Nonadherence to treatment continues to be one of psychiatry's greatest challenges. To improve adherence and thus improve the care of patients, clinicians and patients' family members sometimes resort to hiding medication in food or drink, a practice referred to as covert/ surreptitious medication. The practice of covert drug administration in food and beverages is well known in the treatment of psychiatrically ill world-wide but no prevalence rates exist. Covert medication may seem like a minor matter, but it touches on (...) legal and ethical issues of a patient's competence, autonomy, and insight. Medicating patients without their knowledge is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of care giving. The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent. Ethically, covert/surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Covert medication contravenes contemporary ethical practice. Legally, treatment without consent is permissible only where common law or statute provides such authority. The practice of covert administration of medication is not specifically covered in the mental health legislation in developing countries. Many of the current dilemmas in this area have come to public attention because of two important developments in medical ethics and the law - the increasing importance accorded to respect for autonomy and loss of the parens patriae jurisdiction of the courts [parens patriae means 'parent of the country'; it permitted a court to consent or refuse treatment on behalf of an 'incapacity', or alternatively to appoint a guardian with such powers]. (shrink)

_Covert treatment raises a number of ethical and practical issues in psychiatry. Viewpoints differ from the standpoint of psychiatrists, caregivers, ethicists, lawyers, neighbours, human rights activists and patients. There is little systematic research data on its use but it is quite certain that there is relatively widespread use. The veil of secrecy around the procedure is due to fear of professional censure. Whenever there is a veil of secrecy around anything, which is aided and abetted by vociferous opposition from some (...) sections of society, the result is one of two: 1) either the activity goes underground or 2) it is reluctantly discarded, although most of those who used it earlier knew it was needed. Covert treatment has the dubious distinction of suffering both such secrecy and disapproval. Covert treatment has a number of advantages and disadvantages in psychotic disorders. The advantages are that it helps solve practical clinical problems; prevents delays in starting treatment, which is associated with clinical risks and substantial costs; prevents risk of self-destructive behaviour and/or physical assault by patient; prevents relapse; and prevents demoralization of staff. The disadvantages are that it maybe used with malafide intent by caregivers with or without the complicity of psychiatrists; it may be used to force conformity in dissenters; and the clinician may land himself in legal tangles even with its legitimate use. In addition, it may prevent insight, encourage denial, promote unhealthy practices in the treating staff and prevent understanding of why noncompliance occurs in the first place. Some support its use in dementia and learning disorders but oppose it in schizophrenia. The main reason is that uncooperative patients of schizophrenia (and related psychoses) are considered to be those who refuse treatment but retain capacity; while in dementia and severe learning disorder, uncooperative patients are those who lack capacity. This paper disputes this contention by arguing that although uncooperative patients of schizophrenia (and related psychoses) apparently retain capacity, it is limited, in fact distorted, since they lack insight. It presents the concept of insight-unconsciousness in a patient of psychosis. Just as an unconscious patient has to be given covert medical/surgical treatment, similarly an insight-unconscious patient with one of the different psychoses (in the acute phase or otherwise) may also have to be given covert treatment till he regains at least partial insight. It helps control psychotic symptoms and assists the patient in regaining enough insight to realize he needs treatment. Another argument against covert treatment is that people with schizophrenia have the capacity to learn and therefore can learn that they are required to take medications, but if medications are given covertly it may well fuel their paranoia. However, it should be noted that the patient who has lack of insight cannot learn unless he regains that insight, and he may need covert treatment to facilitate this process. Covert treatment can fuel the paranoia, true, but it can also control the psychotic symptoms sufficiently so that regular treatment can be initiated. In a patient who refuses to accept that he is sick and when involuntary commitment is not an option to be considered, covert treatment is the only option, apart from physical restraint. Ultimately, a choice has to be made between a larger beneficence (control of symptoms and start of therapy) and a smaller malevolence (necessary therapy, but without the patient's knowledge and consent). A number of practical clinical scenarios are outlined wherein the psychiatrist should adopt covert treatment in the best interests of the patient. Ethical issues of autonomy, power, secrecy and malafide intent arise; each of these can be countered only by non-malfeasance (above all, do no harm) under the overarch of beneficence (even above that, dare to care). An advance directive with health care proxy that sanctions covert treatment is presented. Questions raised by the practical clinical scenarios are then answered. The conclusions are as follows: covert treatment, i.e, temporary treatment without knowledge and consent, is seldom needed or justified. But, where needed, it remains an essential weapon in the psychiatrist's armamentarium: to be used cautiously but without guilt or fear of censure. However, the