Robert F. is an eighty-five-year-old who suffered a heart attack at home in a rural location some thirty minutes from any major hospital. By the time the paramedics arrived, he was unconscious and nonresponsive. After spontaneous return of circulation, they began their standard procedure of therapeutic hypothermia. Robert's core temperature was lowered using ice packs, and cold intravenous fluids were initiated. Soon afterward, Robert started to shiver when his body temperature reached 35.6° Celsius. He was then given a (...) bolus of vecuronium as a neuromuscular blockade, sedated, and intubated. He was also given a low-dose vasopressin for blood-pressure control. Shortly after Robert arrived in the emergency room, his daughter, his medical decision-maker, produced an advance directive documenting that her father has a do-not-resuscitate order, and she demanded that the breathing tube and any other life-sustaining treatments be withdrawn immediately. The medical staff is very reluctant to comply with this demand for immediate action. Until the neuromuscular blockade wears off, removing the ventilator will prevent Robert from breathing. Furthermore, it may take some time to reverse the therapeutic hypothermia procedure to the point that the patient is at normal temperature. In addition, therapeutic hypothermia itself often causes arrest, so the patient may need to be resuscitated again. Should the staff wait until the patient is warm or honor the decision of his daughter, who holds his medical power of attorney? (shrink)

OBJECTIVE: Following two randomized controlled trials that demonstrated reduced mortality and better neurological outcome in cardiac arrest patients, mild therapeutic hypothermia was implemented in many intensive care units. Up to now, no large observational studies have confirmed the beneficial effects of mild therapeutic hypothermia. DESIGN: Internet-based survey combined with a retrospective, observational study. PATIENTS: All patients admitted to an intensive care unit in The Netherlands after cardiac arrest from January 1, 1999 until January 1, 2009. DATA (...) SOURCE: Dutch National Intensive Care Evaluation database. METHODS: The moment of implementation of mild therapeutic hypothermia for each hospital participating in the Dutch National Intensive Care Evaluation database was determined with an Internet survey. To compare mortality before and after implementation of mild therapeutic hypothermia, the odds ratio adjusted for Simplified Acute Physiology Score II score, age, gender, propensity score, and in- or out-of-hospital cardiac arrest was calculated. Patients were excluded if 1) they were admitted to an intensive care unit that did not respond to the survey, 2) they were admitted within 3 months after implementation of mild therapeutic hypothermia, 3) they had a Glasgow Coma Scale score of >8, or 4) they did not satisfy the Simplified Acute Physiology Score II inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 13,962 patients were admitted to an intensive care unit following cardiac arrest. In total 8,645 patients were excluded, 5,544 because of a Glasgow Coma Scale score of >8. Of the resultant 5,317 patients, 1,547 patients were treated before and 3,770 patients after implementation of mild therapeutic hypothermia. Patients admitted after implementation of mild therapeutic hypothermia had lower minimal and maximal temperatures (p < .0001) during the first 24 hrs on the intensive care unit compared to patients admitted before implementation of mild therapeutic hypothermia. The adjusted odds ratio of the hospital mortality of patients treated after implementation of mild therapeutic hypothermia was 0.80 (95% confidence interval of 0.65-0.98, p = .029). CONCLUSION: The results of this retrospective, observational survey suggest that implementation of mild therapeutic hypothermia in Dutch intensive care units is associated with a 20% relative reduction of hospital mortality in cardiac arrest patients. (shrink)

