[Show abstract][Hide abstract] ABSTRACT: The use of charged-particle radiation therapy (CPRT) is an increasingly important development in the treatment of cancer. One of the most pressing controversies about the use of this technology is whether randomised controlled trials are required before this form of treatment can be considered to be the treatment of choice for a wide range of indications. Equipoise is the key ethical concept in determining which research studies are justified. However, there is a good deal of disagreement about how this concept is best understood and applied in the specific case of CPRT. This report is a position statement on these controversies that arises out of a workshop held at Wolfson College, Oxford in August 2011. The workshop brought together international leaders in the relevant fields (radiation oncology, medical physics, radiobiology, research ethics and methodology), including proponents on both sides of the debate, in order to make significant progress on the ethical issues associated with CPRT research. This position statement provides an ethical platform for future research and should enable further work to be done in developing international coordinated programmes of research.
Journal of medical ethics 09/2013; · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: On the basis of detailed interviews of females aged between fifteen and twenty-six years with a diagnosis of anorexia nervosa we argue that the autonomy of people with this condition may be severely compromised in four ways, particularly in relation to eating and weight. First there are problems with agency. Second, affective components, particularly anxiety, can dominate beliefs such that the grounds for making a decision may differ from the reasons given in justification. Third, the interactions between the affective components and the objective evidence lead to substantial inner conflicts with resulting lack of stability in preferences and beliefs. Fourth, this lack of stability leads to concerns around identity and authenticity. We argue that some of the ways in which autonomy is compromised reduce competence to decide on treatment. We suggest that these results may be relevant to other mental disorders and have clinical and policy implications.
International Journal of Law in Context 03/2013; 9(01).
[Show abstract][Hide abstract] ABSTRACT: We are grateful for these two insightful commentaries, which both see novelty and value in the manner in which we invoke the hypothesis that anorexia nervosa is a passion, to help explain data from the Anorexia Experiences Study, which provides the basis of our inquiry. In this response, we wish to clarify and elaborate on our hypothesis; in particular, the difference between passions and moods, the manner in which our hypothesis touches on issues of authenticity and identity, and the compelling parallel with addiction. We also wish to emphasize that, in proposing the hypothesis that anorexia nervosa is a passion, our primary aim is not so much to exclude or replace alternative theoretical approaches. Our focus, really, is to argue that the hypothesis that anorexia nervosa is a passion adds something rich and unique to our current understanding of that condition, which is not fully or adequately captured by alternative accounts.
Hannah Bowden asks whether the descriptive theoretical virtues we attribute to ‘passion’ might also be accomplished by referring to “Heideggerian mood,” or “a form of Heideggerian mood in combination with certain beliefs” (Bowden 2013, 368). She explicitly asks how passions differ from moods. These are important questions.
To begin, note that in her remarks Bowden is inquiring about the descriptive capabilities of the theoretical constructs ‘passion’ and ‘mood.’ Her concern is largely with phenomenological description. Now it is indeed true that we argue that ‘passion’ plays a pivotal role in the description of the clinical course and nature of anorexia nervosa, although admittedly we do not engage in phenomenology per se. However, what must be emphasized is that we also wish to argue that, properly understood, the construct ‘passion’ plays a theoretically irreducible and ineliminable role in the explanation of the clinical course of anorexia nervosa; in particular, the manner in which many of the feelings and emotions in anorexia nervosa succeed one another in apparently rule-governed and even law-like ways. Our contention is that neither the concepts ‘emotion,’ ‘feeling,’ ‘mood,’ ‘belief,’ or any combination of these, can adequately describe or explain the complex progressive syndrome that is anorexia nervosa. Something like the concept of passion we invoke from Ribot is required. Although much work remains to be done, this at least is the essence of our case.
We believe that it is an especially important theoretical virtue of the concept of passion that we employ that it helps to describe and explain, both how and why the anorexic syndrome can sometimes take the tragic, progressive, worsening, course it does. Indeed, at one point Ribot likens passions where there is a loss of control of this sort to an ‘avalanche.’ This compelling metaphor suggests a tightly bound, progressive, worsening, affective–intellectual–motivational syndrome that, in our view, cannot credibly be labeled or identified, described or explained, with moods, or simply moods plus certain beliefs. Furthermore, ‘passion’ in our view cannot be accounted for using other preexisting theoretical concepts, or any combination of these. Our claim is that the concept ‘passion’—and not simply the term—must be added (reinstated, to be precise) to our current existing theoretical framework. None of this is to say that moods might not play an important part in the phenomenological and clinical description of the anorexic syndrome, or its explanation. But that is an independent empirical question that we did not attempt to answer in our article.
To further clarify, there are in fact quite a few important differences between moods and passions on our account. First, passions may initially be voluntarily chosen, whereas moods, normally, are not. Second, passions are tied to an ‘intentional object’ or fixed idea, whereas moods, normally, are not. Third, passions require the intellectual resources of reason and cognition, whereas moods, normally, do not. Fourth, passions are often tied to specific stereotypical action tendencies, whereas moods, normally, are not. Fifth, passions are stable and may endure for years, whereas moods tend to be more fleeting and temporary, lasting minutes, days, or maybe months, but not (continuously) years or decades. Sixth, passions necessarily move us to action, although this is not necessarily true of moods. Finally, seventh, passions can sometimes be harder to resist than...
[Show abstract][Hide abstract] ABSTRACT: Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that conceptualizing anorexia nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals.