psychiatrist must use it very judiciously, in the rarest of rare cases, provided: i) he is firmly convinced that it is needed for the welfare of the patient; ii) it is the only option available to tide over a crisis; iii) continuing efforts are made to try and get the patient into regular psychiatric care; iv) the psychiatrist makes it clear that its use is only as a stop-gap; v) he is always alert to the chances of malevolence inherent in such a process and keeps away from conniving or associating with anything even remotely suspicious; and vi) he takes due precautions to ensure that he does not land into legal tangles later. The need of the hour is to explore in greater detail the need and justification for covert treatment, to lay out clear and firm parameters for its legitimate use, follow it up with standard literature and, finally, to establish clinical practice guidelines by unconflicted authors. The term "covert treatment" is preferable to "surreptitious prescribing"; they should not be used synonymously, the latter term being reserved for those cases where there is malafide intent._. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Rhetoric 35.4 (2002) 345-367 [Access article in PDF] Imagining in the Public Sphere Robert Asen Contemporary public sphere scholarship has been motivated significantly by a concern to overcome historical and conceptual exclusions in public spheres. Recent theory and criticism has investigated direct and indirect exclusions. Direct exclusions expressly prevent the participation of particular individuals and groups in public discussions and debates. Prohibitions against women speaking in public, (...) for example, have served historically to inhibit women's participation in various forums (see, e.g., Landes 1998). Indirect exclusions function tacitly through discursive norms and practices that prescribe particular ways of interacting in public forums. Indirect exclusions compel participants to conform to established modes of discourse that effectively negate the perspectives and contributions of previously directly excluded individuals and groups. Calls for "objective" and "dispassionate" debate, for instance, sometimes have restricted public agendas by portraying culturally specific forms of address as universally practiced (see, e.g., Warner 1993). Indirect exclusions may regulate discourse in various forums even when direct exclusions have been counteracted. Scholarship seeking to overcome these exclusions has proceeded on two levels. On one level, scholars have recounted the efforts of excluded persons to participate in public life despite restrictions by developing alternative modes of publicity (see, e.g., Ryan 1990; Zaeske 2002). On a second level, theorists have proposed more inclusive conceptual models of the public sphere that may overcome historical exclusions of the bourgeois public sphere while retaining a commitment to critical publicity (see, e.g., Asen 1999; Benhabib 1996; Hauser 1999; Mouffe 2000).Practicing democratic discourse fairly and justly depends indispensably on enabling inclusion. Proponents of deliberative democracy argue that political legitimacy arises from processes of inclusive public debate. Seyla Benhabib asserts that "legitimacy in complex societies must be [End Page 345] thought to result from the free and unconstrained public deliberation of all about matters of common concern" (1996, 68). Others regard inclusive public discourse as crucial for the formation of affirmative individual and collective identities. Craig Calhoun faults bourgeois notions of publicity for treating "identity formation as essentially private and prior to participation in the idealized public sphere of rational-critical discourse" (1993, 274). Identity formation entails mutual recognition among members of diverse cultures, yet theorists have observed that truncated discursive processes may inhibit mutual recognition. Charles Taylor writes that practicing a politics of recognition requires an openness toward other cultures—a presumption of value tested through sustained engagement so that "what we have formerly taken for granted as the background to valuation can be situated as one possibility alongside the background of the formerly unfamiliar culture" (1994, 67). Inclusiveness is also important for individuals and groups seeking to advance self-fashioned interpretations of their interests and needs against interpretations imposed by others. Nancy Fraser explains that self-fashioning is necessary because in public debates and controversies "who gets to establish authoritative thick definitions of people's needs is itself a political stake" (1989, 164).Although inclusion is indispensable, exclusion is never total. Sometimes, people force their way into public forums and agendas. For example, participation by activists in discussions of AIDS research and treatment often has been limited by researchers' assertions of expert privilege in investigating scientific matters. Valeria Fabj and Matthew J. Sobnosky (1995) detail how AIDS activists have responded by engaging in discursive acts of redefinition and translation to gain entry into previously circumscribed forums. At other times, people surreptitiously access public arenas. Prison writing is one way that those officially banished from public view nevertheless continue to participate in oppositional discourses and movements. Gerard A. Hauser (2001) considers how dissident Adam Michnik remained a vibrant voice in Polish civil society through his writings even after his imprisonment in the 1980s by an authoritarian regime. At still other times, typically excluded people may be invited to participate in public discussions. Members of the AIDS activist group ACT UP occasionally have testified in the traditional setting of the congressional committee hearing as invited witnesses. Daniel C. Brouwer (2001) maintains that politically sympathetic committee chairs facilitated ACT UP's "official" appearances before members of Congress. Whether invited or... (shrink)

