Pragmatism is a distinctive approach to clinical research ethics that can guide bioethicists and members of institutional review boards (IRBs) as they struggle to balance the competing values of promoting medical research and protecting human subjects participating in it. After defining our understanding of pragmatism in the setting of clinical research ethics, we show how a pragmatic approach can provide guidance not only for the day-to-day functioning of the IRB, but also for evaluation of policy standards, such as the one (...) that addresses acceptable risks for healthy children in clinical research trials. We also show how pragmatic considerations might influence the debate about the use of deception in clinical research. Finally, we show how a pragmatic approach, by regarding the promotion of human research and the protection of human subjects as equally important values, helps to break down the false dichotomy between science and ethics in clinical research. (shrink)

Explanatory models in psychiatry reflect what clinicians deem valuable in rendering people's behavior intelligible and thus help guide treatment choices for mental illnesses. This article outlines some key scientific and ethical principles of clinical explanation in twenty-first century psychiatry. Recent work in philosophy of science, clinical psychiatry, and psychiatric ethics are critically reviewed in order to elucidate conceptual underpinnings of contemporary explanatory models. Many explanatory models in psychiatry are reductionistic or eclectic. The former restrict options for diagnostic and therapeutic paradigm (...) choice, while the latter lack a well-defined theoretical basis. These two methodological approaches stand in a dialectical relation to one another insofar as clinicians often move from one approach to its antithesis, ultimately seeking a synthesis of the two approaches that satisfies clinical needs. Pragmatic considerations can help to transcend the reductionism/eclecticism dialectic. In the absence of a completed science of mental disorders, psychiatrists must tolerate ambiguity and uncertainty as they strive to integrate diverse explanatory concepts in a rigorous and evidence-based fashion. A pragmatic explanatory model in clinical psychiatry must focus on favorable treatment outcomes for patients by respecting the pluralistic, participatory, and provisional nature of psychiatric explanation. (shrink)

The rapid emergence and exploding usage of online social networking forums, which are frequented by millions, present clinicians with new ethical and professional challenges. Particularly among a younger generation of physicians and patients, the use of online social networking forums has become widespread. In this article, we discuss ethical challenges facing the patient–doctor relationship as a result of the growing use of online social networking forums. We draw upon one heavily used and highly trafficked forum, Facebook, to illustrate the elements (...) of these online environments and the ethical challenges peculiar to their novel form of exchange. Finally, we present guidelines for clinicians to negotiate responsibly and professionally their possible uses of these social forums. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Beyond EngelClinical Pragmatism as the Foundation of Psychiatric PracticeDavid H. Brendel (bio)Keywordsbiopsychosocial model, pluralism, pragmatism, psychiatryFor many years now, there has been growing recognition of the powerful role of pragmatic reasoning in numerous disciplines, including bioethics, medicine, law, political science, and philosophy (Dickstein 1998; Rosenthal, Hausman, and Anderson 1999). But until recently, philosophical pragmatism was neglected by scholars exploring the clinical challenges and theoretical underpinnings of psychiatry. In his (...) noteworthy article The Biopsychosocial Model and Philosophic Pragmatism: Is George Engel a Pragmatist?, Bradley Lewis offers a significant contribution to the small but gradually increasing literature in this area. Lewis appropriately presents Engel as a major figure in twentieth-century American medicine and psychiatry, a critic and a visionary who dared to question the dominant paradigm of biomedical reductionism (Engel 1977)—a paradigm that led to important scientific advances, but also restricted the physician’s understanding of the patient as a complex individual with an inner world and interpersonal relationships. Lewis argues that medicine and psychiatry a generation after Engel’s seminal 1977 paper can be revitalized by reinterpreting Engel in the intellectual tradition of classical American pragmatism and neo-pragmatism. Placing Engel in the pragmatic tradition, Lewis suggests, could enhance the biopsychosocial model and have substantial benefits for both individual patients and society as a whole.There is no disputing Lewis’s argument that a pragmatic philosophy of medicine and psychiatry is a noble goal. In fact, in my book Healing Psychiatry: Bridging the Science/Humanism Divide (Brendel 2006), I present philosophical pragmatism as the most compelling theoretical approach to clinical psychiatry in the twenty-first century—the approach that is most likely to empower the clinician and the patient to collaboratively develop a treatment plan that heeds the multidimensional complexity of the patient’s life, recognizes the confusion and uncertainty that grows out of this complexity, and aims for a favorable therapeutic outcome. Drawing on work of the classical American pragmatists and contemporary pragmatic bioethicists, I identify four dimensions of philosophical pragmatism that provide a sound foundation for clinical work, which I call the “four ps”: (1) diagnostic formulations and treatment plans in psychiatry are practical insofar as they focus on results rather than a commitment to any particular theory; (2) they are pluralistic [End Page 311] insofar as they incorporate explanatory concepts that span the biopsychosocial spectrum; (3) they are participatory and collaborative, not imposed authoritatively by the clinician; and (4) they are provisional, open-ended, and malleable to newly acquired information and evolution of the patient’s condition.Lewis casts Engel as a philosophical pragmatist who battled the Goliath of biomedical reductionism that had come to dominate American medicine and psychiatry in the latter half of the twentieth century. Unfortunately, however, regardless of how elegantly Lewis reinterprets Engel, he cannot render him a full-blown pragmatist for the medicine and psychiatry of the twenty-first century. Lewis provides quotations to suggest that Engel valued a results-oriented clinical sensibility, for example “the value of a scientific model is measured not by whether it is right or wrong but by how useful it is” (Engel 1980). But Engel was not fully committed to clinical outcome as the supreme judge of theory in medicine and psychiatry. Lewis notes that Engel understood the biopsychosocial model as less “a matter of compassion and humanity” and more a matter of “rigorous application of the principles and practices of science”; he was a man of his time who could not fully escape the scientism of the day. Working within this scientistic world, he distinguished himself by reintroducing psychological, sociological, and humanistic concepts into clinical medicine, which had become obsessed with the power and robustness of the natural sciences but had neglected the suffering human subject and the social context of illness. Engel undoubtedly hoped the biopsychosocial model would lead to better clinical results but, unlike the classical American pragmatists and contemporary pragmatic bioethicists, he did not make a systematic case for privileging clinical outcome above strict adherence to scientific theory.In fact, Engel’s biopsychosocial model runs the risk of becoming a reified end in itself; those who unquestioningly espouse its basic tenets are in danger of... (shrink)

