Philosophy, Ethics, and Humanities in Medicine - Latest Comments

Duality, polarity in medicine

Michael H. Kottow — 2010-03-01T00:00:00Z

MA. Schwartz and O.P. Wiggins thoughtful article is an audacious attempt to deal with the mind-body problem, and the first question that comes to mind is whether Descartes’ dualism can ever be solved, or perhaps dissolved at least for medical purposes. Psychosomatic’s valiant effort finally backfired because it could not avoid thinking about the integration and mutual influence of two components –psyche and soma-. Hans Jonas taught us that subjectivity runs through most animal species, but only humans are aware of it and therefore bound to be ethical. Awareness recreates a duality, in that human beings are their own observers as they dislocate their conscious self from their body: our subjectivity is eccentric to our body, as H. Plessner remarked.
Merleau Ponty saw the body as a “system open towards the world”, prompting Plügge to understand the physical body (Körper) in its phenomenological dimension as Leib (stretching scholarly grammar which often differentiates Leib (living body) from Körper (dead body). Referring to the body that we are and the body we have, the Anglophonic literature refers to the lived –phenomenological- body and the living –physical- body. In all three languages, the distinction has phenomenology in mind, trying to present the lived body as experiencing the world -and itself-, and the living body as a physical organism. This has enriched medical thinking by reaffirming the distinction between feeling ill and having a disease. A vast field of inquiry is thus opened, which will also lead to exploring the conceivable difference between, and the ethical consequences of, being genetically engineered and living the experience of being programmed.
There is unanimous agreement that this distinction is in clear opposition to Cartesian dualism. Intertwinement is often mentioned, and in his German text, Plügge speaks of Ambiguïté (sic). It remains a major task to understand what it is that intertwines, and explore the nature of this interaction. This may well be the Gordian knot Schwartz and Wiggins are focusing on. It also remains to be seen whether the concept of polarities will be a unifying element. Nuclei may be understood as a unity, but poles present as a duality.
This stimulating article confirms Toulmin’s belief that medical ethics may have saved the life of philosophy.
Miguel Kottow
Universidad de Chile

Georges Canguilhem

Michael Schwartz — 2010-02-18T00:00:00Z

Regretfully, we have misspelled the name of the French philosopher and physician Georges Canguilhem (1904-1995) throughout this manuscript. Veuillez nous excuser!

Michael Schwartz and Osborne Wiggins

Problems with principlism

Daniel Goldberg — 2010-01-15T00:00:00Z

On the kind advice of Michael Schwartz, I am cross-posting this comment from my weblog, Medical Humanities Blog.

"A couple of thoughts spring to mind. First, one can be dubious of the implication that the proliferation of codes of ethics is either necessary or sufficient to produce virtuous behavior. Second, one can be equally if not more dubious of the idea that a consensus on the importance of certain principles is either necessary or sufficient to produce virtuous behavior. My problem with principlism, per se, is that it seems either false or thin. As Mackie argued, the stunning diversity of moral beliefs across communities and cultures requires the belief either that moral universalism and moral objectivism are quite simply wrong or that the vast majority of moral communities are delusional or mistaken when it comes to practicing virtuous forms of life.

Even if universal principles are coherent, one has to articulate them at such a high level of generality they become greatly detached from the local moral worlds in which people live their lives. Moral thickness is found only in these local worlds, which is one reason I find moral particularism so attractive. A broad commitment to justice is perfectly fine; but such a commitment has little to do with whether Paul and Jane may reach diametrically opposed positions on what such a commitment entails in this case or that case.

This argument is both quite friendly to a Wittgensteinian moral epistemology, as well as the ethos of the humanists, who demanded of themselves and their educational program (studia humanitatis) that it be deeply rooted in actual practices, as opposed to the abstractions of the Scholastics.

Thus, while I am sympathetic to the pedagogical aims of the authors -- that we need to find ways of faciliating the translation of ethics education into medical practice -- I am quite dubious that searching for a "unified" principlism in applied ethics is likely to succeed in this endeavor. As noted here, I believe that we must dispense with the quixotic quest for what Leigh Turner has termed "moral Esperanto" and get on with the tasks of reflecting how practical wisdom is and ought to be expressed in particular (local) moral worlds.

Finally, kudos to the authors for actually engaging the literature on the hidden and informal curricula, which suggest that efforts to improve ethical practices among clinicians simply will not succeed if they consist merely of formal pedagogies targeted at undergraduate medical students. Because it is the more senior practitioners who shape professional practices, if attitudes, practices, and beliefs regarding ethics are problematic in any given scenario, ethics education simply must proceed from the top-down as well as the bottom-up if change is desired.