In this commentary I argue that Byrne & Hilbert commit a number of philosophical solecisms: They beg the question of “realism,” they take the phenomenon and the theoretical model to be the same thing, and they surreptitiously substitute data sets for the life-world.

It is conventional wisdom among political philosophers that ideal principles of justice must guide our attempts to design institutions to avert actual injustice. Call this the ideal guidance approach. I argue that this view is misguided— ideal principles of justice are not appropriate "guiding principles" that actual institutions must aim to realize, even if only approximately. Fortunately, the conventional wisdom is also avoidable. In this paper, I develop an alternative approach to institutional design, which I call institutional failure analysis. The (...) basic intuition of this approach is that our moral assessment of institutional proposals is most effective when we proceed from a detailed understanding of the causal processes generating problematic social outcomes. Failure analysis takes the institutional primary design task to be obviating or averting institutional failures. Consequently, failure analysis enables theorists to prescribe more effective solutions to actual injustice because its focuses on understanding the injustice, rather than specifying an ideal of justice. (shrink)

Joshua Parker’s article on green inhaler prescribing is important and timely. I agree with much of it, specifically regarding the institutional duty to make climate-friendly changes (from environmentally expensive prescriptions to ‘greener,’ similarly effective ones). The challenge, however, comes in determining how that institutional obligation impacts the rights and duties of patients. In this commentary, I want to offer a friendly alternative to Parker’s view of individual patient obligation, which I suggest is important for reasons that go beyond this (...) one case. Parker’s broad view is that, because metered-dose inhalers (MDIs) emit far more greenhouse gases (GHG) than do dry powder inhalers (DPIs), and the two are equally effective for most patients, the healthcare system should switch most patients on MDIs to DPIs, and the patients have a pro tanto duty to accept this change.1 The problem is that no individual inhaler use causes harmful climate change, and so it is difficult to explain a duty not to use MDIs. It seems that my individual behaviour ‘makes no difference’ to climate change, so familiar more principles have a difficult time justifying a prohibition of such behaviour. Parker’s response to this worry fits into the consequentialist tradition,2 3 as he argues that each individual contribution to climate change causes some amount of ‘expected harm,’ because it contributes a little bit to future climate changes which will cause harm. And since we have a duty to minimise expected harm, we have a duty not to make such small contributions to climate change. I think we should be sceptical of this sort of argument. It makes the most sense if we endorse a bathtub metaphor, in which the atmosphere is like a bathtub, and once it is full, every …. (shrink)

Teachers are no longer simply being told what to teach, but also how to teach it. It is important therefore to examine whether some prescriptions of teaching methods are acceptable while others are not, and to justify opposition to certain forms of prescription. I show that some attempts to prescribe teaching methods are either empty, or incompatible with holding teachers to account for the pupil learning which is supposed to result. My argument does not depend on making any value assumptions (...) about ultimate educational aims. Examples from the National Literacy and Numeracy Strategies are discussed. (shrink)

