (...) cases decided in state supreme courts from 1973 through 2005. It looks specifically at whether the participation of an animal advocacy organization increases the chance of a favorable decision, while controlling for legal and political influences on case outcomes. Logistic regression reveals that the presence of animal advocacy groups does not exert a statistically significant impact on case outcomes. Further analysis demonstrates, however, that animal advocacy groups are significantly more likely than nongroup litigators to pursue cases that are difficult to win. (shrink)

An adaptation of Pascal’s Wager argument has been considered useful in deciding about the provision of life-sustaining treatment for patients in persistent vegetative state. In this article, I assess whether people making such decisions should resort to the application of Pascal’s idea. I argue that there is no sufficient reason to give it an important role in making the decisions.

In this article, we explore alternative conflict resolution strategies to assist families and clinicians in cases of intractable dissent in paediatric health care decision-making. We focus on the ethical and legal landscape using cases from the Australian jurisdiction in New South Wales, while referencing some global sentinel cases. We highlight a range of alternative means of addressing conflict, including clinical ethics support, and contrast and contextualise facilitative or interest-based mediation, concluding that legal intervention via the courts can be protracted and (...) distressing and should be a ‘last resort’. We acknowledge many might view this as the current status quo, but we go further to recommend strategies optimal for all parties to recognise early signs of conflict and prevent its harmful escalation. While more empirical research is needed, we contend that interest-based mediation may be a valuable adjunctive method of conflict resolution. If judiciously distinguished from and utilised with clinical ethical support, it can be an effective tool to address dissent and its negative sequelae in paediatric healthcare decision-making. (shrink)

Deepfakes are hyper-realistic but fabricated videos created with the use of artificial intelligence. In the context of psychotherapy, the first studies on using deepfake technology are emerging, with potential applications including grief counselling and treatment for sexual violence-related trauma. This paper explores these applications from the perspective of medical ethics and health law. First, we question whether deepfake therapy can truly constitute good care. Important risks are dangerous situations or ‘triggers’ to the patient during data collection for the creation (...) of a deepfake, and when deepfake therapy is started, there are risks of overattachment and blurring of reality, which can complicate the grieving process or alter perceptions of perpetrators. Therapists must mitigate these risks, but more research is needed to evaluate deepfake therapy’s efficacy before it can be used at all. Second, we address the implications for the person depicted in the deepfake. We describe how privacy and portrait law apply and argue that the legitimate interests of those receiving therapy should outweigh the interests of the depicted, as long as the therapy is an effective and ‘last resort’ treatment option, overseen by a therapist and the deepfakes are handled carefully. We suggest specific preventative measures that can be taken to protect the depicted person’s privacy. Finally, we call for qualitative research with patients and therapists to explore dependencies and other unintended consequences. In conclusion, while deepfake therapy holds promise, the competing interests and ethicolegal complexities demand careful consideration and further investigation alongside the development and implementation of this technology. (shrink)

With narrow exception, physicians’ treatment of incapacitated patients requires the consent of health surrogates. Although the decision-making authority of surrogates is appropriately broad, their moral authority is not without limits. Discerning these bounds is particularly germane to ethically complex treatments and has important implications for the welfare of patients, for the professional integrity of clinicians, and, in fact, for the welfare of surrogates. Palliative sedation is one such complex treatment; as such, it provides a valuable model for analyzing (...) the scope of surrogates’ moral authority. Guidelines for palliative sedation that present it as a “last-resort” treatment for severe and intractable suffering yet require surrogate consent in order to offer it are ethically untenable, precisely because the moral limits of surrogate authority have not been considered. (shrink)

Deep brain stimulation (DBS) is frequently described as a ‘reversible’ medical treatment, and the reversibility of DBS is often cited as an important reason for preferring it to brain lesioning procedures as a last resort treatment modality for patients suffering from treatment-refractory conditions. Despite its widespread acceptance, the claim that DBS is reversible has recently come under attack. Critics have pointed out that data are beginning to suggest that there can be non-stimulation-dependent effects of DBS. Furthermore, (...) we lack long-term data about other potential irreversible effects of neuromodulation. This has considerable normative implications for comparisons of DBS and brain lesioning procedures. Indeed, Devan Stahl and colleagues have recently argued that psychiatric DBS should be subject to the same legal safeguards as other forms of psychosurgery, supporting their position by forcibly criticising the claim that DBS is reversible. In this paper, I respond to these criticisms by first clarifying the descriptive and evaluative elements of the reversibility claim that supporters of DBS might invoke, and the different senses of ‘reversibility’ that we might employ in discussing the effects of medical procedures. I go on to suggest that it is possible to defend a nuanced version of the reversibility claim. To do so, I explain how DBS has some effects that are stimulation dependent in the short term, and argue that these effects can have significant normative implications for patient well-being and autonomy. I conclude that we should not abandon a nuanced version of the reversibility claim in the DBS debate. (shrink)

Involuntary civil commitment to treatment for opioid use disorder prevents imminent overdose, but also restricts autonomy and raises other ethical concerns. Using the Kass Public Health Ethics Framework, we identified ICC benefits and harms. Benefits include: protection of vulnerable, underserved patients; reduced legal consequences; resources for families; and “on-demand” treatment access. Harms include: stigmatizing and punitive experiences; heightened family conflict and social isolation; eroded patient self-determination; limited or no provision of OUD medications; and long-term overdose risk. To use (...) ICC ethically, it should be recognized as comprising vulnerable patients worthy of added protections; be a last resort option; utilize consensual, humanizing processes; provide medications and other evidence-based-treatment; integrate with existing healthcare systems; and demonstrate effective outcomes before diffusion. ICC to OUD treatment carries significant potential harms that, if unaddressed, may outweigh its benefits. Findings can inform innovations for ensuring that ICC is used in an ethically responsible way. (shrink)

This paper provides a discussion of the role that emotions may play in the justification of punishment. On the expressivist account of punishment, punishment has the purpose of expressing appropriate emotional reactions to wrongdoing, such as indignation, resentment or guilt. I will argue that this expressivist approach fails as these emotions can be expressed other than through the infliction of punishment. Another argument for hard treatment put forward by expressivists states that punitive sanctions are necessary in order for the (...) law to be valid. But this justification of punishment, too, is unconvincing. There are no good reasons to assume that we have to resort to punitive measures in order to vindicate the law. I will then raise the more general worry whether there is any intelligible link at all between moral emotions such as indignation, resentment or guilt and retributive behaviour. I will finally conclude with some sceptical remarks on the moral worth of retribution. (shrink)

Davidson’s treatment of akrasia resorts to the introduction of a type of operator, the prima facie connector. This operator should yield conditional judgments in which the affirmation of the antecedent does not admit to obtain the consequent as a separate conclusion; and it must allow to separate ..