It is long past time to dispense with the convenient fiction that the best way to produce virtuous behavior in health providers is via an ethics course in the formal curriculum. I hasten to add I certainly applaud the presence of such courses; I merely object to the practice by which such courses constitute the majority of ethics education in health professional education."

Abuse of Antidepressant Medications

jacob ross — 2009-09-06T00:00:00Z

In many instances individuals who are suffering from depression often turn to drugs or alcohol instead of seeking proper antidepressant medications. In some instances individuals may abuse the antidepressant medications prescribed to them. This is done in order to help cope with the illness and can lead to a drug addiction. Drug addiction requires immediate attention in centers specifically designed to help those with any number of addictions and addictive behaviors.

malibu prescription drug rehab

Erratum

Ray Greek — 2009-08-28T00:00:00Z

Dr Andrew Knight was kind enough to notify us of several errors we made in quoting from Knight et al. cited as reference 43 in our in our section entitled Carcinogenesis (pp. 8-9). We apologize to Drs Knight, Bailey, and Balcombe and wish to correct the errors at this time.

On page 8 of the paper we state:

"According to Knight et al. [43] as of 1 January 2004, IRIS was unable to classify the carcinogenic status of 93 out of 160 chemicals that had been evaluated only by animal tests."

Concerning this claim Dr Knight has made the following comments (email communication):

"Unfortunately, this statement is actually incorrect. The EPA did indeed provide a human carcinogenic classification for many of these chemicals, and I did not state otherwise in my paper [43]. Allow me to explain:

"Of the 543 chemicals catalogued in the EPA’s IRIS chemicals database at the time of my study, 235 had been assigned human carcinogenicity classifications. Of these, 17 were classified as definite or probable human carcinogens on the basis of their human carcinogenicity data. Of the remaining 218 chemicals lacking even limited human data, 160 were associated with animal carcinogenicity data (these are the 160 on which my study focused, and to which you refer).

"64 of these were assessed by the EPA as probable human carcinogens, and three were considered probably not carcinogenic to humans. The remaining 93 chemicals were considered unclassifiable as to their human carcinogenicity (53) or to be possible human carcinogens (40) , based on animal data considered inadequate to support a stronger classification.

"The key point, which I emphasized in my paper, is that in a majority of cases (58.1%; 93/160), the EPA considered animal carcinogenicity data inadequate to support a classification of probable human carcinogen or non-carcinogen. These are clinically useful human carcinogenicity classifications.

"As you can see, however, in 40 of these 93 cases, the EPA did consider the animal data sufficient to classify the chemical as a ‘possible human carcinogen.’ However, I not consider this classification to be clinically useful, in comparison to ‘probable human carcinogen’ or ‘non-carcinogen.’ Hence, my results demonstrate that in the majority of cases, the EPA considered the animal data insufficient to deliver human carcinogenicity classifications of significant clinical use, rather than no classifications at all – as your statement asserts."

By “carcinogenic status” from our quote we meant categorization that is clinically useful e.g., either human carcinogen or non-carcinogen. As Dr Knight has pointed out, he does not consider the classification “possible human carcinogen” to be clinically useful either. We apologize for any ambiguity in our original statement.

Further on page 8 we quoted Knight et al as follows:

"For the 128 chemicals with human or animal data also assessed by the human carcinogenicity classifications were compatible with EPA classifications were compatible with EPA classifications only for those 17 having at least limited human data (p = 0.5896) [43]."

It should read:

"For the 128 chemicals with human or animal data also assessed by the IARC human carcinogenicity classifications were compatible with EPA classifications only for those 17 having at least limited human data (p = 0.5896). [43]"

We left the word IARC out of the sentence. This was a transcriptional error and we apologize for them.

On page 9 we quoted Knight et al as follows:

"... based on these IARC figures, the positive predictivity of the animal bioassay for definite of probable human carcinogens was only around 7% (104/502), while the false positive rate was a disturbing 79.3% (398/502) [43]."

The above should be:

"... based on these IARC figures, the positive predictivity of the animal bioassay for definite or probable human carcinogens was only around 20.7% (104/502), while the false positive rate was a disturbing 79.3% (398/502) [43]."

We mistakenly said of instead of or in the second line and 7% instead of 20.7% . These were transcriptional errors and we apologize for them.

Finally on page 9 we state:

"More-recent IARC classifications indicate little movement in the positive predictivity of the animal bioassay for human carcinogens. By January 2004, a decade later, only 105 additional agents had been added to the 1993 figure, yielding a total of 885 agents or exposure circumstances listed in the IARC Monographs [46]. Not surprisingly the proportion of definite or probable human carcinogens resembled the 1993 figure of 13.3%. By 2004, only 9.9% of these 885 were classified as definite human carcinogens, and only 7.2% as probable human carcinogens, yielding total of 17.1%."

