Title III of the Americans with Disabilities Act (ADA) grants people with disabilities access to public accommodations, including the offices of medical providers, equal to that enjoyed by persons without disabilities. The Department of Justice (DOJ) has unequivocally declared that the law requires effective communication between the medical provider and the Deaf patient. Because most medical providers are not fluent in sign language, the DOJ has recognized that effective communication calls for the use of appropriate auxiliary aids, including sign language (...) interpreters. The final decision on what to offer the Deaf patient is the doctor's, and under current DOJ regulations, the doctor does not have to consult with the patient or give "primary consideration" to the patient's choice of auxiliary aid as long as what the doctor offers results in effective communication. However, given the great variation in people's communication styles and skills, a standard, one-size-fits-all auxiliary aid would fail to achieve effective communication in many cases, harming not only that Deaf patient, but also the medical provider, who would be potentially liable for violating the ADA as well as hamstrung in getting accurate information for purposes of diagnosis and treatment. Moreover, most doctors are not savvy about Deafness and Deaf culture. Thus, the best way to ensure effective communication would be to require the medical provider to ask the Deaf patient for his or her choice of auxiliary aid and to give "primary consideration" to the patient's expressed choice of auxiliary aid. Such an approach is required under Title II of the ADA, which makes it mandatory for state and local governments to consult with people with disabilities and give "primary consideration" to the patient's choice of auxiliary aid. Given that there is no difference between a public doctor and a private doctor that would justify the two different approaches and that cost is not a factor, since under either title, a medical provider cannot pass on the costs to the person with a disability, the DOJ should revise its interpretation of Title III in order to bring in into line with its interpretation of Title II. To fail to do so would operate to frustrate both the letter and the spirit of the ADA. Until the DOJ brings the titles into line, the courts should decline to give controlling weight to the DOJ's interpretation of Title III. (shrink)
In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further (...) questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)
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. (shrink)
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 took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, 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. (shrink)
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 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, 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. (shrink)
This article by Louis Sass, Josef Parnas, and Dan Zahavi takes us into the midst of a debate over recent developments in phenomenological psychiatry. In "Phenomenological Psychopathology and Schizophrenia: Contemporary Approaches and Misunderstandings" (Sass et al. 2011), Sass et al. are responding to criticisms of their position lodged by Aaron L. Mishara in "Missing Links in Phenomenological Clinical Neuroscience: Why We Are Still Not There Yet" (Mishara 2007). In their reply, Sass et al. offer several helpful clarifications and justifications of (...) their position, a position they have advanced in numerous important articles and books in the past. We are grateful for these clarifications and additional .. (shrink)
Basing ourselves on the writings of Hans Jonas, we offer to psychosomatic medicine a philosophy of life that surmounts the mind-body dualism which has plagued Western thought since the origins of modern science in seventeenth century Europe. Any present-day account of reality must draw upon everything we know about the living and the non-living. Since we are living beings ourselves, we know what it means to be alive from our own first-hand experience. Therefore, our philosophy of life, in addition to (...) starting with what empirical science tells us about inorganic and organic reality, must also begin from our own direct experience of life in ourselves and in others; it can then show how the two meet in the living being. Since life is ultimately one reality, our theory must reintegrate psyche with soma such that no component of the whole is short-changed, neither the objective nor the subjective. In this essay, we lay out the foundational components of such a theory by clarifying the defining features of living beings as polarities . We describe three such polarities: 1) Being vs. non-being: Always threatened by non-being, the organism must constantly re-assert its being through its own activity. 2) World-relatedness vs. self-enclosure: Living beings are both enclosed with themselves, defined by the boundaries that separate them from their environment, while they are also ceaselessly reaching out to their environment and engaging in transactions with it. 3) Dependence vs. independence: Living beings are both dependent on the material components that constitute them at any given moment and independent of any particular groupings of these components over time. We then discuss important features of the polarities of life: Metabolism; organic structure; enclosure by a semi-permeable membrane; distinction between "self" and "other"; autonomy; neediness; teleology; sensitivity; values. Moral needs and values already arise at the most basic levels of life, even if only human beings can recognize such values as moral requirements and develop responses to them. (shrink)
Schizophrenia, like other pathological conditions of mental life, has not been systematically included in the general study of consciousness. By focusing on aspects of chronic schizophrenia, we attempt to remedy this omission. Basic components of Husserl’s phenomenology (intentionality, synthesis, constitution, epoche, and unbuilding) are explicated and then employed in an account of chronic schizophrenia. In schizophrenic experience, basic constituents of reality are lost and the subject must try to explicitly re-constitute them. “Automatic mental life” is weakened such that much of (...) the world that is normally taken-for-granted cannot continue to be so. The subject must actively re-lay the ontological foundations of reality. (shrink)
The clinical ethics propounded by Richard Zaner is unique. Partly because of his phenomenological orientation and partly because of his own daily practice as a clinical ethicist in a large university hospital, Zaner focuses on the particular concrete situations in which patients and their families confront illness and injury and struggle toward workable ways for dealing with them. He locates ethical reality in the clinical encounter. This encounter encompasses not only patient and physician but also the patients family and friends (...) and indeed the entire lifeworld in which the patient is still striving to live. In order to illuminate the central moral constituents of such human predicaments, Zaner discusses the often-overlooked features of disruption and crisis, the changed self, the patients dependence and the physicians power, the violation of personal boundaries and their necessary reconfiguring, and the art of listening. (shrink)