The Brain Death Reconsidered – Is It a Tenable Concept? Since 1968 it has been recognized in the medical practice that irreversible coma connected with apnea can serve as a criterion of human death. This approach was first introduced in the so called Harvard Protocol. As a result of the work of this commission, the brain-based criteria of human death were quickly legally introduced in America and in most countries in the world. The only symptom on which death can be (...) pronounced is, according to this new definition, the absence of spontaneous brain function. However, the acceptance of the new definition of death did not eliminate the old one completely. In many states both old and new definitions of death are legally valid. Practically, in these countries the alternative definition of death functions alongside the old one and diagnosis of death can be based both on the cardiac/respiratory and brain symptoms. One of the few exceptions proved to be Japan. The law in this country does not provide a uniform answer to the question of what human death is. Instead, it allows people to choose between traditional death and brain death. The law states that if a person wants to be an organ donor after brain death has occurred, he or she must record that intention on a donor card or label beforehand. Those who object to brain death and transplantation do not need donor cards. They are considered to be alive until the heart stops beating. In this way the Japanese law respects the opinion of 20-40% of the society who do not believe in the brain death. The opinion of the same percentage of people in Western societies who oppose BD is ignored by their legal systems. Initially the concept of BD did not cause a lot of controversy but this situation changed in the nineties of the last century. Since then many authors have criticized the validity of the brain-based criteria of death. They maintain that it is impossible to declare the absence of all the functions of the whole brain on the basis of the clinical tests supposed to detect it. There may be present some level of consciousness in brain death (BD) patients and therefore, they may feel pain. It is significant that 27% of the members of the teams which perform the excision of the heart for transplantation think that they are killing a living person and that in many countries during this operation a normal general anesthesia is required because of the vivid reaction of the body of the patient. The opponents of the brain death theory stress that the accurate examination of the so-called brain dead persons shows the persistence of the functions of significant parts of their brains. There are EEG waves recorded in 20-40% of BD patients. Event related potentials (ERP) show the reaction to verbal and non-verbal stimuli and the hormone production by the brain tissue can be detected in many BD people. The proper treatment could not only significantly prolong lives of the BD patients, but around 60% of possible donors with the lowest result of 3 in Glasgow Coma Scale could be restored to normal life if their brain edema is properly treated. This treatment should be based on the therapeutic hypothermia connected with the application of the thyroid hormones, whose level is usually too low in the patients with the brain injury. There is a growing lack of consensus regarding the issue of brain death, especially among physicians. Some regard brain death as a biological one, some as the death of the person but not of the human body, and the rest, as a definition accepted by the society, which doesn’t require other legitimacy than the freely chosen criteria. The brain death concept is also criticized from the philosophical point of view. The strength of the brain death theory was based on the premise that the brain is the integrating center of the body. According to this argument, the death of the brain means that the organism ceases to exist for it is no longer a functioning whole. To this argument the opponents of the brain death concept say that this question is not a question a priori but an empirical one and that the empirical data validate the opposite opinion, which says that the bodies of brain dead patients are alive. Some widely known cases show that even the real death of the entire brain means the death of the body and, therefore, may not signify the death of a human person. The integration of the body is the function of the organism as a whole and not of a single organ, even if this organ is the brain. This point of view can be confirmed by the opinion of St. Thomas Aquinas who says that the soul is primarily and per se connected with the body as a whole as the proportionate perfectible and only secondarily with the parts of the body, according to their ordination to the whole. So, the death of any single organ does not preclude the union of the soul with the rest of the body as a living whole. Moreover, the terms such as “consciousness” and “person” should not be identified. The term such as “human living nonpersons”, proposed by some bioethicists and referring to the people without consciousness has not been accepted in the official documents concerning BD. Bodies of the BD people are alive, therefore, it is not right to use the term “brain death” to describe the state of these patients, but rather the term “brain failure” should be used. As the result, according to some authors, the dead donor rule should be abolished. The Catholic Church stresses the sacredness of the human life from the beginning to the end. Therefore She requires that there be no doubts that the donor in BD is really dead. Because of the lack of consensus among physicians, philosophers and theologians, the popes John Paul II and Benedict XVI decided to continue the scientific research and discussion concerning BD between the representatives of various disciplines. Keywords: brain death, brain edema, global ischemic penumbra, therapeutic hypothermia, consciousness, person, substantial form. (shrink)

In a current clinical trial for Emergency Preservation and Resuscitation, Dr. Samuel Tisherman of the University of Maryland aims to induce therapeutic hypothermia in order to ‘buy time’ for operating on victims of severe exsanguination. While recent publicity has framed this controversial procedure as ‘killing a patient to save his life’, the US Army and Acute Care Research appear to support the study on the grounds that such patients already face low chances of survival. Given that enrollment in (...) the trial must be non-voluntary, the study has received an exemption from federal standards for obtaining informed consent. How exactly, if at all, is non-voluntary enrollment morally justifiable? In this essay, I appeal to the notable work of Hans Jonas in an effort to defend the EPR trial's use of non-voluntary enrollment. It is often thought and, as I show, it may appear that Jonas has called for the end of experimental medical practice. Still, I derive from Jonas a principle of double-effect upon which physicians may be seen as morally permitted to pursue innovations in emergency medicine but only as a byproduct of pursuing therapeutic success. With this position, I argue that the EPR trial can be granted a stronger philosophical justification than simply waiving the requirement of obtaining informed consent. The double-effect justification would obtain, perhaps regardless of the success of such innovative procedures as therapeutic hypothermia. (shrink)

In a current clinical trial for Emergency Preservation and Resuscitation, Dr. Samuel Tisherman of the University of Maryland aims to induce therapeutic hypothermia in order to ‘buy time’ for operating on victims of severe exsanguination. While recent publicity has framed this controversial procedure as ‘killing a patient to save his life’, the US Army and Acute Care Research appear to support the study on the grounds that such patients already face low chances of survival. Given that enrollment in (...) the trial must be non-voluntary, the study has received an exemption from federal standards for obtaining informed consent. How exactly, if at all, is non-voluntary enrollment morally justifiable? In this essay, I appeal to the notable work of Hans Jonas in an effort to defend the EPR trial's use of non-voluntary enrollment. It is often thought and, as I show, it may appear that Jonas has called for the end of experimental medical practice. Still, I derive from Jonas a principle of double-effect upon which physicians may be seen as morally permitted to pursue innovations in emergency medicine but only as a byproduct of pursuing therapeutic success. With this position, I argue that the EPR trial can be granted a stronger philosophical justification than simply waiving the requirement of obtaining informed consent. The double-effect justification would obtain, perhaps regardless of the success of such innovative procedures as therapeutic hypothermia. (shrink)