Interactions between medicine and the pharmaceutical and device industries have become widespread in medicine. Despite their promise for improving patient care through innovation, there are ways in which these relationships may compromise patient care by creating conflicts of interest for physicians—both actual and perceived—that may result in delivery of poorly justified treatment, mistrust of doctors by the public, and an undermining of the integrity of the medical profession (IOM 2009). Conflicts of interest can arise in all arenas of medicine, due (...) to discord between the responsibility to patients and the opportunity for personal financial gain. But academic medicine presents an additional interest to protect: .. (shrink)

Relationships between patients and psychiatrists are shaped by a complex array of factors. The clinical experience centers on diagnostic and treatment decisions occurring in the context of a structured relationship that is regulated by principles of professional ethics and personal boundaries. At the same, however, patients and psychiatrists are unique and autonomous agents with emotional responses to one another that may evoke a wish for a personal friendship or other sorts of personal relationships that are outside the bounds of the (...) usual professionally defined structures. Negotiating the tension between the need for professional regulation and the desire for developing a friendship with certain patients can present clinical and ethical challenges in psychiatric practice. Pragmatist reasoning can help the psychiatrist and patient to successfully negotiate the dilemma that may arise when either or both of them wishes to develop a personal friendship but still adhere to the ethical tenets of the patient/psychiatrist professional dyad. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychophysical Causation and a Pragmatist Approach to Human BehaviorDavid H. Brendel (bio)Keywordsmind-body problem, philosophy, pragmatism, psychology, psychophysical causationJochen Fahrenberg and Marcus Cheetham have performed a valuable service by conducting and presenting an empirical study of some basic philosophical assumptions of psychologists, philosophers, and scientists. Well-designed, large-scale empirical studies of this kind are all too rare in the literature. Those of us interested in the human sciences are rather in (...) the dark about the assumptions of others working in our own and related fields. For the most part, we are privy only to the philosophical assumptions of friends and colleagues we know intimately and of those relative few who publish their views. We can only speculate about the views of the countless others with whom we have not had the opportunity to establish direct philosophical discourse. The findings presented by Fahrenberg and Cheetham give us an intriguing glimpse at some of the key philosophical assumptions of a variety of clinicians and academics who are interested in human nature and the human sciences.My aim in this commentary is to present an interpretation of a central finding of this questionnaire study: that psychologists were more likely than philosophers and scientists to embrace “psychophysical causation” as a part of their philosophical worldview. It is not, I think, too much of an oversimplification to define psychophysical causation as the presumption that mental events and physical events can cause other mental events and physical events. Psychophysical causation can be distinguished from other positions on the mind–body relation, some of which Fahrenberg and Cheetham mention in their article. Among these alternative positions is epiphenomenalism, the position that physical events cause other physical events and can cause mental events, but that mental events themselves have no causal power. Another philosophical position distinct from psychophysical causation is monism, which holds that all events in the world in general (and in human beings in particular) are physical and are best described in physical terms. Fahrenberg and Cheetham do not describe the multiple forms of monism in detail, but it is worth noting that reductive materialism (Wilson 1998) and eliminative materialism (Churchland 1981) are two highly developed forms of the kind of monism to which they allude. It is beyond the scope of this commentary to explore the differences between the two, but suffice it to say that both these forms of materialism reject the legitimacy of mental [End Page 205] events or the mental vocabulary that refers to such events.It is also beyond the scope of this commentary to advance arguments either for or against psychophysical causation in the philosophy of mind. The concept of psychophysical causation certainly has multiple proponents among philosophers, including those who are ontological monists. The compelling nonreductive materialism of a philosopher such as Terence Horgan, for example, suggests the viability of combining ontological monism with methodological pluralism. In a book chapter entitled “Nonreductive Materialism and the Explanatory Autonomy of Psychology,” Horgan (1993) developed the position that the world is entirely physical (i.e., there are no disembodied minds, persons, or other entities) but is so complex that it can only be understood and explained by employing many vocabularies and methodologies, spanning “the microphysical, neurobiological, macrobiological, and psychological.” This kind of methodological pluralism in the philosophy of mind can be disputed on conceptual grounds, but it seems to be at least as justifiable (and perhaps more justifiable) when compared with other well-defined positions on the mind–body relation.The appeal of nonreductive materialism and psychophysical causation comes into particularly clear focus in contexts where our philosophical concerns are pragmatic in nature. In other words, when we need to achieve practical goals in our everyday lives, we usually benefit from a philosophy that provides us with the flexibility to use a broad range of ideas, conceptual tools, and causal hypotheses that can be adapted to specific needs and challenges. Nonreductive materialism regards the world as a purely physical place, but ensures this kind of conceptual and methodological flexibility when it comes to explaining and predicting complex human experience and behavior. “Typically, certain context-relative features of discourse,” Horgan wrote (1993, 298), “will determine, in a given... (shrink)