In Good White People: The Problem with Middle-Class White Anti-Racism, Shannon Sullivan considers: "What can white people do to help end racial injustice?". As one response to this question, Sullivan argues that prescribing "white shame" and "white guilt" is useless, since promoting these ideas leads to self-hate and inaction on the part of white people. In this paper, I agree with Sullivan, but for different reasons. I argue that assuming that white people can feel ashamed simply about being white (...) within our current society is unfounded. I will maintain that the project of "promoting white shame" is fraught to begin with, and show the significance of this finding for conversations about white people's role in... (shrink)

Teachers are no longer simply being told what to teach, but also how to teach it. It is important therefore to examine whether some prescriptions of teaching methods are acceptable while others are not, and to justify opposition to certain forms of prescription. I show that some attempts to prescribe teaching methods are either empty, or incompatible with holding teachers to account for the pupil learning which is supposed to result. My argument does not depend on making any value assumptions (...) about ultimate educational aims. Examples from the National Literacy and Numeracy Strategies are discussed. (shrink)

The moral dimensions of undercover investigations by reporters are explored for their deception characteristics, using disclosures about a clinic in which doctors told women they were pregnant when they were not as an example. Three test questions are posed for the justifying of deceptive tactics in gathering information. In addition to undercover investigations, the morality of surreptitious taping is also discussed.

What is good prescribing? In this paper we will look at the kinds of criteria which are relevant to evaluating prescribing. In particular we wish to challenge, or at least re-frame, the picture of prescribing as an essentially technical process. In so doing we hope to indicate something more general about the power, and limitations, of technical rationality in health care, and to contribute something to work in health care technology assessment. Finally we hope this discussion will (...) act as a stimulus towards a much needed revision of the way ‘good’ prescribing is defined by current policies, guidelines and protocols. (shrink)

Kihlbom has recently argued that a system of seeking negatively informed consent might be preferable in some cases to the ubiquitous informed consent model. Although this theory is perhaps not powerful enough to supplant informed consent in most settings, it lends strength to Evans’ and Hungin’s proposal that it can be ethical to prescribe placebos rather than "active" drugs. This paper presents an argument for using negatively informed consent for the specific purpose of authorising the use of placebos in clinical (...) contexts. (shrink)

In many Western jurisdictions cannabis, unlike most other psychoactive drugs, cannot be prescribed to patients even in cases where medical professionals believe that it would ease the patient’s pain or anxiety. The reasons for this prohibition are mostly ideological, although medical and moral arguments have been formulated to support it. In this paper, it is argued that freedom, properly understood, provides a sound ethical reason to allow the use of cannabis in medicine. Scientific facts, appeals to harm and autonomy, and (...) considerations of symbolic value cannot consistently justify prohibitions. (shrink)

Legislation enabling pharmacists to prescribe is being drafted and passed in Canada and internationally. But is it a good idea for pharmacists to be prescribing psychotropic medications? In this discussion, the term “pharmacist prescribing” is dei ned, the issues of the potential conl ict of interest of pharmacists discussed, and the education and training of pharmacists reviewed. Finally, an experienced psychiatrist weighs in on the discussion with a personal rel ection on this important discussion, concluding that “we should (...) move forward cautiously but in a spirit of collaboration, mutual respect and above all in the best interests of the patient. (shrink)

Sildenafil citrate (Viagra) and other newly released pharmaceuticals that assist erectile dysfunction may be one of the most important categories of drugs released in the past decade. Sildenafil is distinctive because it creates a new therapeutic relationship not only between patient and physician, but also with sexual partner(s). Physicians must first evaluate the patient comprehensively, addressing not only erectile function and sexual performance, but overall physical and mental health. Since the drug does impact others, an expanded model for informed consent (...) needs to be considered. Three models to consider include the public health one, ethically justified limits on confidentiality, and a biopsychosocial one. The biopsychosocial model may be preferred because it expands the patient-physician dyad to directly include others. Physicians also need to distinguish between professional, role-related obligations and personal conscience when treating patients whose sexual beliefs and practices differ from their own. Other ethical issues include inappropriate prescribing over the Internet, dealing with unrealistic patient expectations, and fairness in paying for treatment for sexual conditions in both men and women. With these proposed guidelines, physicians can continue to provide steady, reliable guidance for patients while working with yet another scientific advance in medicine. (shrink)