The practical aspect of ancient philosophy has been recently made a focus of renewed metaphilosophical investigation. After a brief presentation of three accounts of this kind developed by Martha Nussbaum, Pierre Hadot, and Michel Foucault, the model of the therapeutic argument developed by Nussbaum is called into question from the perspectives offered by her French colleagues, who emphasize spiritual exercise (Hadot) or the care of the self (Foucault). The ways in which the account of Nussbaum can be defended are (...) then discussed, including both a ‘negative’ defense, i.e. the indication of the weaknesses of Hadot and Foucault’s proposals, and a ‘positive’ one focused on the points in which Nussbaum can convincingly address doubts about her metaphilosophical account. In response to these analyses, some further remarks made by Hadot and Foucault are discussed in order to demonstrate that their accounts are not as distant from Nussbaum after all. Finally, a recent metaphilosophical study by John Sellars together with a therapeutic (medical) model developed by the author of the present article are suggested as providing a framework for potential reconciliation between all three accounts discussed and a resource for further metaphilosophical studies. (shrink)

We present a dynamic programming model which is used to investigate hypothermia as an adaptive response by small passerine birds in winter. The model predicts that there is a threshold function of reserves during the night, below which it is optimal to enter hypothermia, and above which it is optimal to rest. This threshold function decreases during the night, with a particularly sharp drop at the end of the night, representing the time and energy costs associated with returning (...) to normal body temperature. The results of the model emphasise the trade-off between energy and predation, not just between foraging options, but also between foraging during the day and entering hypothermia at night. The value of being able to use hypothermia represents not just energy savings, but also reduced predation risk due to changes in the optimal foraging strategy. Conditions which give a high value of hypothermia are short photoperiod, variable food supply, low temperatures, poor and scarce food supplies. (shrink)

This article utilizes recent Western approaches to the ethical inquiry into human activities of forgetting, especially the approach represented by Ricoeur’s work on memory and forgetting and their ethical functioning. The three areas of Ricoeur’s investigation includes the therapeutic/pathological area; pragmatic area, which deals with the issue of individual and group’s self-identity in relation to time and otherness; and the more explicitly ethical area. These three divisions are useful to start with, but Ricoeur’s work shows some narrowness in neglect (...) of positive, productive and healthy forgetting, which has been deemed significant by the Zhuangzi. This paper is the first of the author’s serial writings to apply Ricoeur’s three areas of forgetting to investigate the forgetfulness of the Zhuangzi, and examines therapeutic forgetting and its ethical dimension only. (shrink)

In their thought-provoking article, Sedlakova and Trachsel (2023) defend the view that the status—both epistemic and ethical—of Conversational Artificial Intelligence (CAI) used in psychotherapy is complicated. While therapeutic CAI seems to be more than a mere tool implementing particular therapeutic techniques, it falls short of being a “digital therapist.” One of the main arguments supporting the latter claim is that even though “the interaction with CAI happens in the course of conversation… the conversation is profoundly different from a (...) conversation with a human therapist” (Sedlakova and Trachsel 2023, 8). In particular, unlike a human therapist, CAI cannot help its users gain new insight and self-understanding (Sedlakova and Trachsel 2023). We agree that currently available therapeutic CAI cannot be considered a “digital therapist,” however, we think that the issue surrounding the acquisition of new self-understanding in the interaction with therapeutic CAI is more complicated than Sedlakova and Trachsel suggest. (shrink)

The doctrines of therapeutic nihilism and administrative nihilism are both based on the belief that the norms of activity are intrinsically linked to the structure of the body. Just as there is a vis medicatrix naturae in the individual organism, which renders any intervention of the therapist vain, there would be a vis medicatrix rei publicae in the social body, which makes the intervention of the legislator in economic life pointless and even dangerous. However, such a symmetry is not (...) quite as clear as it appears at first. It has also been upheld that the real parallel is not between therapeutic and administrative nihilism, but between therapeutic nihilism and statism. In this view, government is less comparable to a therapist than to the nervous system, and just as a well regulated organism is a one with an extensive nervous system, a well regulated society is one with a strong State.We intend to retrace the historical origin of these two schemas of correspondence, which has his roots in the celebrated controversy in the 1870’s between Herbert Spencer and Thomas Henry Huxley. We examine the causes of this apparent paradox, which sometimes views the doctrine of administrative nihilism, and sometimes the opposing doctrine of statism, as being the equivalent in politics of therapeutic nihilism in medicine. In our opinion, an important part of the explanation must be sought in the variations of the field of extension, which is implicitly given to the concept of vis medicatrix, or –as we now usually call this notion– that of Self-regulation. (shrink)

Abstract:Therapeutic misconception (TM)—when clinical research participants fail to adequately grasp the difference between participating in a clinical trial and receiving ordinary clinical care—has long been recognized as a significant problem in consent to clinical trials. We suggest that TM does not primarily reflect inadequate disclosure or participants’ incompetence. Instead, TM arises from divergent primary cognitive frames. The researchers’ frame places the clinical trial in the context of scientific designs for assessing intervention efficacy. In contrast, most participants have a cognitive (...) frame that is personal and focused primarily on their medical problems. To illustrate this, we draw on interview material from both clinical researchers and participants in clinical trials. We suggest that reducing TM requires encouraging subjects to adjust their frame, not just add information to their existing frame. What is necessary is ascientific reframingof participation in a clinical trial. (shrink)