Nonadherence to treatment continues to be one of psychiatry's greatest challenges. To improve adherence and thus improve the care of patients, clinicians and patients' family members sometimes resort to hiding medication in food or drink, a practice referred to as covert/ surreptitious medication. The practice of covert drug administration in food and beverages is well known in the treatment of psychiatrically ill world-wide but no prevalence rates exist. Covert medication may seem like a minor matter, but it (...) touches on legal and ethical issues of a patient's competence, autonomy, and insight. Medicating patients without their knowledge is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of care giving. The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent. Ethically, covert/surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Covert medication contravenes contemporary ethical practice. Legally, treatment without consent is permissible only where common law or statute provides such authority. The practice of covert administration of medication is not specifically covered in the mental health legislation in developing countries. Many of the current dilemmas in this area have come to public attention because of two important developments in medical ethics and the law - the increasing importance accorded to respect for autonomy and loss of the parens patriae jurisdiction of the courts [parens patriae means 'parent of the country'; it permitted a court to consent or refuse treatment on behalf of an 'incapacity', or alternatively to appoint a guardian with such powers]. (shrink)

У статті проаналізовано стан санаторно-курортної діяльності України. Відзначається, що в останні роки в санаторно-курортній сфері переважає скорочення кількості установ, які спеціалізуються на оздоровленні населення, зниження якості та номенклатури надаваних послуг, кількість оздоровлених людей. Підкреслюється, що у 2014 році Україна втратила значну частину курортного потенціалу в результаті анексії Криму і військових дій на сході країни. Як подальший напрямок розвитку запропоновано реформувати галузь з метою вдосконалення лікувальної та діагностичної баз на основі останніх розробок в області медицини й курортології, розвитку інфраструктури, підвищення якості (...) та номенклатури надаваних послуг, підвищення ефективності та результативності роботи здравниць. (shrink)

Санаторно-курортна справа у Галичині була започаткована ще наприкінці XVI ст., однак до кінця XIX ст. вона не набула масового характеру через низький рівень розвитку сфери послуг, незадовільний стан доріг, низький рівень культури обслуговуючого персоналу. Із часом у місцевостях з мінеральними водами спритні підприємці та лихварі будували водолікарні, невеликі літні будинки санаторного типу й здавали їх за певну плату. Потужного розвитку курортна справа набула в останній чверті XIX - першій третині XX ст. На теренах Галичини в 1930-х рр. існувало понад 20 (...) великих кліматичних і бальнеологічних курортів, які входили до переліку найкращих у Польщі, та ще 30 малих, де оздоровлювалося місцеве населення та мешканці навколишніх населених пунктів. (shrink)

Roland Barthes’ entire career pursued a dream of being freed from the tyranny of ossified, institutionalized, rote language use, as articulated from his first massively influential work on ‘writing degree zero’ in 1953. The anaemic role of institutional rhetoric and its dusty formulations dulled the capacity for using language and thought otherwise. For Barthes, fragments played a privileged role in the escape from the tyranny of meaning imposed by doxa and received wisdom, sometimes called ‘literature’ and ‘rhetoric’. Barthes once referred (...) to almost all of his writing, and indeed theorizing, as ‘a circle of fragments’. The artist and theorist Victor Burgin has been profoundly influenced by Barthes’ writings and his attempts to escape the ideological constraints of language, institutions and images. His visual rhetorical practice now often takes the form of projection loops that are accessible by gallery attendees at any point in the loop. Their basic building block is also the fragment, and the loop constitutes another circle of fragments. His 2016 work Belledonne uses the time Barthes spent in the sanatorium for tuberculosis treatment as the basis for the piece, its computer-generated imagery and textual intertitles. This article examines Barthes’s writings on pre-Socratic rhetoric, as well as his self-reflexive engagement with his own theorizing, combined with Burgin’s reconsideration of moving image work in gallery or museum spaces as attempts to offer potentially liberatory strategies for eluding rote use and effects of language, image and thought. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Breathing:Proustian Therapy1Christopher Prendergast (bio)I begin with a question I would never have imagined myself asking. Is Proust good for you? Might there even be, albeit in carefully controlled doses, a place for him in modern 'health care'? He certainly belongs in the select, if occasionally scary, company of writers whose name, or that of one of their fictional characters, has lent itself to the designation of a psycho-physical condition (...) often with medical characteristics. A short list includes: Stendhal ('Stendhal syndrome,' the condition of obsessional attachment to works of art); Musset (the 'Musset Sign,' manifested as an uncontrollable tremor of the head); Gogol's Plyushkin in Dead Souls ('compulsive hoarding syndrome'); Dickens's Miss Havisham in Great Expectations ('senile squalor syndrome'); Wilde's Lady Windermere ('Lady Windermere syndrome,' associated with pulmonary illness and breathing difficulties).There is no evidence that Proust was directly acquainted with Wilde's play, but there can be little doubt that what came to be called 'Lady Windermere Syndrome' would have spoken to him loud and clear. In an early story called L'Indifférent, Proust penned an encomium to the air we breathe: "A child who from birth has always breathed without paying any attention has no idea how much the air, which swells so sweetly his chest that he doesn't even notice it, is essential to life." A memory of this is doubtless somewhere in the background of the passing mention in Le Côté de Guermantes of "the alpine resort" that teaches him "that the act of breathing, to which we habitually pay no attention, can be a constant source of pleasure." It was almost certainly also in Proust's thoughts when, in the final volume, he penned the famous definition of Paradise Lost as the place and time of "an air we have breathed before, this purer air which the poets have tried in vain to make reign in paradise and which could not provide this profound feeling of renewal if it has not already been breathed, for the only true paradise is a paradise that we have lost."But the early story, like the novel itself, is also haunted by a subtext in which what is precious to life can also be the enemy of life, as, in an access of fever and sudden convulsion, the child feels himself to be suffocating. The story clearly has its origins in Proust's own life, the moment of his first asthma attack as a young boy on a family outing to the Bois de Boulogne. It struck out of the blue with a frightening intensity, and was to pursue [End Page 49] him throughout his life like a fury, proliferating further symptoms such as emphysema and cardiac seizures. As late as 1919, he writes in a letter of an attack that leaves him "gasping like someone half-drowned who is pulled out of water." And it was there again at the moment of Proust's exit from the world, carried off by a bout of pneumonia exacerbated by a pulmonary abscess.There were treatments and consultations galore, the former on a spectrum from inhalations to cauterizing of the nasal tubes, and the latter including a meeting with his father's colleague, Dr. Buissand, who inclined to the view– and increasingly fashionable in medical circles–that the prime cause was neurasthenic. Proust himself hesitated: in a letter he described it as "a bodily illness," but in the Recherche, "asthma crises" are linked to a "mystery" of the "unconscious" and strike out of the blue. The 'mystery' is often, and plausibly, associated with fear of separation from the protective mother. This will be one of the major themes of the novel, and the source of the "sobs that never cease" of which the narrator speaks in the opening volume. But whether physical or psychosomatic, a guaranteed trigger was proximity to tree blossoms (apple especially virulent) and certain flowers–that is, the very things that, for Proust, often something approaching quasi-sacred status, thus illustrating the law that it is what you most love that can kill you.In the novel, however, much of this is distilled into comedy, all terrifying... (shrink)