The general aim of this work is to show the importance of the adressee's mind as planned by the author of a speech act or of a norm; in particular, how important are the expected motivations for goal adoption. We show that speech acts differ from one another for the different motivations the speaker is attempting to obtain from the hearer. The description of the participants' social positions is not sufficient. Important conflicts can arise which are not relative to what (...) to do, but to the different motives requested by the speaker. This view is applied to norms, pointing out that what is required by a norm is not only a behaviour but also a mental attitude, and that the prescribed mind might be even more important than the prescribed behaviour. Norms don't want just behavioural conformity, but also that this conformity implies an acknowledgement and a reinforcement of both the authority and the norm itself. Norms ask for submission. Any form of norm is aimed at influencing the addressee by changing his or her mind. (shrink)

The COVID-19 pandemic has exacerbated the drug poisoning epidemic in a number of ways: individuals use alone more often, there is decreased access to harm reduction services and there has been an increase in the toxicity of the unregulated drug supply. In response to the crisis, clinicians, policy makers and people who use drugs have been seeking ways to prevent the worst harms of unregulated opioid use. One prominent idea is safe supply. One form of safe supply enlists clinicians to (...) prescribe opioids so that people have access to drugs of known composition and strength. In this paper, we assess the ethical case for clinicians providing this service. As we describe, there is much that is unknown about safe supply. However, given the seriousness of the overdose death epidemic and the current limited evidence for safe supply’s efficacy, we argue that it is ethically permissible for clinicians to begin prescribing opioids for some select patients. (shrink)

Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians? experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold (...) nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging. [Supplementary materials are available for this article. Go to the publisher's online edition of American Journal of Bioethics for the following free supplemental resource(s): An additional table (Table 5) referred to on p. 5]. (shrink)

The National Health Service (NHS) was the first healthcare system globally to declare ambitions to become net carbon zero. To achieve this, a shift away from metered-dose inhalers which contain powerful greenhouse gases is necessary. Many patients can use dry powder inhalers which do not contain greenhouse gases and are equally effective at managing respiratory disease. This paper discusses the ethical issues that arise as the NHS attempts to mitigate climate change. Two ethical issues that pose a barrier to moving (...) away from metered-dose inhalers are considered: patients who decline an inhaler with a smaller carbon footprint and increased cost. I argue that while a patient is not morally justified in refusing a more environmentally sustainable inhaler due to the expected harms, a doctor may still prescribe a metered-dose inhaler if they believe that switching without consent might undermine trust or substantially worsen the patient’s health. Turning to cost, I argue that the imperative to combat climate change means the NHS should accept small increased financial costs for lower carbon inhalers, even though this provides no additional direct benefit for the patient. I then go on to consider the implications of the preceding analysis for policy and practice. I argue for a policy that minimises the impact of inhalers on the climate by advocating for a principle of environmental prescribing and explore decision-making in practice. While the arguments here pertain primarily to inhalers, the discussion has broader implications for debates around healthcare’s responsibility to be environmentally sustainable. (shrink)