Without taking a position on the overall justification of anti-doping regulations, I analyse the possible justification of Therapeutic Use Exemptions from such rules. TUEs are a creative way to prevent the unfair exclusion of athletes with a chronic condition, and they have the potential to be the least bad option. But they cannot be competitively neutral. Their justification must rest, instead, on the relevance of intentions to permissibility. I illustrate this by means of a set of thought experiments in (...) which only an athlete’s intentions vary. I argue that the Doctrine of Double Effect sheds some light on TUEs and illustrate this by applying different readings of the DDE to the thought experiment. This underpins a justification of anti-doping exemptions very different from the approach adopted by the World Anti-Doping Agency. I argue for three changes to bring TUEs in line with this understanding: rewriting of the regulations, transparency, and a greater role for athletes in determining what exemptions are allowed, and when. (shrink)

Therapeutic touch, a healing technique based upon the laying‐on of hands, has found wide acceptance in the nursing profession despite its lack of scientific plausibility. Its acceptance is indicative of a broad antiscientific trend in nursing. Adherents of this movement use the jargon of postmodern philosophy to justify their enthusiasm for a variety of mystically based techniques, citing such postmodern critics of science as Derrida and Michel Foucault as well as philosophical forerunners Heidegger and Husserl. Between 1997 and 1999, (...) 94 articles in nursing journals referred to postmodernism, according to a database search. This paper criticizes the postmodern movement for abandoning the biological underpinnings of nursing and for misreading philosophy in the service of an antiscientific world‐view. It is also suggested that nursing can retain its tradition of ‘caring’ without abandoning the scientific method. (shrink)

Although the therapeutic misconception (TM) has been well described over a period of approximately 20 years, there has been disagreement about its implications for informed consent to research. In this paper we review some of the history and debate over the ethical implications of TM but also bring a new perspective to those debates. Drawing upon our experience of working in the context of translational research for rare childhood diseases such as Duchenne muscular dystrophy, we consider the ethical and (...) legal implications of the TM for parental consent to research. In this situation, it is potentially the parent who is vulnerable to TM. In our analysis we not only consider the context of informed consent for research but also the wider environment in which the value of research is promoted, more broadly through the media but also more specifically through the communication strategies of patient organizations. All dissemination about developments in research for health runs the risk of portraying an overly optimistic view of the promise of biotechnological solutions and has the potential to encourage a ‘collective’ TM. In this paper we consider the challenge that TM presents to parents as well as explore the ethical and legal responsibilities of researchers to ensure an appropriately informed consent: compatible with a hopeful disposition of parents who consent for the their children whilst avoiding a blind and misleading optimism. (shrink)

The unexpected roles of the microbiota in cancer challenge explanations of carcinogenesis that focus on tumor-intrinsic properties. Most tumors contain bacteria and viruses, and the host’s proximal and distal microbiota influence both cancer incidence and therapeutic responsiveness. Continuing the history of cancer–microbe research, these findings raise a key question: to what extent is the microbiota relevant for clinical oncology? We approach this by critically evaluating three issues: how the microbiota provides a predictive biomarker of cancer growth and therapeutic (...) responsiveness, the microbiota’s causal role(s) in cancer development, and how therapeutic manipulations of the microbiota improve patient outcomes in cancer. Clarifying the conceptual and empirical aspects of the cancer-associated microbiota can orient future research and guide its implementation in clinical oncology. (shrink)

\noindent\textbf{Introduction} Online interventions hold great potential for Therapeutic Change Process Research (TCPR), a field that aims to relate in-therapeutic change processes to the outcomes of interventions. Online a client is treated essentially through the language their counsellor uses, therefore the verbal interaction contains many important ingredients that bring about change. TCPR faces two challenges: how to derive meaningful change processes from texts, and secondly, how to assess these complex, varied and multi-layered processes? We advocate the use text mining (...) and multi-level models (MLMs): the former offers tools and methods to discovers patterns in texts; the latter can analyse these change processes as outcomes that vary at multiple levels. \noindent\textbf{Method} We (re-)used the data from \cite{Lamers2015} because it includes outcomes and the complete online intervention for clients with mild depressive symptoms. We used text mining to obtain basic text-variables from e-mails, that we analysed through MLMs. \noindent\textbf{Results} We found that we could relate outcomes of interventions to variables containing text-information. We conclude that we can indeed bridge text mining and MLMs for TCPR as it was possible to relate text-information (obtained through text mining) to multi-levelled TCPR outcomes (using a MLM). \noindent\textbf{Discussion} Text mining can be helpful to obtain change processes, which is also the main challenge for TCPR. We showed how MLMs and text mining can be combined, but our proposition leaves open how to obtain the most relevant textual operationalization of TCPR concepts. That requires interdisciplinary collaboration and discussion. The future does look bright: based on our proof-of-concept study we conclude that MLMs and text mining can indeed advance TCPR. (shrink)

The theme of the philosopher as therapist dominates Nietzsche's entire opus, from his earliest writings to the Zarathustra period and beyond. Nietzsche wishes to hasten the coming and future sanctification of a new type of synthetic human being, and his entire teaching is shaped by his own struggles against illness.Yet few Nietzsche scholars have paid this crucial therapeutic element of his thought sufficient attention. This collection of essays by leading scholars in the field is composed around the Nietzschean insight, (...) which has its roots in the Hippocratic tradition of ancient medicine, that beliefs, behaviours, ideals and patterns of striving are not things for which individuals or even cultures are responsible. Rather, they are symptoms of what an individual or culture is, which symptoms require diagnostic interpretation and evaluation. The book identifies three principal approaches in Nietzsche's philosophy: diagnostic, prognostic and therapeutic. Each essay takes up this essential insight into Nietzsche's therapeutic philosophy from a different perspective and collectively they reveal an array of insightful approaches to self-induced enhancement, for both individuals and cultures. (shrink)