ABSTRACT I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments. INTRODUCTION In contrast to the classic model of randomized-control trials, often with a large number of (...) subjects enrolled, precision medicine attempts to optimize therapeutic outcomes by focusing on the individual.[i] A recent publication highlights the strengths and weakness of both traditional evidence-based medicine and precision medicine.[ii] Plus, it outlines a tension in the shift from evidence-based medicine’s inductive reasoning style (the collection of data to postulate general theories) to precision medicine’s abductive reasoning style (the generation of an idea from the limited data available).[iii] The paper’s main example is the application of precision medicine for the treatment of cancer.[iv] I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. As the name suggests, brain-computer interfaces are a significant advancement in neurotechnology that directly connects someone’s brain to external or implanted devices.[v] Among the various kinds of brain-computer interfaces, adaptive deep brain stimulation devices require numerous personalized adjustments to their settings during the implantation and computation stages in order to provide adequate relief to patients with treatment-resistant disorders. What makes these devices unique is how adaptive deep brain stimulation integrates a sensory component to initiate the stimulation. While not commonly at the level of sophistication as self-supervising or generative large language models,[vi] they currently allow for a semi-autonomous form of neuromodulation. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments.[vii] ANALYSIS I. The State of Precision Medicine in Oncology and the Epistemological Shift While a thorough overview of precision medicine for the treatment of cancer is beyond the scope of this article, its practice can be roughly summarized as identifying clinically significant characteristics a patient possesses (e.g., genetic traits) to land on a specialized treatment option that, theoretically, should benefit the patient the most.[viii] However, in such a practice of stratification patients fall into smaller and smaller populations and the quality of evidence that can be applied to anyone outside these decreases in turn.[ix] As inductive logic helps to articulate, the greater the number of patients that respond to a particular therapy the higher the probability of its efficacy. By straying from this logical framework, precision medicine opens the treatment of cancer to more uncertainty about the validity of these approaches to the resulting disease subcategories.[x] Thus, while contemporary medical practices explicitly describe some treatments as “personalized”, they ought not be viewed as inherently better founded than other therapies.[xi] A relevant contemporary case of precision medicine out of Norway focuses on the care of a patient with cancer between the ventricles of the heart and esophagus, which had failed to respond to the standard regimen of therapies over four years.[xii] In a last-ditch effort, the patient elected to pay out-of-pocket for an experimental immunotherapy (nivolumab) at a private hospital. He experienced marked improvements and a reduction in the size of the tumor. Understandably, the patient tried to pursue further rounds of nivolumab at a public hospital. However, the hospital initially declined to pay for it given the “lack of evidence from randomised clinical trials for this drug relating to this [patient’s] condition.”[xiii] In rebuttal to this claim, the patient countered that he was actually similar to a subpopulation of patients who responded in “open‐label, single arm, phase 2 studies on another immune therapy drug” (pembrolizumab).[xiv] Given this interpretation of the prior studies and the patient’s response, further rounds of nivolumab were approved. Had the patient not had improvements in the tumor’s size following a round of nivolumab, then pembrolizumab’s prior empirical evidence in isolation would have been insufficient, inductively speaking, to justify his continued use of nivolumab.[xv] The case demonstrates a shift in reasoning from the traditional induction to abduction. The phenomenon of ‘cancer improvement’ is considered causally linked to nivolumab and its underlying physiological mechanisms.[xvi] However, “the weakness of abductions is that there may always be some other better, unknown explanation for an effect. The patient may for example belong to a special subgroup that spontaneously improves, or the change may be a placebo effect. This does not mean, however, that abductive inferences cannot be strong or reasonable, in the sense that they can make a conclusion probable.”[xvii] To demonstrate the limitations of relying on the abductive standard in isolation, commentators have pointed out that side effects in precision medicine are hard to rule out as being related to the initial intervention itself unless trends from a group of patients are taken into consideration.[xviii] As artificial intelligence (AI) assists the development of precision medicine for oncology, this uncertainty ought to be taken into consideration. The implementation of AI has been crucial to the development of precision medicine by providing a way to combine large patient datasets or a single patient with a large number of unique variables with machine learning to recommend matches based on statistics and probability of success upon which practitioners can base medical recommendations.[xix] The AI is usually not establishing a causal relationship[xx] – it is predicting. So, as AI bleeds into medical devices, like brain-computer interfaces, the same cautions about using abductive reasoning alone should be carried over. II. Responsive Neurostimulation, AI, and Personalized Medicine Like precision medicine in cancer treatment, computer-brain interface technology similarly focuses on the individual patient through personalized settings. In order to properly expose the intersection of AI, precision medicine, abductive reasoning, and implantable neurotechnologies, the descriptions of adaptive deep brain stimulation systems need to deepen.[xxi] As a broad summary of adaptive deep brain stimulation, to provide a patient with the therapeutic stimulation, a neural signal, typically referred to as a local field potential,[xxii] must first be detected and then interpreted by the device. The main adaptive deep brain stimulation device with premarket approval, the NeuroPace Responsive Neurostimulation system, is used to treat epilepsy by detecting and storing “programmer-defined phenomena.”[xxiii] Providers can optimize the detection settings of the device to align with the patient’s unique electrographic seizures as well as personalize the reacting stimulation’s parameters.[xxiv] The provider adjusts the technology based on trial and error. One day machine learning algorithms will be able to regularly aid this process in myriad ways, such as by identifying the specific stimulation settings a patient may respond to ahead of time based on their electrophysiological signatures.[xxv] Either way, with AI or programmers, adaptive neurostimulation technologies are individualized and therefore operate in line with precision medicine rather than standard treatments based on large clinical trials. Contemporary neurostimulation devices are not usually sophisticated enough to be prominent in AI discussions where the topics of neural networks, deep learning, generative models, and self-attention dominate the conversation. However, implantable high-density electrocorticography arrays (a much more sensitive version than adaptive deep brain stimulation systems use) have been used in combination with neural networks to help patients with neurologic deficits from a prior stroke “speak” through a virtual avatar.[xxvi] In some experimental situations, algorithms are optimizing stimulation parameters with increasing levels of independence.[xxvii] An example of neurostimulation that is analogous to the use of nivolumab in Norway surrounds a patient in the United States who was experiencing both treatment-resistant OCD and temporal lobe epilepsy.[xxviii]Given the refractory nature of her epilepsy, implantation of an adaptive deep brain stimulation system was indicated. As a form of experimental therapy, her treatment-resistant OCD was also indicated for the off-label use of an adaptive deep brain stimulation set-up. Another deep brain stimulation lead, other than the one implanted for epilepsy, was placed in the patient’s right nucleus accumbens and ventral pallidum region given the correlation these nuclei had with OCD symptoms in prior research. Following this, the patient underwent “1) ambulatory, patient-initiated magnet-swipe storage of data during moments of obsessive thoughts; (2) lab-based, naturalistic provocation of OCD-related distress (naturalistic provocation task); and (3) lab-based, VR [virtual reality] provocation of OCD-related distress (VR provocation task).”[xxix] Such signals were used to identify when to deliver the therapeutic stimulation in order to counter the OCD symptoms. Thankfully, following the procedure and calibration the patient exhibited marked improvements in their OCD symptoms and recently shared her results publicly.[xxx] In both cases, there is a similar level of abductive justification for the efficacy of the delivered therapy. In the case study in which the patient was treated with adaptive deep brain stimulation, they at least had their neural activity tested in various settings to determine the optimum parameters for treatment to avoid them being based on guesswork. Additionally, the adaptive deep brain stimulation lead was already placed before the calibration trials were conducted, meaning that the patient had already taken on the bulk of the procedural risk before the efficacy could be determined. Such an efficacy test could have been replicated in the first patient’s cancer treatment, had it been biopsied and tested against the remaining immunotherapies in vitro. Yet, in the case of cancer with few options, one previous dose of a drug that appeared to work on the patient may justify further doses. However, as the Norwegian case presents, corroboration with known responses to a similar drug (from a clinical trial) could be helpful to validate the treatment strategy. (It should be noted that both patients were resigned to these last resort options regardless of the efficacy of treatment.) There are some elements of inductive logic seen with adaptive deep brain stimulation research in general. For example, abductively the focus could be that patient X’s stimulation parameters are different from patient Y’s and patient Z’s. In contrast, when grouped as subjects who obtained personalized stimulation, patients X, Y, and Z demonstrate an inductive aspect to this approach’s safety and/or efficacy. The OCD case holds plenty of abductive characteristics in line with precision medicine’s approach to treating cancer and as more individuals try the method, there will be additional data. With the gradual integration of AI into brain-computer interfaces in the name of efficacy, this reliance on abduction will continue, if not grow, over time. Moving forward, if a responsive deep brain stimulation treatment is novel and individualized (like the dose of nivolumab) and there is some other suggestion of efficacy (like clinical similarities to other patients in the literature), then it may justify insurance coverage for the investigative intervention, absent other unrelated reasons to deny it. III. Ethical Implications and Next Steps While AI’s use in oncology and neurology is not yet as prominent as its use in other fields (e.g., radiology), it appears to be on the horizon for both.[xxxi] AI can be found in both the functioning of the neurotechnologies as well as the implementation of precision medicine. The increasing use of AI may serve to further individualize both oncologic and neurological therapies. Given these implications and the handful of publications cited in this article, it is important to have a nuanced evaluation of how these treatments, which heavily rely on abductive justification, ought to be managed. The just use an abductive approach may be difficult as AI infused precision medicine is further pursued. At baseline, such technology relies on a level of advanced technology literacy among the general public and could exclude populations who lack access to basic technological infrastructure or know-how from participation.[xxxii] Even among nations with adequate infrastructure, as more patients seek out implantable neurotechnologies, which require robust healthcare resources, the market will favor patient populations that can afford this complex care.[xxxiii] If patients already have the means to pay for an initial dose/use of a precision medicine product out of pocket, should insurance providers be required to cover subsequent treatments?[xxxiv] That is, if a first dose of a cancer drug or a deep brain stimulator over its initial battery life is successful, patients may feel justified in having the costs of further treatments covered. The Norwegian patient’s experience implies there is a precedent for the idea that some public insurance companies ought to cover successful cancer therapies, however, insurance companies may not all see themselves as obligated to cover neurotechnologies that rely on personalized settings or that are based on precision/abductive research more than on clinical trials. CONCLUSION The fact that the cases outlined above rely on abductive style of reasoning implies that there may not be as strong a justification for coverage by insurance, as they are both experimental and individualized, when compared to the more traditional large clinical trials in which groups have the same or a standardized protocol (settings/doses). If a study is examining the efficacy of a treatment with a large cohort of patients or with different experimental groups/phases, insurance companies may conclude that the resulting symptom improvements are more likely to be coming from the devices themselves. A preference for inductive justification may take priority when ruling in favor of funding someone’s continued use of an implantable neurostimulator. There are further nuances to this discussion surrounding the classifications of these interventions as research versus clinical care that warrant future exploration, since such a distinction is more of a scale[xxxv] than binary and could have significant impacts on the “right-to-try” approach to experimental therapies in the United States.[xxxvi] Namely, given the inherent limitations of conducting large cohort trials for deep brain stimulation interventions on patients with neuropsychiatric disorders, surgically innovative frameworks that blend abductive and inductive methodologies, like with sham stimulation phases, have traditionally been used.[xxxvii] Similarly, for adaptive brain-computer interface systems, if there are no large clinical trials and instead only publications that demonstrate that something similar worked for someone else, then, in addition to the evidence that the first treatment/dose worked for the patient in question, the balance of reasoning would be valid and arguably justify insurance coverage. As precision approaches to neurotechnology become more common, frameworks for evaluating efficacy will be crucial both for insurance coverage and for clinical decision making. ACKNOWLEDGEMENT This article was originally written as an assignment for Dr. Francis Shen’s “Bioethics & AI” course at Harvard’s Center for Bioethics. I would like to thank Dr. Shen for his comments as well as my colleagues in the Lázaro-Muñoz Lab for their feedback. - [i] Jonathan Kimmelman and Ian Tannock, “The Paradox of Precision Medicine,” Nature Reviews. Clinical Oncology 15, no. 6 (June 2018): 341–42, https://doi.org/10.1038/s41571-018-0016-0. [ii] Henrik Vogt and Bjørn Hofmann, “How Precision Medicine Changes Medical Epistemology: A Formative Case from Norway,” Journal of Evaluation in Clinical Practice 28, no. 6 (December 2022): 1205–12, https://doi.org/10.1111/jep.13649. [iii] David Barrett and Ahtisham Younas, “Induction, Deduction and Abduction,” Evidence-Based Nursing 27, no. 1 (January 1, 2024): 6–7, https://doi.org/10.1136/ebnurs-2023-103873. [iv] Vogt and Hofmann, “How Precision Medicine Changes Medical Epistemology,” 1208. [v] Wireko Andrew Awuah et al., “Bridging Minds and Machines: The Recent Advances of Brain-Computer Interfaces in Neurological and Neurosurgical Applications,” World Neurosurgery, May 22, 2024, S1878-8750(24)00867-2, https://doi.org/10.1016/j.wneu.2024.05.104. [vi] Mark Riedl, “A Very Gentle Introduction to Large Language Models without the Hype,” Medium (blog), May 25, 2023, https://mark-riedl.medium.com/a-very-gentle-introduction-to-large-language-models-without-the-hype-5 f67941fa59e. [vii] David E. Burdette and Barbara E. Swartz, “Chapter 4 - Responsive Neurostimulation,” in Neurostimulation for Epilepsy, ed. Vikram R. Rao (Academic Press, 2023), 97–132, https://doi.org/10.1016/B978-0-323-91702-5.00002-5. [viii] Kimmelman and Tannock, 2018. [ix] Kimmelman and Tannock, 2018. [x] Simon Lohse, “Mapping Uncertainty in Precision Medicine: A Systematic Scoping Review,” Journal of Evaluation in Clinical Practice 29, no. 3 (April 2023): 554–64, https://doi.org/10.1111/jep.13789. [xi] Kimmelman and Tannock, “The Paradox of Precision Medicine.” [xii] Vogt and Hofmann, 1206. [xiii] Vogt and Hofmann, 1206. [xiv] Vogt and Hofmann, 1206. [xv] Vogt and Hofmann, 1207. [xvi] Vogt and Hofmann, 1207. [xvii] Vogt and Hofmann, 1207. [xviii] Vogt and Hofmann, 1210. [xix] Mehar Sahu et al., “Chapter Three - Artificial Intelligence and Machine Learning in Precision Medicine: A Paradigm Shift in Big Data Analysis,” in Progress in Molecular Biology and Translational Science, ed. David B. Teplow, vol. 190, 1 vols., Precision Medicine (Academic Press, 2022), 57–100, https://doi.org/10.1016/bs.pmbts.2022.03.002. [xx] Stefan Feuerriegel et al., “Causal Machine Learning for Predicting Treatment Outcomes,” Nature Medicine 30, no. 4 (April 2024): 958–68, https://doi.org/10.1038/s41591-024-02902-1. [xxi] Sunderland Baker et al., “Ethical Considerations in Closed Loop Deep Brain Stimulation,” Deep Brain Stimulation 3 (October 1, 2023): 8–15, https://doi.org/10.1016/j.jdbs.2023.11.001. [xxii] David Haslacher et al., “AI for Brain-Computer Interfaces,” 2024, 7, https://doi.org/10.1016/bs.dnb.2024.02.003. [xxiii] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 103–4; “Premarket Approval (PMA),” https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100026. [xxiv] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 104. [xxv] Burdette and Swartz, 126. [xxvi] Sean L. Metzger et al., “A High-Performance Neuroprosthesis for Speech Decoding and Avatar Control,” Nature 620, no. 7976 (August 2023): 1037–46, https://doi.org/10.1038/s41586-023-06443-4. [xxvii] Hao Fang and Yuxiao Yang, “Predictive Neuromodulation of Cingulo-Frontal Neural Dynamics in Major Depressive Disorder Using a Brain-Computer Interface System: A Simulation Study,” Frontiers in Computational Neuroscience 17 (March 6, 2023), https://doi.org/10.3389/fncom.2023.1119685; Mahsa Malekmohammadi et al., “Kinematic Adaptive Deep Brain Stimulation for Resting Tremor in Parkinson’s Disease,” Movement Disorders 31, no. 3 (2016): 426–28, https://doi.org/10.1002/mds.26482. [xxviii] Young-Hoon Nho et al., “Responsive Deep Brain Stimulation Guided by Ventral Striatal Electrophysiology of Obsession Durably Ameliorates Compulsion,” Neuron 0, no. 0 (October 20, 2023), https://doi.org/10.1016/j.neuron.2023.09.034. [xxix] Nho et al. [xxx] Nho et al.; Erik Robinson, “Brain Implant at OHSU Successfully Controls Both Seizures and OCD,” OHSU News, accessed March 3, 2024, https://news.ohsu.edu/2023/10/25/brain-implant-at-ohsu-successfully-controls-both-seizures-and-ocd. [xxxi] Awuah et al., “Bridging Minds and Machines”; Haslacher et al., “AI for Brain-Computer Interfaces.” [xxxii] Awuah et al., “Bridging Minds and Machines.” [xxxiii] Sara Green, Barbara Prainsack, and Maya Sabatello, “The Roots of (in)Equity in Precision Medicine: Gaps in the Discourse,” Personalized Medicine 21, no. 1 (January 2024): 5–9, https://doi.org/10.2217/pme-2023-0097. [xxxiv] Green, Prainsack, and Sabatello, 7. [xxxv] Robyn Bluhm and Kirstin Borgerson, “An Epistemic Argument for Research-Practice Integration in Medicine,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 43, no. 4 (July 9, 2018): 469–84, https://doi.org/10.1093/jmp/jhy009. [xxxvi] Vijay Mahant, “‘Right-to-Try’ Experimental Drugs: An Overview,” Journal of Translational Medicine 18 (June 23, 2020): 253, https://doi.org/10.1186/s12967-020-02427-4. [xxxvii] Michael S. Okun et al., “Deep Brain Stimulation in the Internal Capsule and Nucleus Accumbens Region: Responses Observed during Active and Sham Programming,” Journal of Neurology, Neurosurgery & Psychiatry 78, no. 3 (March 1, 2007): 310–14, https://doi.org/10.1136/jnnp.2006.095315. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychodramatic Psychotherapy for Schizophrenic IndividualsJohn Nolte, MD, PhD (bio)As a long-time student, practitioner, trainer, author and advocate of J. L. Moreno, MD,’s works and specifically the psychodramatic method, I am always appreciative of efforts, like Chapy’s, to commend and advocate for psychodrama. This is especially so because for a time, Moreno and psychodrama were heavily criticized, even maligned in the mental health professions. At the same time, considering how (...) poorly Moreno and his methods have been understood as well as the difficulty of accessing his original material, I feel an obligation to set the record straight when confronted with incomplete, inadequate, or sometimes incompetent expositions of Moreno’s psychodrama.Chapy’s article recommends psychodrama as a treatment method for schizophrenic people by calling upon existentialist and phenomenological concepts. Psychodrama, he proposes, opens up existence by allowing “schizophrenic patients to incorporate the experience of an ‘absolutely other.’”There are major flaws in Chapy’s presentation. His “clinical illustration,” the presentation of a psychodrama with a schizophrenic patient, while it may be considered psychodrama under the broadest definition of the term, hardly fulfills the requirements of a psychotherapeutic psychodrama. We must question the competence of the psychodramatist in Chapy’s example. Chapy’s description of the drama itself falls short of being an adequate account of a psychodrama, failing to convey the emotional intensity and realness which a well directed and reported psychodrama achieves. We do not learn, for example, if Damien’s perception of his father is introduced through role reversal with the father, a standard psychodramatic technique which is done in order to give the auxiliary ego taking that role an understanding how Damien experiences his father. We do not know if role reversals are made throughout the drama so that Damien can experience how he is perceived by father, can feel the force of his confrontation in the role of father, and is required to reply as his father to his confrontation. We are given little information about the psychodramatic techniques employed by the director other than the scene setting of the studio in which the psychodramatic [End Page 227] encounter takes place, and the soliloquy in which Damien expresses his worry and hopes for the outcome of the confrontation. It should be clear in the description of the drama whether the father’s statements in the drama were produced by Damien in role reversal, or by the auxiliary ego playing the role. There is a difference and it is significant. Although we are told that Damien “evokes a systematic relationship between him and his father” during the psychodrama, we do not see how this happens. Every psychodrama is an existential experience and its description should fully communicate its meaning and emotion.A more serious problem, however, is that this drama does not deal with Damien’s psychosis. Although Damien may be diagnosed as schizophrenic, his disorder is obviously in remission or controlled by psychotropic drugs. The drama reveals none of the hallucinations, delusions, or disorder characteristic of schizophrenic disorders. It could be psychodrama of any young man with a complaint about his father.The notion that people with schizophrenia can be successfully treated by psychodrama is not new. Moreno began developing psychodramatic psychotherapy at his Beacon Hill Sanitarium, established in 1936. He and psychodrama gained some fame because of his success in treating schizophrenic patients at a time when schizophrenic individuals were considered incapable of benefitting from psychotherapy. Moreno’s approach to the treatment of schizophrenic patients was much more robust than the psychodrama described by Chapy. During a psychotic attack, the individual’s perception of the world and self are distorted in ways that made action and interaction in the world of conventional reality impossible. Additionally, the psychotic episode makes the psychotic person incapable of being comprehended by anyone else, including the psychiatrist. Moreno’s solution was to make the chaotic, bewildering, sometimes violent and always terrifying inner world visible and tangible in the surplus reality of the psychodramatic stage. In moments of lucidity following the psychotic episode, he asked his schizophrenic patients to reenact their psychotic experiences. The result was that, “In this imaginary reality on the psychodramatic stage, the... (shrink)