Background While it is generally acknowledged that self-prescribing among physicians poses some risk, research finds such behaviour to be common and in certain cases accepted by the medical community. Largely absent from the literature is knowledge about other activities doctors perform for their own medical care or for the informal treatment of family and friends. This study examined the variety, frequency and association of behaviours doctors report providing informally. Informal care included prescriptions, as well as any other type of (...) personal medical treatment (eg, monitoring chronic or serious conditions). Method A survey was sent to 2500 randomly-selected physicians in Colorado, 600 individuals returned questionnaires with usable data. The authors hypothesised: (1) physicians would prescribe the same types of treatment at home as they prescribed professionally; and (2) physicians who informally prescribed addictive medications would be more likely to engage in other types of informal medical care. Results Physicians who wrote prescriptions for antibiotics, psychotropics and opioids at work were more likely to prescribe these medications at home. Those prescribing addictive drugs outside of the office treated more serious illnesses in emergency situations, more chronic conditions and more major medical/surgical conditions informally than did those not routinely prescribing addictive medications. Physicians reported a variety of informal care behaviour and high frequency of informal care to family and friends. Discussion The frequency and variety of informal care reported in this study strongly argues for profession-wide discussion about ethical and guideline considerations for such behaviour. These areas are discussed in the paper. (shrink)

Off-label prescribing is an integral part of contemporary medicine. Many patients benefit when they receive drugs or devices under circumstances not specified on the label approved by the Food and Drug Administration. An off-label use may provide the best available intervention for a patient, as well as the standard of care for a particular health problem. In oncology, pediatrics, geriatrics, obstetrics, and other practice areas, patient care could not proceed without off-label prescribing. When scientific and medical evidence justify (...) off-label uses, physicians promote patients’ interests by prescribing products off label.Off-label prescribing can also harm patients, however. The potential for harm is greatest when an offlabel use lacks a solid evidentiary basis. A 2006 study examining prescribing practices for 169 commonly prescribed drugs found high rates of off-label use with little or no scientific support. Researchers examining off-label use in U.S. children’s hospitals concluded, “[W]e still have incomplete knowledge about the safety and efficacy of many medications commonly used to treat children across a range of drug classes and clinical diagnoses.”. (shrink)

Name der Zeitschrift: Kant-Studien Jahrgang: 105 Heft: 4 Seiten: 491-508.

This article explores the friendship of Maurice Blanchot and Georges Bataille through a close reading of their thought on death and dying. An intellectual and personal friendship, both conceived of death as an “impossible” space and “limit-experience” that not only constituted human subjectivity, but could also puncture it, leading to joy through deindividuation. This could only occur indirectly – for Bataille, via the sacrifice, eroticism, drunkenness or laughter – and for Blanchot, via literature. This line of thinking leads to varying (...) formulations of sovereignty at odds with the prosaic world of use-value. Proceeding first through their friendship, this paper then explores this thinking death through the contexts of French Hegelianism, Kojève and Heidegger. While holding much similar, the paper argues that Bataille’s transgressive, embodied and deindividuating visions of death present a form of community that was overlooked by Blanchot subsequently, with consequences for theories of community and collective power today. (shrink)

The central contentions of this paper are two: first, that contextualism about knowledge cannot fulfil the eirenic promise which, for those who are drawn to it, constitutes, I believe, its main attraction; secondly, that the basic diagnosis of epistemological scepticism as somehow entrapping us, by diverting attention from a surreptitious shift to a special rarefied intellectual context, rests on inattention to the details of the principal sceptical paradoxes. These contentions are consistent with knowledge-contextualism, of some stripe or other, being (...) true. What follows will not bear directly on that. (shrink)

Under current U.S. law, physicians may prescribe drugs and devices in situations not covered on the label approved by the Food and Drug Administration. Those supporting this system say that requiring FDA approval for off-label uses would unnecessarily impede the delivery of benefits to patients. Patients do benefit from off-label prescribing that is supported by sound scientific and medical evidence. In the absence of such evidence, however, off-label prescribing can expose patients to risky and ineffective treatments. The medical (...) community and federal authorities should more actively promote patients' interests in receiving beneficial off-label treatments. To exercise responsible self-regulation, members of the medical community must determine whether available evidence justifies specific off-label uses and must promote information-gathering when the evidence is inadequate. Physicians should also discuss with patients the uncertainties accompanying off-label uses. Federal authorities should more closely monitor the effects of off-label prescribing and adopt other measures to reduce harm and enhance benefits produced by off-label prescribing. (shrink)