[Show abstract][Hide abstract] ABSTRACT: The non-identity problem arises when an intervention or behavior changes the identity of those affected. Delaying pregnancy is an example of such a behavior. The problem is whether and in what ways such changes in identity affect moral considerations. While a great deal has been written about the non-identity problem, relatively little has been written about the implications for physicians and how they should understand their duties. We argue that the non-identity problem can make a crucial moral difference in some circumstances, and that it has some interesting implications for when it is or is not right for a physician to refuse to accede to a patient's request. If a physician is asked to provide an intervention (identity preserving) that makes a person worse off, then such harm provides a good reason for the physician to refuse to provide the intervention. However, in cases where different (identity-altering) interventions result in different people having a better or worse life, physicians should normally respect patient choice.
The American Journal of Bioethics 08/2012; 12(8):21-9. · 4.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: People with anorexia nervosa struggle with questions of authenticity. More attention should be paid this concept—both how patients think about it, and how clinicians should think about it.
[Show abstract][Hide abstract] ABSTRACT: Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong.
Journal of medical ethics 12/2011; 38(4):204-9. · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fall detectors are a form of remote monitoring assistive technology that have the potential to enhance the wellbeing of adults at risk from falling. In this paper, the ethical issues raised by the use of fall detectors are examined. The fall detection devices currently available are outlined, and a summary of how these devices require social-care services, or family carers, to respond in particular ways, is provided. The ethical issues associated with the use of fall detectors are classified under four headings: autonomy, privacy, benefit, and the use of resources. These issues, we argue, arise out of the nature of the technology itself, and the way that this technology is integrated into the day-to-day support package of the person for whom it is provided. It is argued that manufacturers have a duty to provide information about the ‘ethical side-effects’ associated with the use of a particular device, and that the process of making a decision to provide a person with a fall detector should include a checklist of questions that is designed to enable decision makers to work through the ethical issues raised.
Ageing and Society 10/2011; 31(08):1350 - 1367. · 1.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: People with anorexia nervosa struggle with questions of authenticity. They thought about whether they were being their authentic selves, and which of their desires, emotions, and choices were authentic. More attention should be paid this important concept and its role and status--both how patients think about it, and how clinicians should think about it.
The Hastings Center Report 01/2011; 41(6):19-29. · 1.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intensive care units (ICUs) are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients who would benefit from intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care.
[Show abstract][Hide abstract] ABSTRACT: Neuropsychiatric behaviours occur frequently in Alzheimer's disease and other dementias and are thought to arise from the neurodegenerative process. However, it is unclear whether neurodegenerative changes in the hippocampus are associated with neuropsychiatric behaviours such as aggression. In this study, semiquantitative measurements of cell loss, atrophy, neuritic plaque and neurofibrillary tangle load in the postmortem hippocampus were taken for dementia patients, prospectively assessed for neuropsychiatric behaviours. It was found that increased tangle load, but not other hippocampal neuropathological variables, was associated with increased severity of aggressive behaviours and presence of chronic aggression. This study suggests a pathogenic link between neurofibrillary tangle load and aggressive behaviours in the hippocampus of dementia patients.
[Show abstract][Hide abstract] ABSTRACT: The Mental Capacity Act (2005) is an impressive piece of legislation that deserves serious ethical attention, but much of the commentary on the Act has focussed on its legal and practical implications rather than the underlying ethical concepts. This paper examines the approach that the Act takes to best interests. The Act does not provide an account of the underlying concept of best interests. Instead it lists factors that must be considered in determining best interests, and the Code of Practice to the Act states that this list is incomplete. This paper argues that this general approach is correct, contrary to some accounts of best interests. The checklist includes items that are unhelpful. Furthermore, neither the Act nor its Code of Practice provides sufficient guidance to carers faced with difficult decisions concerning best interests. This paper suggests ways in which the checklist can be developed and discusses cases that could be used in an updated Code of Practice.
Journal of medical ethics 12/2009; 35(12):733-8. · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that patients are often subject to compulsion and coercion even without formal compulsory treatment orders. Research also suggests that patients suffering from anorexia nervosa can change their minds in retrospect about compulsion.
Qualitative interviewing methods were used to explore the views of 29 young women concerning compulsion and coercion in the treatment of anorexia nervosa. The participants were aged between 15 to 26years old, and were suffering or had recently suffered from anorexia nervosa at the time of interview.
Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals.
People with anorexia nervosa appear to agree with the necessity of compulsory treatment in order to save life. The perception of coercion is complex and not necessarily related to the degree of restriction of freedom.
International Journal of Law and Psychiatry 11/2009; 33(1):13-9. · 1.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hyperphagia and associated eating changes occur frequently in Alzheimer's disease (AD) and lead to considerable morbidity. However, the neurochemical basis for these neuropsychiatric behaviours is at present unclear. In this study, we measured serotonin transporters, 5-HT(1A), 5-HT(2A), and 5-HT(4) receptors using radioligand binding assays in the postmortem temporal cortex of a cohort of controls and AD patients longitudinally assessed for hyperphagia. We found significant decreases in 5-HT(4) receptor densities in the hyperphagic, but not normophagic, AD group. Our data suggest that 5-HT(4) receptor deficits may be a specific neurochemical correlate of hyperphagia, and point to the potential pharmacotherapeutic utility of 5-HT(4) agonists for these behaviours in AD.
Journal of the neurological sciences 10/2009; 288(1-2):151-5. · 2.32 Impact Factor