It's not unusual to hear someone say, ‘I'd rather be dead than have Alzheimer's’. In ‘Alzheimer Disease and Preemptive Suicide’,1 Dena Davis explains why this is a reasonable position. People taking this position will welcome the discovery of biomarkers permitting very early AD diagnosis, Davis suggests, for this will enable more of them to end their lives while they remain motivated and able to do so. At the same time, Davis observes, people would have less reason to resort to (...) the drastic remedy of pre-emptive suicide if they had absolute authority over the medical treatment they received as patients with dementia; but the threat of pre-emptive suicide is not, in my view, a sufficient reason to grant competent individuals that authority.If preclinical diagnosis of AD becomes possible, some pre-emptive suicides will probably occur. There would be no ethical or practical way to ban such suicides, and it would be silly to try. Clinicians will undoubtedly try to discourage people seeking biomarker information in furtherance of a suicide plan, but savvy individuals will simply conceal their true motivation for having the tests. The real problem for people intent on self-destruction is that biomarkers are unlikely to deliver a clear suicide signal.First, as Davis notes, work on biomarkers remains in the research stage. No one yet knows whether biomarker tests will prove accurate enough to warrant clinical use. Second, even clinically accepted biomarker tests will generate imperfect information about future disease. Biomarkers may produce more accurate estimates of a person's risk of developing AD, but like all predictive tests, they will also yield false positive and negative results. The …. (shrink)