This paper develops and defends a new account of therapeutic trust, its nature and its constitutive norms. Central to the view advanced is a distinction between two kinds of therapeutic trust – default therapeutic trust and overriding therapeutic trust – each which derives from a distinct kind of trusting competence. The new view is shown to have advantages over extant accounts of therapeutic trust, and its relation to standard (non-therapeutic) trust, as defended by Hieronymi, (...) Frost-Arnold, and Jones. (shrink)

Clinical trials play a crucial role in generating evidence about healthcare interventions and improving outcomes for current and future patients. For individual trial participants, however, there are inevitably trade‐offs involved in clinical trial participation, given that trials have traditionally been designed to benefit future patient populations rather than to offer personalised care. Failure to understand the distinction between research and clinical care and the likelihood of benefit from participation in clinical trials has been termed the ‘therapeutic misconception’. The evolution (...) of the clinical trials landscape, including greater integration of clinical trials into healthcare and development of novel trial methodologies, may reinforce the significance of the therapeutic misconception and other forms of misunderstanding while at the same time (paradoxically) challenging its salience. Using cancer clinical trials as an exemplar, we describe how methodological changes in early‐ and late‐phase clinical trial designs, as well as changes in the design and delivery of healthcare, impact upon the therapeutic misconception. We suggest that this provides an impetus to re‐examine the ethics of clinical research, particularly in relation to trial access, participant selection, communication and consent, and role delineation. (shrink)

: "Therapeutic misconception" has been misconstrued, and some of the newer, mistaken interpretations are troublesome. They exaggerate the distinction between research and treatment, revealing problems in the foundations of research ethics and possibly weakening informed consent.

Recognizing and aligning individuals’ unique adaptive beliefs or “priors” through cooperative communication is critical to establishing a therapeutic relationship and alliance. Using active inference, we present an empirical integrative account of the biobehavioral mechanisms that underwrite therapeutic relationships. A significant mode of establishing cooperative alliances—and potential synchrony relationships—is through ostensive cues generated by repetitive coupling during dynamic touch. Established models speak to the unique role of affectionate touch in developing communication, interpersonal interactions, and a wide variety of (...) class='Hi'>therapeutic benefits for patients of all ages; both neurophysiologically and behaviorally. The purpose of this article is to argue for the importance of therapeutic touch in establishing a therapeutic alliance and, ultimately, synchrony between practitioner and patient. We briefly overview the importance and role of therapeutic alliance in prosocial and clinical interactions. We then discuss how cooperative communication and mental state alignment—in intentional communication—are accomplished using active inference. We argue that alignment through active inference facilitates synchrony and communication. The ensuing account is extended to include the role of tactile afferents in realizing the beneficial effect of therapeutic synchrony. We conclude by proposing a method for synchronizing the effects of touch using the concept of active inference. (shrink)

Conversational Artificial Intelligence (CAI) systems (also known as AI “chatbots”) are among the most promising examples of the use of technology in mental health care. With already millions of users worldwide, CAI is likely to change the landscape of psychological help. Most researchers agree that existing CAIs are not “digital therapists” and using them is not a substitute for psychotherapy delivered by a human. But if they are not therapists, what are they, and what role can they play in mental (...) health care? To answer these questions, we appeal to two well-established and widely discussed concepts: cognitive and affective artifacts. Cognitive artifacts are artificial devices contributing functionally to the performance of a cognitive task. Affective artifacts are objects which have the capacity to alter subjects’ affective state. We argue that therapeutic CAIs are a kind of cognitive-affective artifacts which contribute to positive therapeutic change by (i) simulating a (quasi-)therapeutic interaction, (ii) supporting the performance of cognitive tasks, and (iii) altering the affective condition of their users. This sheds new light on why virtually all existing mental health CAIs implement principles and techniques of Cognitive Behavioral Therapy — a therapeutic orientation according to which affective change and, ultimately, positive therapeutic change is mediated by cognitive change. Simultaneously, it allows us to conceptualize better the potential and limitations of applying these technologies in therapy. (shrink)

Psychotherapists and counsellors confront several ethical dilemmas as they tend to provide effective services. There has been much debate among psychotherapists and counsellors alike around the utility of therapeutic contracts. Some view contracts as being restrictive to the therapeutic process and often hindering the work done in sessions. In contrast, many counsellors and psychotherapists use those agreements to revisit specific therapeutic topics and establish the guidelines necessary for this professional arrangement. No matter the opinion or preference of (...) contracts, the development of written and/or verbal consent of specific topics in psychotherapy remains essential. This remains one of the formal features of the arrangement and starting relationship in current counselling and psychotherapy practice. This paper aims to discuss the necessity and ethical demand of therapeutic contract in counselling and psychotherapy practice. (shrink)