This is, in fact, a continuation of the previous quotation but the indentation was moved left during our editing process. This was our mistake and we apologize.

We thank Dr Knight for bringing these matters to our attention.

proposed difinition of MIND

PRAMOD KUMAR — 2009-04-10T00:00:00Z

Mind may be explained as M.I.N.D where M= denotes memory, I= mean intelligence, and N= represents all neural activities and lastly D= represents, drive / movements.<br> Here, we propose the protocol for study of MIND as part of neurobehavioral studies which includes all parameters representing the outcome/details of MIND.<br>PRAMOD

Clarification re: complicated grief

Ronald Pies — 2009-03-11T00:00:00Z

Addendum: After several discussions with Dr. Naomi Simon and Dr. Sidney Zisook, it has emerged that the category known as "complicated grief" [CG]remains somewhat murky, vis-a-vis the affective continuum I propose in my article. For example, some elements of CG resemble post-traumatic stress disorder, or overlap with PTSD. Nonetheless, I believe there are compelling reasons, at present, for keeping CG on the affective disorders continuum (e.g., its association with suicidal ideation and apparent responsiveness to antidepressants, as per Dr. Simon's case reports--
see Am J Psychiatry. 2007 Nov;164(11):1760-1.)

I also wanted to clarify that, in addition to Dr. Simon, several other investigators pioneered the concept of "complicated grief", including but not limited to Drs. George Bonanno, Kathy Shear, Holly Prigerson, and Mardi Horowitz.

Ronald Pies MD

The writer reports no competing interests with respect to the above.

The interface of worldwide religions and the ideology behind the practice of end-of-life organ donation for transplantation

Mohamed Rady — 2009-02-20T00:00:00Z

The interface of worldwide religions and the ideology behind the practice of end-of-life organ donation for transplantation

Mohamed Y Rady; Joseph L Verheijde; Catherine Friederich-Murray
Departments of Critical Care Medicine,Physical Medicine and Rehabilitation, and Biomedical Ethics, Mayo Clinic Hospital, Phoenix, Arizona, USA. Bioethics, Policy, and Law Program, Arizona State University, Tempe, Arizona, USA.

For more than 40 years, the end-of-life practice of heart-beating (called brain death) or non–heart-beating (called cardiac or circulatory death) organ procurement for transplantation has thrived on an ideology based on concepts of “altruism,” “gift of life,” or “saving human life” without scrutiny of that medical practice [1]. Proponents have used this ideology to dismantle any opposing fundamental values and beliefs about human life and culture. The study by the Schweda and Schicktanz confirms that religious and cultural values about the human body—both in life and in death—have implications on people’s attitudes and the acceptability of the current practice of procuring organs for transplantation [2].

In the zeal to support the current practice of organ procurement, transplant advocates and many in the transplant community have customized ethical arguments (often abstract and inherently conflicting), justifying serious infractions of centuries-old precepts firmly founded in all major worldwide religions [3]. A few examples of customized ethical justifications[4] that seriously challenge the core principles of worldwide religions include redefining human death to procure transplantable organs from the incipiently dying, resuscitating and reanimating human beings as part of procedures for organ preservation, avoiding transparency during the voluntary consent process [5], and legislating presumed intent to donate organs (in the United States)[6] and consent to donate organs (in the European Union countries)[7] at the end of life.

Organ-procurement agencies consistently claim that all major world religions approve of organ donation and do not address the growing ethical and religious controversies about organ procurement in the context of heart-beating (brain-dead) human beings [8, 9]. Instead, transplant advocates ignore these serious ethical and religious controversies as long as government agencies continue to sanction education campaigns about organ donation. These education outreach campaigns become an indoctrinating tool for an ideology in children as young as elementary-school age [10]. The ideologic transformation is launched not only without open and broad societal discussion, but also with proponents fully aware that this transformation transgresses the rights of others’ diverse religious and cultural values and practices and the respect of human dignity.

References
1. Verheijde JL, Rady MY, McGregor JL, Friederich-Murray C: Enforcement of presumed-consent policy and willingness to donate organs as identified in the European Union Survey: The role of legislation in reinforcing ideology in pluralistic societies. At
[ http://dx.doi.org/10.1016/j.healthpol.2008.08.008 ]. Health Policy in press, Early online doi:10.1016/j.healthpol.2008.08.008

2. Schweda M, Schicktanz S: The "spare parts person"? Conceptions of the human body and their implications for public attitudes towards organ donation and organ sale.
At [ http://www.peh-med.com/content/4/1/4 ]. Philos Ethics Humanit Med 2009, 4(1):4.