A principal goal of this book is to develop and apply the Situation Semantics framework. Jean Mark Gawron and Stanley Peters adopt a version of the theory in which meanings are built up via syntactically driven semantic composition rules. They provide a substantial treatment of English incorporating treatments of pronomial anaphora, quantification, donkey anaphora, and tense. The book focuses on the semantics of pronomial anaphora and quantification. The authors argue that the ambiguities of sentences with pronouns cannot be adequately (...) accounted for with a theory that represents anaphoric relations only syntactically; their relational framework uniformly deals with anaphoric relations as relations between utterances in context. They argue that there is no need for a syntactic representation of anaphoric relations, or for a theory that accounts for anaphoric ambiguities by resorting to two or more kinds of anaphora. Quantifier scope ambiguities are handled analogously to anaphoric ambiguities. This treatment integrates the Cooper Store mechanism with a theory of meaning that provides both a natural setting for it and a convincing account of what, semantically, is going on. Jean Mark Gawron is a researcher for Hewlett Packard Laboratories, Palo Alto. Stanley Peters is professor of linguistics and symbolic systems at Stanford University and is director of the Center for the Study of Language and Information. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Towards a Design-Based Analysis of Emotional Episodes”Dan Lloyd (bio)To think about grief is to think about many things. My one-year-old daughter was practicing opening and closing a cabinet door as I puzzled over a response to Wright, Sloman, and Beaudoin’s “Toward a Design-Based Analysis of Emotional Episodes.” She was completely absorbed in her project, and as I watched my elf at her task, I thought about the (...) voices of loss that speak briefly in section 3.1. How terrible it would be to lose a loved one. With that, I was overcome with a pang of love for my daughter, and further thought about the paper ceased.In the authors’ terms, my feelings about my daughter were “perturbances,” states that interfered with the internal management of my thought process, derailing it from the deliberate project of responding to the paper. Reading and thinking about loss activated the attachment structures involving those whose loss would be most devastating to me. The activation of the attachment structure was my episode of intense feeling, arising in me with an insistence level that temporarily exceeded my academic pursuits. The whole sequence of mental events arose through the interaction of major processes of perception, beliefs, “motivators,” plans, self-monitoring, and global control. The mind, according to the authors, is a collection of such processes.Is that all there is? The familiar objection to this brand of functionalist analysis is that it leaves out the most important part of mind, namely, conscious experience. Such an “architecture” for an “intelligent agent” is at best a simulation of some aspects of cognition, but the feelings, the moods, the subjective what-it-is-like of experience are missing. And without them, say the familiar critics, the mind is missing. The authors are naturally aware of this objection, and are careful to hedge their project: “In our discussion the ‘phenomenological problem’ is factored out and placed to one side.”I wonder, however, whether the authors are too quick to concede that their model omits the phenomenal. The symptoms of grief expressed by its sufferers would all be considered reports of the experience of grief, aspects of its phenomenology. The authors use these reports to guide their analysis of the functional processes of grief, and their analysis in turn explains why the grievers experience their losses as they do. Functionalist psychologists usually base their analyses on strictly observable responses obtained in cognitive psychology experiments. In using first-person reports as their guide, the authors inaugurate a promising union of phenomenology and functionalism. After their treatment of grief, the left over and left out phenomenology is noticeably slimmer.What remains of grief is its pain. In the spirit [End Page 127] of the paper, I will close with a brief speculative extension of the authors’ approach, using it to examine the core of the experience of grief. Like physical pain, emotional pain is curiously resistant to description, and not even easy to remember. (One remembers that one was in pain, and that it was hateful, but such reminiscences are faint shadows of the experience itself.) Though its phenomenology is elusive, pain has a clear function. It is aversive. As the authors note, pain involves “dispositions to terminate or reduce some state or process.” In their terms, pain is a motivator with a very high insistence level. Motivators motivate plans, and an aversive motivator would principally motivate a plan to remove the cause of the pain. However, grief and other chronic emotional pains are marked by irremediability. There can be no plan that replaces the loss, only fantasy plans or reversions to infant strategies of last resort (like crying). Within the cognitive architecture proposed by this paper, emotional pain is thus characterized by a collision of two processes, a highly insistent motive meeting a vacuum where a plan should be. The unanswered insistence would make the collision hateful, while the absent plan would leave a state partly without intentional content, and thus hard to describe or remember. This breakdown, arguably, is the pain—an emergent state or states arising in just this sort of wrenching bind.The traditional critic will insist that the painfulness... (shrink)