The recent renaissance in research on psychedelic-assisted psychotherapy is showing great promise for the treatment of many psychiatric conditions. Interestingly, therapeutic outcomes for patients undergoing these treatments are predicted by the occurrence of a mystical experience—an experience characterised in part by a sense of profound meaning. This has led to hypotheses that psychedelic-assisted psychotherapy is therapeutic because it enhances perception of meaning, and consequently leads to a meaning response. The putative mechanism of action of psychedelics as meaning enhancers raises normative (...) ethical questions as to whether it can be justified to pharmacologically increase the perception of meaning in order to heal patients. Using the perspectives of hedonistic moral theories, this paper argues that if psychedelics operate as meaning enhancers, psychedelic-assisted psychotherapy can be ethically justified. An anti-hedonistic objection is presented by applying Robert Nozick’s Experience Machine thought experiment to the case of psychedelic-assisted psychotherapy. However, it is argued that this objection falls short for two reasons. First, even if pleasure and pain are not the only consequences which have moral value they are not morally irrelevant, therefore, therapeutic meaning enhancement can still be justified in cases of extreme suffering. Second, it is possible that psychedelic states of consciousness do not represent a false reality, hence their therapeutic meaning enhancement is not problematic according to Nozick’s standards. (shrink)

Background: Physicians sometimes are asked by co-workers for prescriptions to deal with their medical problems. These “hallway” requests typically occur outside a formal doctor-patient relationship. There are professional guidelines on serving as physician for family members and friends, but no guidelines address writing prescriptions for co-workers. The frequency of these requests and the factors physicians consider in responding to them have not been examined.Objectives: To obtain data on the frequency of these requests and physicians’ attitudes and practices in responding to (...) them, and to explore the ethical considerations in writing prescriptions for co-workers.Design: A survey was administered to all physician faculty and residents in an academic department of internal medicine. The questions included whether the respondent had ever been asked for a prescription by a co-worker and how often the respondent had received such requests and written such prescriptions in the previous three months. Respondents also were asked to rate how likely they would be to write such a prescription in 15 hypothetical scenarios.Results: Of the 113 respondents who completed surveys, 68 percent reported having been asked for a prescription by a co-worker. Among those who had ever been asked, 59 percent had been asked one or more times during the previous three months and 88 percent had ever written such a prescription. Also, 88 percent of all respondents stated they were “very likely” or “likely” to write the prescription in one or more of the hypothetical scenarios.Conclusions: Most physicians in our sample had been asked for prescriptions by co-workers, and most had written such prescriptions. Many respondents indicated a willingness to write such prescriptions in a variety of scenarios, despite the absence of a formal doctor-patient relationship. Further discussion of the ethical considerations in writing prescriptions for co-workers is needed. (shrink)

Drawing upon concepts from actor-network theory (ANT), this article explores how the principle of symmetry can provide alternative readings of the translations of the prescribed into the enacted curriculum, without reducing understanding to explanation. The paper explores the contrasting ways in which the prescribed curriculum is translated into the enacted curriculum as certain organisations, individuals and artefacts become enrolled through networks of school and college. It points to the ways in which a position which eschews conventional distinctions e.g. between the (...) human and non-human, and enacts an anti-foundationalist ontology provides the basis for a radical materialist understanding of the multiplicity of educational practices. (shrink)

Drawing upon concepts from actor‐network theory (ANT), this article explores how the principle of symmetry can provide alternative readings of the translations of the prescribed into the enacted curriculum, without reducing understanding to explanation. The paper explores the contrasting ways in which the prescribed curriculum is translated into the enacted curriculum as certain organisations, individuals and artefacts become enrolled through networks of school and college. It points to the ways in which a position which eschews conventional distinctions e.g. between the (...) human and non‐human, and enacts an anti‐foundationalist ontology provides the basis for a radical materialist understanding of the multiplicity of educational practices. (shrink)

This chapter contains sections titled: Introduction Background to the Study Actor‐Network Theory The Prescribed Curriculum: An (In)visible Token? Inferences Acknowledgments References.