The current legal status and medical ethics of routine or religious penile circumcision of minors is a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative example, giving a detailed analysis of the most recent British Medical Association guidance from 2019. We argue that the guidance paints a confused and conflicting portrait of the law and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions surrounding child genital (...) cutting practices more generally. Of particular note is a lack of clarity around how to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision making regarding therapeutic options for a medically unwell patient—to a parental request for a medically unnecessary surgery to be carried out on the genitalia of a healthy child. Challenges arise in measuring and assigning weights to intended sociocultural or religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent safeguarding standards being applied to children based on their birth sex categorization or gender of rearing. We identify and discuss recent trends in British and international medical ethics and law, finding gradual movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy children's genitals before they can meaningfully participate in the decision. (shrink)

I argue that a variety of physical disabilities, and neurological and psychiatric disorders can be understood in terms of changes to the subject’s affordance space. Understanding disorders in this way also has some implications for therapy. On the basis of a phenomenological- and pragmatist-inspired enactivism I propose an affordance-based approach to therapy with a focus on changing physical, social, and cultural environments, and I consider the role of virtual and mixed realities in this context.

The British Parliament legalized therapeutic cloning in December 2000 despite opposition from the European Union. The watershed event in Parliament's move was the active and unprecedented government support for the generation and destruction of human embryonic life merely as a means of medical advancement. This article contends that the utilitarian analysis of this procedure is necessary to identify the real world risks of therapeutic cloning but insufficient to identify the breach of defensible ethical limits that this procedure represents. (...) A value-oriented approach to Kantian ethics demonstrates that the utilitarian endorsement of therapeutic cloning entails a contradiction of the necessity of human vulnerability and a faulty valuation of the human embryo. The concern is that a narrow utilitarian focus ultimately commodifies human embryonic life and preferences outcomes as the sole determinant of moral value. (shrink)

Dissecting Bioethics, edited by Tuija Takala and Matti Hayry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The department is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people’s actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are particularly appreciated. To submit a paper or to discuss (...) a suitable topic, contact Tuija Takala [email protected].:This article examines some of the assumptions and implications associated with the Belmont era context in which the concept of therapeutic misconception was forged. We argue that the justification of therapeutic misconception should be reconsidered based on less paternalistic and more participatory models of research. Finally, we identify conceptual and practical approaches that might better reflect contemporary research practice. (shrink)

_Therapeutic Approaches in Psychology_ is a simple introduction to the many psychological therapies in use today, including cognitive-behavioural, humanistic and psychodynamic approaches.

Ethical concerns about therapeutic misconception have been raised since the early 1980s. This concept was originally described as research participants' assumptions that decisions relating to research interventions are made on the basis of their individual therapeutic needs. The term has since been used to refer to a range of ‘misunderstandings’ that research participants may have. In this paper, we describe a new concept—therapeutic appropriation. Therapeutic appropriation occurs when patients, or clinicians, actively reframe research participation as an (...) opportunity to enhance patients' clinical care, while simultaneously acknowledging the generalised research aims. To illustrate the concept of therapeutic appropriation, we draw on data from an interview study which we conducted to investigate the experiences of patients and general practitioners involved in clinical trials in primary care. We argue that therapeutic appropriation has two key elements: comprehension that the research project is not necessarily aiming to benefit participants and the deliberate use of incidental features of the research for personal therapeutic benefit of various kinds. We conclude that therapeutic appropriation is a useful concept that refines understanding of potential ethical problems in clinical research, and points to strategies to address them. (shrink)

The therapeutic and integrative significance of faith in the African quest for healing and wholeness has attracted a considerable level of interest amongst scholars in recent times. Despite the increasing interest in places of healing, faith communities have not paid much attention to studying the intersection of these practices for appropriate community hermeneutics. By means of qualitative methods, this research explored the therapeutic implication of the role of faith in the quest and appropriation of health and wholeness in (...) modern Africa. Exploring perspectives from Ghana and Nigeria, the study engaged, through focus groups and individual interviews, the proper place of therapeutic significance of faith in the quest for healing and wholeness. Findings revealed that the African quest for health and wellness is anchored in the belief of a deity whose presence, love and benevolence transcend the ecclesiastical boundaries of one’s faith tradition. The study further describes the therapeutic and integrative significance of these prevailing faiths in God within the appropriation of health and wholeness in modern Africa, with the possibility of fostering a partnership amongst the three key players in the triangulation process.Contribution: The study falls within the field of practical theology and its major contribution falls within the quest of wellness and healing in Africa. (shrink)

Cloning Trevor, a story about therapeutic cloning research, appeared in the June issue of The Atlantic Monthly. The story gives a human face to the people whom therapeutic cloning could benefit. It presents an argument for government funding and it puts the usual calls for a moratorium on embryonic stem cell research to allow for more debate, in a less favourable light. The story also highlights some problems with ethical oversight.