This article examines HIV-positive patients’ experiences of treatments within a context characterized by the multiplicity of opinions expressed both by specialists and the public domain. It is based upon a survey of 63 patients encountered in a Paris hospital. The authors demonstrate the contrasts between these patients in terms of two main dimensions: the degree of the patients’ proximity to specialist knowledge, and the level of homogeneousness that the patients attribute to medical know-how. At the point where these two dimensions (...) meet, the article distinguishes between three forms of patient attitude towards treatment; in other words, three ways of simultaneously positioning oneself with regard to the media, associations, doctors and family circles/entourage: resorting to exteriority; self-integration into biomedical institutions; arranging heterogeneous actors. It analyses the transformations relating to the main experience profiles highlighted by sociological studies of other pathologies. (shrink)

A recent project at the University of Denver Libraries used handwritten text recognition (HTR) software to create transcriptions of records from the Jewish Consumptives’ Relief Society (JCRS), a tuberculosis sanatorium located in Denver, Colorado from 1904 to 1954. Among a great many other potential uses, these type- and hand-written records give insight into the human experience of disease and epidemic, its treatment, its effect on cultures, and of Jewish immigration to and early life in the American West. Our (...) intent is to provide these transcripts as data so the text may be computationally analyzed, pursuant to a larger effort in developing capacity in services and infrastructure to support digital humanities as a library, and to contribute to the emerging HTR ecosystem in archival work. Just because we can, however, doesn’t always mean we should: the realities of publishing large datasets online that contain medical and personal histories of potentially vulnerable people and communities introduce serious ethical considerations. This paper both underscores the value of HTR and frames ethical considerations related to protecting data derived from it. It suggests a terms-of-use intervention perhaps valuable to similar projects, one that balances meeting the research needs of digital scholars with the care and respect of persons, their communities and inheritors, who lives produced the very data now valuable to those researchers. (shrink)

Six years ago, when I last wrote on tobacco policy, my perspective was to offer an assessment of the strengths and weaknesses of a halfcentury of tobacco control strategies aimed at reducing the health risks associated with cigarette smoking. I began with a discussion of informational strategies; then turned to public place restrictions; and followed with a treatment of excise tax initiatives. In my view, restrictions on advertising and promotion and resort to tort litigation had been less effective (...) as control efforts, but nonetheless also warranted consideration. In the ensuing years, there have been a number of significant developments that have altered the course of tobacco control policy. Prominent among these developments has been the authority granted to the Food and Drug Administration in the Family Smoking Prevention and Tobacco Control Act of 2009; the resort by the industry to litigation in a new guise - particularly reliant on the First Amendment - as an offensive weapon targeting regulatory controls; and the publication of the 2012 Surgeon General’s Report on youth smoking, which makes the case for top-priority attention to underage smoking behavior. These and related measures point to new pathways for breaking through a perceived recent loss of momentum in achieving further reductions in tobacco-related disease, without abandoning what has worked in the recent past. I attempt to pull together these multiple fronts in a Section focused primarily on youth smoking, assessing the promise of present efforts to reduce the harms associated with tobacco. Finally, I offer some brief thoughts from a broader public-health perspective, discussing the framework of tobacco control initiatives from the vantage point of the obesity problem. (shrink)

