http://www.peh-med.com The most accessed research articles published by Philosophy, Ethics, and Humanities in Medicine 2012-01-13T00:00:00Z In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. http://www.peh-med.com/content/7/1/3 James Phillips Allen Frances Michael Cerullo John Chardavoyne Hannah Decker Michael First Nassir Ghaemi Gary Greenberg Andrew Hinderliter Warren Kinghorn Steven LoBello Elliott Martin Aaron Mishara Joel Paris Joseph Pierre Ronald Pies Harold Pincus Douglas Porter Claire Pouncey Michael Schwartz Thomas Szasz Jerome Wakefield G Scott Waterman Owen Whooley Peter Zachar Philosophy, Ethics, and Humanities in Medicine 2012, null:3 2012-01-13T00:00:00Z doi:10.1186/1747-5341-7-3 /content/figures/1747-5341-7-3-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 3 2012-01-13T00:00:00Z PDF Over 45 million Americans are uninsured or underinsured. Those living in poverty exhibit the worst health status. Employment, education, income, and race are important factors in a person's ability to acquire healthcare access. Having established that there are people lacking healthcare access due to multi-factorial etiologies, the question arises as to whether the intervention necessary to assist them in obtaining such access should be considered a privilege, or a right. The right to healthcare access is examined from the perspective of Western thought. Specifically through the works of Aristotle, Immanuel Kant, Thomas Hobbes, Thomas Paine, Hannah Arendt, James Rawls, and Norman Daniels, which are accompanied by a contemporary example of intervention on behalf of the medically needy by the The Johns Hopkins Urban Health Institute.As human beings we are all valuable social entities whereby, through the force of morality, through implicitly forged covenants among us as individuals and between us and our governments, and through the natural rights we maintain as individuals and those we collectively surrender to the common good, it has been determined by nature, natural laws, and natural rights that human beings have the right, not the privilege, to healthcare access. http://www.peh-med.com/content/2/1/2 Thomas Papadimos Philosophy, Ethics, and Humanities in Medicine 2007, null:2 2007-03-28T00:00:00Z doi:10.1186/1747-5341-2-2 /content/figures/1747-5341-2-2-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 2 2007-03-28T00:00:00Z XML Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD. http://www.peh-med.com/content/6/1/17 Ari Joffe Joe Carcillo Natalie Anton Allan deCaen Yong Han Michael Bell Frank Maffei John Sullivan James Thomas Gonzalo Garcia-Guerra Philosophy, Ethics, and Humanities in Medicine 2011, null:17 2011-12-29T00:00:00Z doi:10.1186/1747-5341-6-17 /content/figures/1747-5341-6-17-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 17 2011-12-29T00:00:00Z PDF This Editorial introduces the thematic series on 'Toward a New Psychiatry: Philosophical and Ethical Issues in Classification, Diagnosis and Care' http://www.biomedcentral.com/series/newpsychiatry. http://www.peh-med.com/content/7/1/1 Sabina Alam Jigisha Patel James Giordano Philosophy, Ethics, and Humanities in Medicine 2012, null:1 2012-01-13T00:00:00Z doi:10.1186/1747-5341-7-1 Psychiatry moving forward In response to the forthcoming release of the DSM-5, James Giordano and colleagues discuss the movement towards a new psychiatry resulting from influences of economic and socio-cultural forces and advances in diagnostic techniques and neurotechnology. /content/figures/1747-5341-7-1-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 1 2012-01-13T00:00:00Z PDF The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the often ambiguous nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria. http://www.peh-med.com/content/7/1/2 Shadia Kawa James Giordano Philosophy, Ethics, and Humanities in Medicine 2012, null:2 2012-01-13T00:00:00Z doi:10.1186/1747-5341-7-2 /content/figures/1747-5341-7-2-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 2 2012-01-13T00:00:00Z PDF The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical concepts of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values. http://www.peh-med.com/content/7/1/5 Dan Stein Philosophy, Ethics, and Humanities in Medicine 2012, null:5 2012-01-13T00:00:00Z doi:10.1186/1747-5341-7-5 /content/figures/1747-5341-7-5-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 5 2012-01-13T00:00:00Z PDF It is one of the central aims of the philosophy of science to elucidate the meanings of scientific terms and also to think critically about their application. The focus of this essay is the scientific term predict and whether there is credible evidence that animal models, especially in toxicology and pathophysiology, can be used to predict human outcomes. Whether animals can be used to predict human response to drugs and other chemicals is apparently a contentious issue. However, when one empirically analyzes animal models using scientific tools they fall far short of being able to predict human responses. This is not surprising considering what we have learned from fields such evolutionary and developmental biology, gene regulation and expression, epigenetics, complexity theory, and comparative genomics. http://www.peh-med.com/content/4/1/2 Niall Shanks Ray Greek Jean Greek Philosophy, Ethics, and Humanities in Medicine 2009, null:2 2009-01-15T00:00:00Z doi:10.1186/1747-5341-4-2 /content/figures/1747-5341-4-2-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 2 2009-01-15T00:00:00Z XML We compare astronomers' removal of Pluto from the listing of planets and psychiatrists' removal of homosexuality from the listing of mental disorders. Although the political maneuverings that emerged in both controversies are less than scientifically ideal, we argue that competition for "scientific authority" among competing groups is a normal part of scientific progress. In both cases, a