ArgumentThis essay places some therapeutic vaccines, including particularly the diphtheria antitoxin, into their larger historical context of the late nineteenth century. As industrially produced drugs, these vaccines ought to be seen in connection with the structural changes in medicine and pharmacology at the time. Given the spread of industrial culture and technology into the field of medicine and pharmacology, therapeutic vaccines can be understood as boundary objects that required and facilitated communication between industrialists, medical researchers, public health officials, (...) and clinicians. It was in particular in relation to evaluation and testing for efficacy in animal models that these medicines became a model for twentieth-century medicine. In addition, these medicines came into being as a parallel invention in two very distinct local cultures of research: the Institut Pasteur in Paris and the Institut für Infektionskrankheiten in Berlin. While their local cultural origins were plainly visible, the medicines played an important role in the alignment of the methods and objects that took place in bacteriology research in France and Germany in the 1890s. This article assesses the two locally specific regimes for control in France and in Imperial Germany. In France the Institut Pasteur, building on earlier successful vaccines, enjoyed freedom from scrutinizing control. The tight and elaborate system of control that evolved in Imperial Germany is portrayed as being reliant on experiences that were drawn from the dramatic events that surrounded the launching of a first example of so-called “bacteriological medicine,” tuberculin, in 1890. (shrink)

In this essay I will discuss the therapeutic application of philosophy in treating what I term “the moral casualties of war.” In doing so, I will develop an etiology of moral injury and focus upon the philosophical reasoning and insights that may be applied in an individual or group setting to foster an understanding of the warexperience as the first treatment step in a long and complex journey to healing.

In this essay I will discuss the therapeutic application of philosophy in treating what I term “the moral casualties of war.” In doing so, I will develop an etiology of moral injury and focus upon the philosophical reasoning and insights that may be applied in an individual or group setting to foster an understanding of the warexperience as the first treatment step in a long and complex journey to healing.

The aim of this paper is to discuss monastic paideia in the context of providing shelter for ASD individuals in the High Middle Ages. Firstly, we will canvas the historical and conceptual shift from Ancient Greek paideitic ideas to their Christian counterparts. Then, by drawing on the recent literature in the history of medicine that traces the signs and symptoms of autism spectrum disorder (ASD) in Hildegard of Bingen, a German abbess in the 12th century, we will turn to her (...) invented language Lingua Ignota as a source of both her diagnosis and a manner of dealing with her disability. This, in turn, could be further advanced by identifying monasteries as therapeutic loci for neuroatypical individuals who had trouble finding their place within the arid and somewhat monochromatic medieval society. (shrink)

In this article I reply to Thomas Schramme's argument that there are no good reasons for the prohibition of severe forms of voluntary non‐therapeutic body modification. I argue that on paternalistic assumptions there is, in fact, a perfectly good reason.

The few people familiar with the pseudo-Platonic dialogue Axiochus generally have a low opinion of it. It's easy to see why: the dialogue is a mish-mash of Platonic, Epicurean and Cynic arguments against the fear of death, seemingly tossed together with no regard whatsoever for their consistency. As Furley notes, the Axiochus appears to be horribly confused. Whereas in the Apology Socrates argues that death is either annihilation or a relocation of the soul, and is a blessing either way, "the (...) Socrates of the Axiochus wants to have it both ways": death is both annihilation and a release of the soul from the body into a better realm. This may be used to construct a valid argument for the conclusion that death is not evil, but at the expense of having a contradiction as one of its premises. But D. S. Hutchinson has recently proposed that these inconsistencies shouldn't surprise us if we view the Axiochus as "an unconventional version of a very conventional genre--the consolation letter." In this paper I expand on Hutchinson's brief suggestion and argue that the Axiochus can be rehabilitated by paying attention to its genre. Although the Axiochus does display many similarities to the consolation letter, the shift from letter to dialogue does--pace Hutchinson--significantly affect what's going on. Within the dialogue, Socrates behaves toward Axiochus in a way similar to the way the author of a consolation letter behaves towards the letter's reader: he is willing to use inconsistent arguments, borrowed from any source, in order to soothe the patient. However, in depicting this type of consolatory relationship between Socrates and Axiochus, the dialogue itself is not aiming at consoling its readers. Instead, it should be seen as displaying for the reader's consideration a certain type of consolatory argumentative practice. -/- Socrates notes that Axiochus is "very much in need of consolation" (365a), and he uses any means necessary to accomplish this task. Socrates exhibits many ways in which he is willing to sacrifice argumentative hygiene for the sake of therapeutic effectiveness. These include: -/- * Use of arguments with inconsistent premises, presented in propria persona. * Appeals to emotion * Tailoring arguments to the audience. * Presenting invalid arguments so as to induce unjustified but comforting beliefs. * Evasion. In these respects, I think that Socrates' argumentative practice is best compared to PH III 280-1, where Sextus Empiricus says that the skeptic will deliberately use logically weak arguments as long as they work. Dorothy Tarrant claims that what links the Socrates of the Axiochus to Socrates as he appears elsewhere in the Platonic corpus is his evident care for the welfare of his interlocutor's psyche. But this concern takes a quite different form in the Axiochus than it usually does. As with Sextus, psychic therapy in the Axiochus involves relief from pain. The primary difference between them is that Socrates, unlike Sextus, is not aiming at producing epochê in his patient. (shrink)