Counter-terrorism officials in the USA and the UK responded to the events of 11 September 2001 and 7 July 2005 with an increasing resort to the use of ?intelligence-led policing? methods such as racial and religious profiling. Reliance on intelligence, to the effect that most people who commit a certain crime have a certain ethnicity, can lead to less favourable treatment of an individual with that ethnicity because of his membership in that group, not because of any act (...) he is suspected or known to have committed. This paper explains the context in which intelligence-led policing flourishes, and how this discussion contributes to the profiling debate in both the USA and the UK, and then sets out two key contentions. First, we argue that Article 14 ECHR as applied under the UK Human Rights Act has a more protective, and less ?prosecutorial?, conception of discrimination than has the US Equal Protection Clause, meaning that judges need not find a discriminatory motive to find that discrimination has occurred. Second, we contend that Article 14 provides the judiciary with the key tool of proportionality, which, when properly applied, makes it harder for discrimination to stand up to scrutiny. (shrink)

This article points out, descriptive moral psychology of human behavior patterns in the handling, in fact, from the outset exceed the boundaries of philosophy, and Cole tried to resort to ethics Fort formalism in order to avoid this problem in practice, can not be established. • Henry Rachael is further motivation for ethical behavior and the psychological concept of Cole Castle together. Although this is certainly an important contribution to the Fort Cole, but Cole Fort critical reflection on the (...) lack of methodology adopted only; secondly that the ideology behind their psychological factors; finally made ​​sense to remedy in the treatment program: to give up on life and psychological describe their condition or results of work. Authors propose a new proposal of psychology, first identified the relationship between psychologists and their research object, this object is, as the subject of people; secondly, from the possibility of speech. Description, either by himself or a third person described in the description, will be replaced by speech interaction. Authors proposed the concept of an interactive framework of doctrine, in which Cole and Rachael • Fort Henry's theory of language games can get a different position. This article attempts to demonstrate that the descriptive psychology, in its treatment of ethical problems, seems to have transgressed the boundary line against philosophy. This problematic situation cannot be circumvented by resorting to an ethical formalism-as L. Kohlberg does in his research program. Rachael M. Henry pushes one step forward to tie the psychodynamic aspect of moral behavior with Kohlberg's concept. The present author, all in affirming the important contribution of Kohlberg to psychology, indicates the insufficiency of a mere reflection of methods in Kohlberg's works. Then he dissects the ideologemes behind Kohlberg's psychology. At last he suggests a therapeutic proposal: the demand for describing psychic life, its conditions or effects, shall be dropped. The author proposes instead a program of new psychology that derives first from the relation of psychologist to his object, the human as subject; and second, from the possibilities of speech in communicative interaction. Description, whether made by oneself or by a third person, shall be substituted by speech interactions. These interactions are considered as successful when the partners in a discussion declare themselves to be understood. Within the framework of this interactionist concept, Kohlberg's and Rachael M. Henry 's theories could assume the status of various language-games. (shrink)

The development and consultation experience of an ethics committee in an urban community hospital has been presented, and various approaches to case consultation have been considered. Our committee has concentrated on the clinical evaluation model. As expected, most consultations have centered on issues of withdrawing or limiting medical care. Most patients evaluated have been unable to clearly express their wishes concerning further treatments, highlighting the need for promoting advance directives. When resorting to substituted judgment, our committee has supported continued care (...) in a majority of cases. Limitation of the consultation process to the attending physician has, in our experience, actually served to increase the credibility of the committee and has promoted acceptance of its recommendations. The committee's most useful function seems to be in assisting physicians and their patients in defining realistic goals and limitations of treatment. Within this context, the coming decade may find ethics committees concerned less with promoting the autonomous wishes of individual patients than with defining the limits of that autonomy against the competing demands of the larger society. Such a shift be approached with caution. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:ConclusionNeil PickeringAs mentioned in my Introduction, and I am delighted to repeat now, the commentaries provided by Calvin Ho and Chua Hong Choon are both excellent. In reading them, some further thoughts were raised for me, and I briefly reflect on these now.In his legal commentary, Calvin Ho makes a plausible argument that Mr. T has the capacity (and hence the right) to make decisions in his current state (...) about his healthcare, and refers to two legal tests of decision-making competency laid down in the Singapore Mental Capacity Act (2008), which he believes Mr. T would pass. A question arises from each of the legal tests which Ho described.The first test involves the question of whether there is any “impairment of, or disturbance in the functioning of Mr. T’s mind or brain”. The claim made by Ho is that there is no impairment or dysfunction of Mr. T’s mind or brain. But, this raises a question: what are the functions of the mind? Christopher Boorse suggested that “We may surely assume … that the main function of perceptual and intellectual processes is to give us knowledge about the world” and against this standard “schizophrenia and all other psychoses with thought disorders look objectively unhealthy”.1 Further — and here is the specific point of discussion in relation to Mr. T — does his continuing denial that he is ill (his lack of insight) also constitute such a dysfunction? Is one function of our mind to tell us things about the functioning of our minds — to correct errors, spot illusions and self-deceptions, and respond to beliefs which are odd? If so, then perhaps Mr. T’s lack of insight indicates the presence of a dysfunction.The second test which (mainly for the sake of completeness) Calvin Ho refers to comprises a list of requirements for decision-making capacity. These are relevant if a dysfunction is identified by the first test. These are:(1). Understand information given to him;(2). Retain that information long enough to make the decision;(3). Use or weigh up that information as part of the process of decision-making; and(4). Communicate his decision.These requirements are familiar from other accounts of decision [End Page 222] making capacity, but at least some of these accounts have added a further requirement, “the ability to appreciate the nature of the situation and its likely consequences”.2 This is not merely the ability to understand what one is being told but also the ability “to apply the information abstractly understood to [one’s] own situation”. Potentially, Mr. T would fail this test. He frequently lacks insight into the fact that he is unwell, that is to say, he does not seem to appreciate that the information he is being given is true of him.I turn now to the clinical commentary by Dr. Chua. What chiefly struck me from this was the determination to engage with the patient as a person. Medication is not the first resort; rather, many other interpersonal approaches can and should be tried first. Medication is of course one aspect of treatment — and in some cases, any hope of any sort of engagement with a patient may rely upon some medical intervention succeeding. Perhaps Mr. T will turn out to be a patient of this kind, who can only be engaged in conversation about his experiences and the state of his mind if he has first taken a course of pills. But it has, over a number of years of speaking to psychiatrist colleagues, been borne in upon me that the psychiatrist himself or herself is a fundamental element of mental healthcare. The psychiatrist is not merely a route to help, the dispenser of prescriptions for pills, but someone with whom the patient can talk to and explore his or her experiences. In short, part of the therapeutic relationship which psychiatrists seek to establish is just a personal relationship. I am sure this is simply obvious to most clinicians and indeed to those who suffer from mental ill health and their caregivers. But sometimes, the obvious is worth pointing out.Indeed, the desire to engage with Mr. T as a person... (shrink)

No matter how far medicine advances, incurable disease will inevitably exist; and the dying patient's last resort will likewise look to medical research. In this report, we examine a case concerning the use of experimental medical therapy on a critically ill child. We discuss the ethical argument pertaining to the recommending of experimental medical therapy to the family of a dying patient.Under the circumstances of having to face the impending death of one's own child, parents of a terminally ill (...) child are extremely vulnerable to suggestion and often loose the ability to make a composed decision._Moreover, there exists the possibility of not only patients, but also medical staff and researchers, to fall into therapeutic misconception. Likewise, for the terminal patient and his/her family though, experimental medical therapy is often the only hope, which is, however, always accompanied by a factor of uncertainty and is considered to be merely an unapproximated gamble. The proposing of experimental medical therapy can result in being cruel by shattering the parent's expectations of saving their child._We examine the issues involved in proposing an experimental medical therapy to patients who are in dire need of a last hope; and conclude that, in times of emergency, we must take great consideration in recommending an experimental medical therapy as an "innovative treatment." In extreme circumstances where an individual's life is on the line, doing nothing can be quite trying; yet, what is right is not necessarily doing something, but rather making the right decision. (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)