A patient’s rights to informed consent and self-determination in psychiatric treatment are well enshrined, but the same rights have not yet been meaningfully extended to patients with regard to psychiatric diagnosis. Andrew Clark’s essay entitled “Psychiatric Diagnoses and Informed Consent” in The Journal of Clinical Ethics empowers both psychiatrists and patients to rethink who “owns” the process of clinical assessment and of bestowing diagnostic labels that may have far-reaching consequences. Clark’s article represents a noteworthy breakthrough in the field’s ongoing journey (...) toward enhancing informed consent, personal dignity, and patients’ active involvement in their own care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 53-55 [Access article in PDF] A Pragmatic Consideration of the Relation between Depression and Melancholia David H. Brendel THE MELANCHOLIA OF THE PAST and the major depression of the present are extraordinarily complex notions that represent different things to different people. With her compelling article "Is This Dame Melancholy? Equating Today's Depression and Past Melancholia," Jennifer Radden makes an important contribution to the (...) debate on whether these concepts are identical, overlapping, or distinct. Exploring both conditions from descriptive and causal points of view, Radden appropriately concludes that fully equating the two of them would constitute a "troubling oversimplification." Her line of reasoning runs as follows. Because past descriptions of melancholia and current descriptions of major depression are marked by dissimilarities (such as the genius and creativity associated with the former and the self-loathing and emphasis on loss associated with the latter), only an underlying causal base common to both conditions would justify our equating them. But the cause (or causes) of melancholia and depression remain mysterious. Thus, although Radden acknowledges that a causal explanation might yield substantial benefits ("research possibilities, further hypotheses, and even hope of prevention, or cure"), she suggests that we remain in a descriptive mode when comparing the two conditions and conclude that they are not one and the same.Radden's argument that past melancholia and contemporary depression are descriptively distinct is convincing and, I think, indisputable. But I would like to challenge and expand upon some of her ideas about considerations of causality and about the role of pragmatic reasoning in working out the relation between melancholia and depression. First of all, although Radden is correct that the cause of many (or perhaps most) depressive states is unknown, she underrates the extent of the empirical knowledge that we have acquired about the causation of depression and, in so doing, undervalues the relevance of causal reasoning to making the melancholia/depression distinction. Recent empirical research has revealed that major depressive episodes can result from brain lesions such as left-sided strokes or metabolic disorders such as hypothyroidism (Yudofsky and Hales 2002). Psychosocial research, moreover, has suggested that stressful life events also can be understood as causes of depression (Kendler, [End Page 53] Karkowski, and Prescott 1999). These findings provide some hope that the identification of causes of various clinical states is a real possibility. Identification of such causes, I believe, could empower us to make some plausible claims about the similarities or differences between past melancholia and current depression. A melancholic individual like van Gogh, for example, had a different illness than a contemporary stroke patient with major depression in a present-day hospital, not only on the basis of descriptive distinctions between their conditions, but also on the basis of the causes of their respective states. Although of course we cannot know the cause of van Gogh's melancholia, we can reasonably assume that it was not the result of a left-sided stroke due to the absence in his case of other clinical deficits that usually result from such a stroke (such as language and motor deficits). Plausible assertions about the causes of melancholic and depressive states would add to the robustness of any claims regarding the distinctness of the conditions.Conversely, careful consideration of the etiology of various clinical presentations might prompt us to hypothesize a shared pathophysiology and thereby lead us to believe that they are essentially identical conditions. It is difficult or impossible to discover a cause of melancholia in individuals who lived in past eras. But we might achieve our goal by comparing well-defined major depression to various forms of what Radden calls "masked depression," such as those seen in cross-cultural settings, where the subjective symptoms of sad mood are absent but numerous somatic signs of depression are observed. If it turned out that major depression and masked depression had the same cause, then differences in their clinical phenomenology would become merely surface differences that belie a shared etiological process. How might one discover the existence of such a process... (shrink)