Montaigne is widely appreciated as an important figure in the history of skepticism, but the precise nature of his skepticism remains unclear. While most treatments of Montaigne’s skepticism focus on the “Apology for Raymond Sebond,” there is reason to believe that the “Apology” does not contain his last word on the subject, and that—as many scholars have pointed out—whatever endorsement he gives there to ancient Pyrrhonism must be qualified in light of the fact that he does maintain beliefs, not only (...) about appearances, but also about reality itself. This essay argues that by the end of the Essais, Montaigne has developed a skepticism that is, as he would say, “all his own,” one that is best understood as a therapeutic practice meant to treat what Montaigne calls our “natural and original malady.”. (shrink)

Religious therapeutics is the term I use to designate relations between health and spirituality, and medicine and religion. Dimensions of religious therapeutics include religious meanings that inform medical theory, religious means of healing, health as part of religious life, and religion as a remedy for human suffering. Classical Yoga is analyzed to establish an initial matrix of religious therapeutics with 5 branches: philosophical foundations, soteriology, value theory, physical practice, and cultivation of consciousness. Through comparative criticism of classical Yoga, the study (...) presents a heuristic of religious therapeutics: a model for interpreting relations among healing and liberative functions in world religions. ;Body and health are of instrumental but not ultimate value in classical Yoga: the body is used to transcend itself for attainment of Yoga's soteriological goal, realization of self as pure consciousness. Yoga's Samkhya-based metaphysics contains an unreconciled dualism, and while practice of Yoga is paradigmatic of mind/body holism, Yoga prescribes realization of a spiritual self, independent of material and psychological nature. The study rehabilitates the body in respect of the compatibility of embodiedness with religiousness. ;Other Indian and world traditions suggest dimensions of religious therapeutics both resonant with classical Yoga and lacking from it. India's Ayurvedic medicine represents the sixth branch of religious therapeutics: medical therapeutics. I distill from Ayurvedic and Western sources a set of determinants of health: biological, medical/psychological, cultural, and metaphysical. Significant determinants of health are wholeness, self-identity, and freedom; these are incorporated in discussion of the complementary functions of medicine and religion, grounding the claim that in classical Yoga, liberation is healing in an ultimate sense. ;Tantric yogas utilize material nature for human spiritual progress, and unlike classical Yoga, esteem nature, body/mind, the feminine, and relationality. Tantra provides another branch of religious therapeutics: aesthetic therapeutics. The study anticipates elements of health/medicine in western religions, Buddhism, and Lakota religious philosophy. Sacred speech and song are explored to demonstrate comparative inquiry into religious therapeutics; some Native American Indian and Hindu applications of sacred language are considered. Finally, the model of religious therapeutics is supplemented with community, embracing ecological, social, and religious relationality and communication. (shrink)

En la actualidad, aún se desconoce el verdadero alcance de la vasta cultura de Lope de Vega, pues, aunque se sabe que fue un gran lector, que legó más de 1500 libros, sus títulos se han perdido a lo largo de la historia. No obstante, en sus obras trasciende una serie de textos que contribuyeron a su formación. En el presente trabajo se analiza La Arcadia, considerada la novela pastoril más erudita del Siglo de Oro, desde la perspectiva de los (...) agentes terapéuticos. En esta obra se mencionan remedios de procedencia herbal, de procedencia mineral y también de procedencia animal. Los resultados confirman que Lope de Vega pudo utilizar una serie de textos científicos en sus citas sobre la materia terapéutica. Entre ellos cabe destacar a Andrés Laguna y su Dioscórides y Plinio el Viejo, cuya Historia Natural pudo haber consultado como fuente primaria, a través de alguna traducción comentada, como la de Gerónimo de Huerta o a través de alguna otra obra basada en ella, como el opúsculo de Constantino Castriota, pues, en este último caso, se encuentran párrafos muy similares y, en algunos casos, casi literales. Nowadays, the true extent of the vast culture of Lope de Vega is still largely unknown. Although it is known that he was a great reader, who bequeathed more than 1500 books, his titles have been lost throughout history. However, a series of texts that contributed to his education become known in his works. In the present paper, La Arcadia, considered the most erudite pastoral romance of Spanish Golden Age, is analyzed from the therapeutic perspective. Remedies of herbal origin, of mineral origin and also of animal origin are mentioned in this novel. The results achieved confirm that Lope de Vega was able to use a series of scientific texts in his quotations on the therapeutic subject. Among them, it is worth mentioning Andres Laguna, and Pliny the Elder, whose Natural History could have been consulted as a primary source, through some commented translation, such as that of Geronimo de Huerta, or through some other work based on it, like Constantino Castriota's opuscule. In the latter case, there are very similar and, in some cases, almost literal paragraphs. (shrink)

The distinction between therapeutic and non-therapeutic research is a familiar one in research ethics. This chapter argues that the term “therapeutic research” is a misnomer. I consider two broad types of ostensibly therapeutic research: controlled trials, and innovative/experimental treatments. I argue that in the former case the term therapeutic research is a misnomer because no reasonable researcher can expect patients/subjects to derive any therapeutic advantage from being entered into an ethically conducted controlled trial. In (...) the latter case, while accepting that there may well be a reasonable expectation of therapeutic benefit from innovative treatments, I argue that the decision whether it is in the interests of a given patient to receive a given treatment is properly made on purely clinical grounds. There is no special feature of the research situation, in either of these types of case, which serves to ensure that participation, qua research subject, is in a patient’s interests. (shrink)