SummarySubjecting to a detailed analysis Kant's diagnosis of dialectical error in the Transcendental Dialectic of the first Critique, the author posits that Kant's understanding of such error is, to the extent that it conflates the subjective‐objective, phenomenal‐noumenal, and regulative‐constitutive distinctions, fundamentally incoherent. The author argues not only that these three distinctions cannot on Kant's own terms be conflated, but also that Kant's treatment of dialectical error is further vitiated by circularity of argument: Kant proposes to explain the three distinctions (...) by means of the notion of transcendental error, which however the distinctions themselves were supposed to explain in the first place. After showing that Kant's diagnosis of dialectical error cannot be salvaged even by resorting to the Kantian concept of “transcendental subreption”, the author concludes that unless Kant could in some other way spell out the minimal conditions for dialectical error, Kant's very distinction between understanding and reason becomes difficult to justify. (shrink)

In the fiqhī doctrine, the issue of nafy al-madārik does not find a place for itself with this very nomenclature, and in the classical approach, it is often referred to by different names, but we have found it appropriate to use this term in order to make the subject more understandable and to lead to a more practical use of the expression rather than a sentence. One of the main reasons why we find the subject worthy of research is that (...) there are almost no independent and original studies on it. Another reason was to determine the relationship between the two, since those who frequently and openly do not give it a chance examine it under the title of istishāb. In the process, our multidisciplinary reading tendency led us to realize how similar some of the terminological expressions that appear in modern logic are. In Islamic legal methodology, the method of “absence of evidence/nafy al-madārik”, which plays an important role in the knowledge of basic methods for experts who will deduce religious rulings from the relevant sources, is mostly discussed together with the evidence of istishāb and not analyzed in a separate context. In the absence of evidence that would constitute the ruling on any subject, jurists have mentioned this method, which states that there is no ruling because there is no evidence. The issue of the absence of evidence, which is usually analyzed by the Hanafīs under the heading of fasid evidence, was occasionally used by other jurists. If the absence of evidence does not result in the absence of the ruling, the scholars have resorted to the evidence of istishāb, which is the opinion that the ruling continues to exist. However, as we have mentioned, the mixed treatment of both methods has led to the problem of where they should be positioned in the hierarchical evidence platform and how they should be perceived. The fact that a sixth prayer was not commanded upon the necessity of the existence of the five daily prayers is one of the main examples of the method of nafy. Accordingly, it is possible to rule that the sixth prayer does not exist in the absence of any evidence showing that the legislator did not impose a new one on top of the five rak'ahs and vice versa. In terms of its scope, the issue of the absence of evidence is not only used in classical fiqh. In fact, the breadth of this subject should not be limited to Islamic sciences. In fact, the method of absence of evidence also guides the modern understanding of science. The method in question, which is mostly expressed as the absence of evidence, is rejected by a considerable number of popular acceptance. Science, so to speak, does not see the absence of evidence as a correct approach. A famous and striking example of the absence of evidence is as follows: “There is no evidence for the existence of aliens on Earth, therefore there are no aliens, or aliens do not exist, based on the lack of evidence for this”.In this study, first of all, the elements constituting the phrase “absence of evidence” are analyzed. The method of absence of evidence is discussed together with its debates and parties in terms of the meaning formed as a result of the examination. Its relationship with istishāb has been analyzed in terms of its relevance. In doing so, we have also included whether it is sufficient for the person who claims that the ruling does not exist due to the absence of the relevant evidence to prove his claim in a mere way. While trying to reveal all these, we have also tried to address how correct it is for the person who claims that there is no evidence for the relevant ruling in the method of absence of evidence to make a decision based solely on this. In addition, we have discussed the issue of absence of evidence together with some issues of various disciplines such as kalam and logic due to its relevance. As a result of the discussions, we tried to show that the method of nafy and istishab are not the same thing. Following these, some evaluations were made about the theory of nafys. Among these evaluations, there are some interpretations that are close to the Hanafīs' stance on this issue and some determinations about the fallacy of nafy in terms of the science of logic. As a result, an independent study on nafy al-madārīq has been presented to you, the reader, based on a logical approach to it. However, this attempt will not completely fill the gap in the literature on the subject. We hope that this study will serve as an opportunity for further research to fill the aforementioned gap, and that the subject will reach a wider audience. (shrink)

Deep brain stimulation — a novel surgical procedure — is emerging as a treatment of last resort for people diagnosed with neuropsychiatric disorders such as severe obsessive-compulsive disorder. The US Food and Drug Administration granted a so-called humanitarian device exemption to allow patients to access this intervention, thereby removing the requirement for a clinical trial of the appropriate size and statistical power. Bypassing the rigors of such trials puts patients at risk, limits opportunities for scientific discovery, and gives (...) device manufacturers unique marketing opportunities. We argue that Congress and federal regulators should revisit the humanitarian device exemption to ensure that it is not used to sidestep careful research that can offer valuable data with appropriate patient safeguards. (shrink)

Application of sedation at the end of life has been fraught with ethical and clinical concerns, primarily focused on its potential to hasten death. However, in the face of clinical data that assuage most of these concerns, a new threat to this treatment of last resort has arisen. Concern now pivots on its effects on the personhood of the patient, underpinned by the manner in which personhood has been conceptualised. For many authors, it is consciousness that is seen (...) to be the seat of personhood, thus its loss is seen to rob a patient of their moral and ethical worth, leaving them in a state that cannot ethically be differentiated from death. Here I proffer a clinically based alternative to this view, the Ring Theory of Personhood, which dispels these concerns about sedation at the end of life. The Ring Theory envisages personhood as a coadunation of three domains of concern: the innate, the individual and the relational elements of personhood. The innate element of personhood is held to be present among all humans by virtue of their links with the Divine and or their human characteristics. The individual elements of personhood pivot on the presence of consciousness-dependent features such as self-awareness, self-determination and personality traits. The relational component of personhood envisages an individual as being ‘socially embedded’ replete with social and familial ties. It is these three equally important inter-related domains that define personhood. (shrink)

The existence of causal explanations in science has been an issue of interest in Western philosophy from its very beginnings. That is the reason this work, following an idea of Mario Bunge, makes a historical review of this matter. The modern treatment of this subject takes place since the postulation by Popper and Hempel of the D-N model of scientific explanation, whose viability is scrutinized here from different points of view in the current philosophy of science. The main object (...) of this paper is to present two arguments against the possibility of causal explanations in theoretical physics. The first one concerns the existence, in certain cases, of inter-theoretical incompatibilities, and the second refers to the need to resort, in other cases, to concatenations of laws of different theories and disciplines. The final conclusion will be the defence of a form of theoretical explanation, which follows the Popper-Hempel model, but devoid of any ontological and metaphysical connotations. (shrink)

In this paper, we intend to demonstrate that the asylum request process can have its semantic and politic structures evidenced from an access via philosophy of language. In order to elucidate the normative nature of this social practice and to take a critical stance in relation to the treatment given to the refuge interview as it has been done in our country, we resort to certain concepts developed by the so called later Wittgenstein. Looking for a more complete (...) treatment of our object of study, we also turn to the authors of Bakhtin’s Circle, which explore communicational dimensions that the Viennese philosopher did not properly explore – with special emphasis on “value accents”. In order to collect empirical evidence relevant to our purposes, a field research was carried out with professionals and volunteers involved in the asylum request interviews. The resulting reports provided us with more basis for the considerations we make about the normative fragility of the interview language game and the intricate value system that guides the interaction between interviewer, interpreter and interviewee. (shrink)