complicated relationship between abstract constructs and evidence made the classification problem thorny. http://www.peh-med.com/content/7/1/4 Peter Zachar Kenneth Kendler Philosophy, Ethics, and Humanities in Medicine 2012, null:4 2012-01-13T00:00:00Z doi:10.1186/1747-5341-7-4 /content/figures/1747-5341-7-4-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 4 2012-01-13T00:00:00Z PDF Antidepressants, in particular newer agents, are among the most widely prescribed medications worldwide with annual sales of billions of dollars. The introduction of these agents in the market has passed through seemingly strict regulatory control. Over a thousand randomized trials have been conducted with antidepressants. Statistically significant benefits have been repeatedly demonstrated and the medical literature is flooded with several hundreds of "positive" trials (both pre-approval and post-approval). However, two recent meta-analyses question this picture. The first meta-analysis used data that were submitted to FDA for the approval of 12 antidepressant drugs. While only half of these trials had formally significant effectiveness, published reports almost ubiquitously claimed significant results. "Negative" trials were either left unpublished or were distorted to present "positive" results. The average benefit of these drugs based on the FDA data was of small magnitude, while the published literature suggested larger benefits. A second meta-analysis using also FDA-submitted data examined the relationship between treatment effect and baseline severity of depression. Drug-placebo differences increased with increasing baseline severity and the difference became large enough to be clinically important only in the very small minority of patient populations with severe major depression. In severe major depression, antidepressants did not become more effective, simply placebo lost effectiveness. These data suggest that antidepressants may be less effective than their wide marketing suggests. Short-term benefits are small and long-term balance of benefits and harms is understudied. I discuss how the use of many small randomized trials with clinically non-relevant outcomes, improper interpretation of statistical significance, manipulated study design, biased selection of study populations, short follow-up, and selective and distorted reporting of results has built and nourished a seemingly evidence-based myth on antidepressant effectiveness and how higher evidence standards, with very large long-term trials and careful prospective meta-analyses of individual-level data may reach closer to the truth and clinically useful evidence. http://www.peh-med.com/content/3/1/14 John Ioannidis Philosophy, Ethics, and Humanities in Medicine 2008, null:14 2008-05-27T00:00:00Z doi:10.1186/1747-5341-3-14 /content/figures/1747-5341-3-14-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 14 2008-05-27T00:00:00Z XML The left ventricular assist device was originally designed to be surgically implanted as a bridge to transplantation for patients with chronic end-stage heart failure. On the basis of the REMATCH trial, the US Food and Drug Administration and the US Centers for Medicare & Medicaid Services approved permanent implantation of the left ventricular assist device as a destination therapy in Medicare beneficiaries who are not candidates for heart transplantation. The use of the left ventricular assist device as a destination therapy raises certain ethical challenges. Left ventricular assist devices can prolong the survival of average recipients compared with optimal medical management of chronic end-stage heart failure. However, the overall quality of life can be adversely affected in some recipients because of serious infections, neurologic complications, and device malfunction. Left ventricular assist devices alter end-of-life trajectories. The caregivers of recipients may experience significant burden (e.g., poor physical health, depression, anxiety, and posttraumatic stress disorder) from destination therapy with left ventricular assist devices. There are also social and financial ramifications for recipients and their families. We advocate early utilization of a palliative care approach and outline prerequisite conditions so that consenting for the use of a left ventricular assist device as a destination therapy is a well informed process. These conditions include: (1) direct participation of a multidisciplinary care team, including palliative care specialists, (2) a concise plan of care for anticipated device-related complications, (3) careful surveillance and counseling for caregiver burden, (4) advance-care planning for anticipated end-of-life trajectories and timing of device deactivation, and (5) a plan to address the long-term financial burden on patients, families, and caregivers.Short-term mechanical circulatory devices (e.g. percutaneous cardiopulmonary bypass, percutaneous ventricular assist devices, etc.) can be initiated in emergency situations as a bridge to permanent implantation of ventricular assist devices in chronic end-stage heart failure. In the absence of first-person (patient) consent, presumed consent or surrogate consent should be used cautiously for the initiation of short-term mechanical circulatory devices in emergency situations as a bridge to permanent implantation of left ventricular assist devices. Future clinical studies of destination therapy with left ventricular assist devices should include measures of recipients' quality of end-of-life care and caregivers' burden. http://www.peh-med.com/content/3/1/20 Aaron Rizzieri Joseph Verheijde Mohamed Rady Joan McGregor Philosophy, Ethics, and Humanities in Medicine 2008, null:20 2008-08-11T00:00:00Z doi:10.1186/1747-5341-3-20 /content/figures/1747-5341-3-20-toc.gif Philosophy, Ethics, and Humanities in Medicine 1747-5341 ${item.volume} 20 2008-08-11T00:00:00Z XML