Patient noncompliance with physician prescriptions, especially in nonsymptomatic chronic diseases, is frequently characterized in the literature as harmful and economically costly (Miller 1997).1 Nancy Houston Miller views patient noncompliance as harmful because noncompliance can result in continued or new health problems leading to hospital admissions. Further, she places the annual monetary cost of noncompliance at $100 billion.Patient noncompliance with prescribed treatment is considered the least understood form of health behavior (Coons 2001). Despite the plethora of attention in journal articles, the (...) issue of noncompliance remains unresolved even in terms of understanding the main correlates to .. (shrink)

Minkoff et al. (2024) discuss the potential deprivation of medical liberties against pregnant persons following Dobbs v. Jackson Women’s Health. Another consideration is how Dobbs may impact physic...

In an accompanying feature article, Parker argued that general practitioners should support efforts by the National Health Service to reduce greenhouse gases by avoiding metered-dose inhalers and by prescribing similarly effective inhalers with smaller carbon footprints.1 He also argued that patients are not morally justified in declining to use dry powder inhalers which do not contain greenhouse gases and when judged to be readily available and similarly effective, unless, when patients resist that option, their trust in the professional relationship (...) is undermined.1 Prescribers should, therefore, take account of factors not only concerning the benefits and costs to individual patients including the strength of the professional relationship, but broader social considerations including potential effects on climate change and planetary health. In this commentary, I present three additional factors to broaden the context of Parker’s excellent analysis. The first is that a discussion with patients on the effects of various forms of inhalers on the environment may bring to their attention the seriousness of anthropogenic climate change and open opportunities …. (shrink)

In everyday interaction, people recurrently animate, enact, or report on talk or thought. In this article, enactments of hypothetical, non-narrative talk in advice-relevant sequences are examined, with a focus on their role in modeling desirable stance or conduct. Data consist of interactions in institutional settings, such as performance appraisal interviews, university teaching, and talk show counseling. It is demonstrated how enactments of possible talk are used as devices for hands-on demonstrations of proper or improper conduct in sequences involving orientations to (...) some kind of problematic behavior or stance, which in turn works to make assessments about different types of conduct. The accomplishment of contrasts between desired and undesired conduct is central, and contributes to the assessment of particular behaviors or stances. Different delivery formats of enactments are examined and compared to the action accomplished. It is argued that modeling talk enactments constitute resources for doing implicit criticism and ‘positive socialization’ in interaction, and that through enactments, participants may perform both explicit and implicit moral work. (shrink)

Kant claims that the understanding prescribes the existence and necessity of empirical laws to nature, while it does not prescribe which particular empirical laws hold. That is to say, the understanding prescribes the general form of nature and the form of the empirical laws without prescribing the material content. But how is this possible? How can the understanding guarantee that there are necessary empirical laws without prescribing particular empirical laws to nature? In this paper, I want to answer (...) this question by analyzing Kant’s argument for the Second Analogy of Experience in combination with an analysis of his conception of actuality. As I want to show, an application of Kant’s conception of actuality to the argument for the Second Analogy not only fills a gap in this argument, but also leads to an explanation of how the understanding can prescribe lawfulness to nature without prescribing particular laws. (shrink)

This article introduces questions in psychiatric ethics regarding the substantial field of qualitative and quantitative research into ‘posttraumatic growth’, which investigates how, after devastating experiences, individuals can come to feel that they have developed warmer relationships, increased spirituality, or a clearer vision of their priorities. In one area of this research, researchers of posttraumatic growth outline strategies for clinicians interested in assisting their patients in achieving such growth. In this article, I articulate two ethical concerns about this account of posttraumatic (...) growth and the practice of growth-oriented therapy. The first is a concern about the status and effects of the ideal of posttraumatic health implicit in their account, and the second a concern about the ethical implications of the clinical recommendations for the post-trauma patient. I argue for the need for more attention to the hazardous implications of relating to patients as though they are on their way to, and themselves largely in control of, their own posttraumatic growth. (shrink)