3. Bruzzone P: Religious Aspects of Organ Transplantation. Transplant Proc 2008, 40(4):1064-1067.

4. Rady MY, Verheijde J, Ali M: Islam and End-of-Life Practices in Organ Donation for Transplantation: New Questions and Serious Sociocultural Consequences. HEC Forum in press.

5. Truog RD: Consent for Organ Donation -- Balancing Conflicting Ethical Obligations. N Engl J Med 2008, 358(12):1209-1211.

6. Verheijde JL, Rady MY, McGregor JL. The United States Revised Uniform Anatomical Gift Act (2006): New challenges to balancing patient rights and physician responsibilities. Philos Ethics Humanit Med. 2007;2(1):19 [http://www.peh-med.com/content/2/1/19].

7. Mossialos E, Costa-Font J, Rudisill C. Does organ donation legislation affect individuals' willingness to donate their own or their relative's organs? Evidence from European Union survey data. BMC Health Serv Res. 2008;8:48: [http://www.biomedcentral.com/1472-6963/8/48 ].

8. Bresnahan MJ, Mahler K: Ethical debate over organ donation in the context of brain death.
At [ http://dx.doi.org/10.1111/j.1467-8519.2008.00690.x ]. Bioethics in press, Early online DOI 10.1111/j.1467-8519.2008.00690.x

9. Pope Beneditc XVI: No suspicion or arbitration in certifying death. The Holy Father praises scientific advances while warning of the need to guard against unethical practices.In L'Osservatore Romano. 12 November 2008, Weekly Edition in English , Vatican City. [http://www.vatican.va/news_services/or/or_eng/text.html#4]

10. Woien S, Rady MY, Verheijde JL, McGregor J: Organ Procurement Organizations Internet Enrollment for Organ Donation: Abandoning Informed Consent.
At http://www.biomedcentral.com/1472-6939/7/14. BMC Med Ethics 2006, 7(12):14-23

The Dec. 11, 2008, Levin-McCain Report on the Treatment of Detainees in U.S. Custody

Abraham Halpern — 2008-12-25T00:00:00Z

I note that the unanimous report by the commission headed by Senators Carl Levin and John McCain validates the comments made in our article (by Halpern, Halpern & Doherty) concerning the aggressive interrogation techniques used in violation of U.S. and international law.

The Need for Transparency of Clinical Trials

Jeffrey Bridge — 2008-11-24T00:00:00Z

The article by Dr. Ioannidis provides a thought-provoking discussion of two recently published meta-analyses—the results of which call into question the apparent efficacy of antidepressant medications—and offers some practical suggestions for ways to improve the evidence base for antidepressants going forward: pre-registration of fully transparent protocols, strict adherence to a priori defined data analysis plans, and public availability of individual patient-level trial data for prospective meta-analyses. The use of “mega-trials” to answer pressing questions about the clinical utility of antidepressant medications is also an attractive proposition as these types of studies use randomization to avoid selection bias, simple designs to reduce investigator and participant burden, and enroll thousands of participants from diverse clinical practice settings, which increases generalizability and provides ample statistical power to identify small but clinically important treatment effects.1, 2

With regard to the issue of transparency, I would like to draw attention to the recently enacted FDA Amendments Act (Public Law 110-85), which mandates registration and results of all controlled, clinical trials other than Phase I investigations.3 This law requires that sponsors and investigators report basic trial results, including demographic and baseline characteristics of the study participants, the number of participants who dropped out or were excluded, and provide tables of values for the primary and secondary efficacy outcome measures as well as serious adverse events (SAEs) and frequent adverse events in each arm of the trial, including statistical significance.4 Although still a long way from achieving the goal of full access to individual patient trial data, the FDA Amendments Act may bring us one step closer to understanding the true benefit-to-risk profile of all medications, including antidepressants.

REFERENCES

1. March JS, Silva SG, Compton S, Shapiro M, Califf R, Krishnan R. The case for practical clinical trials in psychiatry. Am J Psychiatry. May 2005;162(5):836-846.

2. Peto R, Collins R, Gray R. Large-scale randomized evidence: large, simple trials and overviews of trials. J Clin Epidemiol. Jan 1995;48(1):23-40.

3. U.S. Food and Drug Administration. Law Strengthens FDA. http://www.fda.gov/oc/initiatives/advance/fdaaa.html (accessed 11/14/2008).

4. Zarin DA, Tse T. Medicine. Moving toward transparency of clinical trials. Science. Mar 7 2008;319(5868):1340-1342.