Gilbert et al. argue that discussions of self-related changes in patients undergoing DBS are overblown. They show that there is little evidence that these changes occur frequently and make recommendations for further research. We point out that their framing of the issue, their methodology, and their recommendations do not attend to other important questions about these changes.
A number of reports have suggested that patients who undergo deep brain stimulation may experience changes to their personality or sense of self. These reports have attracted great philosophical interest. This paper surveys the philosophical literature on personal identity and DBS and draws on an emerging empirical literature on the experiences of patients who have undergone this therapy to argue that the existing philosophical discussion of DBS and personal identity frames the problem too narrowly. Much of the discussion by neuroethicists (...) centers on the nature of the threat posed by DBS, asking whether it is best understood as a threat to personal identity, autonomy, agency, or authenticity, or as putting patients at risk of self-estrangement. Our aim in this paper is to use the empirical literature on patients’ experiences post-DBS to open up a broader range of questions - both philosophical and practical, and to suggest that attention to these questions will help to provide better support to patients, both before and after treatment. (shrink)
Although researchers in psychiatry have been trying for decades to elucidate the pathophysiology underlying mental disorders, relatively little progress has been made. One explanation for this failure is that diagnostic categories in psychiatry are unlikely to track underlying neurological mechanisms. Because of this, the US National Institutes of Mental Health has recently developed a novel ontology to guide research in biological psychiatry: the Research Domain Criteria. In this paper, I argue that while RDoC may lead to better neuroscientific explanations for (...) mental disorders, it is unlikely that this new knowledge will then lead to an improved diagnostic system. I therefore suggest that researchers in psychiatry should work toward the development of two new ontologies: one for research and one for clinical practice. (shrink)
Feminist scholars have shown that research on sex/gender differences in the brain is often used to support gender stereotypes. Scientists use a variety of methodological and interpretive strategies to make their results consistent with these stereotypes. In this paper, I analyze functional magnetic resonance imaging (fMRI) research that examines differences between women and men in brain activity associated with emotion and show that these researchers go to great lengths to make their results consistent with the view that women are more (...) emotional than men. (shrink)
Neuroscience research examining sex/gender differences aims to explain behavioral differences between men and women in terms of differences in their brains. Historically, this research has used ad hoc methods and has been conducted explicitly in order to show that prevailing gender roles were dictated by biology. I examine contemporary fMRI research on sex/gender differences in emotion processing and argue that it, too, both uses problematic methods and, in doing so, reinforces gender stereotypes.
Evidence-based medicine (EBM) ranks different medical research methods on a hierarchy, at the top of which are randomized controlled trials (RCTs) and systematic reviews or meta-analyses of RCTs. Any study that does not randomly assign patients to a treatment or a control group is automatically placed at a lower level on the hierarchy. This article argues that what matters is whether the treatment and control groups are similar with respect to potential confounding factors, not whether they got that way through (...) randomization. Moreover, nonrandomized studies tend to have other characteristics that make them useful sources of evidence, in that they tend to last longer and to enroll more patients than do randomized trials. Replacing the sharp dichotomy between randomized and nonrandomized studies with a continuum from "clean" studies (which have high internal validity but whose results do not readily generalize to clinical practice) to pragmatic studies (which are designed to more closely reflect clinical practice) would also make a place for outcomes research and research using clinical databases, which are not included in the current hierarchy of evidence but which can provide important information about the safety and efficacy of treatments. (shrink)
Arguments in favor of greater research-practice integration in medicine have tended to be ethical, political, or pragmatic. There are good epistemic reasons to pursue greater integration, and it is important to think through these reasons in order to avoid inadvertently designing new systems in ways that replicate the epistemic elitism common within current systems. Meaningful transformation within health care is possible with close attention to all reasons in favor of greater research-practice integration, including epistemic reasons.
Robert Truog describes the controversial randomized controlled trials (RCTs) of extracorporeal membrane oxygenation (ECMO) therapy in newborns. Because early results with ECMO indicated that it might be a great advance, saving many lives, Truog argues that ECMO should not have been tested using RCTs, but that a long-term, large-scale observational study of actual clinical practice should have been conducted instead. Central to Truog’s argument, however, is the idea that ECMO is an unusual case. Thus, it is an open question whether (...) Truog’s conclusions can be extended to other areas of medical research. In this paper, I look at epistemological and ethical issues arising in the care of patients with chronic diseases, using ECMO as a starting point. Both the similarities and the dissimilarities of these two cases highlight important issues in biomedical research and support a conclusion similar to Truog’s. Observational studies of clinical practice provide the best evidence to inform the treatment of patients with chronic disease. (shrink)
The purpose of this chapter is to describe what we see as several important new directions for philosophy of medicine. This recent work (i) takes existing discussions in important and promising new directions, (ii) identifies areas that have not received sufficient and deserved attention to date, and/or (iii) brings together philosophy of medicine with other areas of philosophy (including bioethics, philosophy of psychiatry, and social epistemology). To this end, the next part focuses on what we call the “epistemological turn” in (...) recent work in the philosophy of medicine; the third part addresses new developments in medical research that raise interesting questions for philosophy of medicine; the fourth part is a discussion of philosophical issues within the practice of diagnosis; the fifth part focuses on the recent developments in psychiatric classification and scientific and ethical issues therein, and the final part focuses on the objectivity of medical research. (shrink)
Philosophy of medicine encompasses a broad range of methodological approaches and theoretical perspectives—from the uses of statistical reasoning and probability theory in epidemiology and evidence-based medicine to questions about how to recognize the uniqueness of individual patients in medical humanities, person-centered care, and values-based practice; and from debates about causal ontology to questions of how to cultivate epistemic and moral virtue in practice. Apart from being different ways of thinking about medical practices, do these different philosophical approaches have anything in (...) common? Are they committed to incompatible assumptions about the nature of science and its relationship to experience, value, and the art of medicine, or are different approaches nonetheless complementary? The chapter examines the questions these different approaches and perspectives raise and considers why so many theorists of medicine seek to find a “base” or “center” for medicine—as though there is, or should be, some general conceptual thread linking the things we call “usual clinical practice” in the real world. It further considers whether there are alternative approaches to the philosophy of medicine, which do not embody this philosophical assumption; and it suggests that a key tool for evaluating approaches must be their ability to contribute something of genuine value to clinical medicine. (shrink)
It seems clear that being sick makes people vulnerable. Not only can even relatively mild, transient illnesses such as colds or flus serve as an unpleasant reminder of the vulnerability of the usual state of health that many of us are fortunate enough to enjoy, but more serious, chronic conditions can force individuals to adapt—or even abandon—life plans or projects, and can also alter their self-conception. Yet philosophical theories of health and disease do not discuss vulnerability, nor does it have (...) a central place in bioethics.1 Bioethicists need to better understand vulnerability, as it has implications for key issues in the field, such as the nature of the relationship between patients and healthcare .. (shrink)
Joshua Greene and his colleagues have proposed a dual-process theory of moral decision-making to account for the effects of emotional responses on our judgments about moral dilemmas that ask us to contemplate causing direct personal harm. Early formulations of the theory contrast emotional and cognitive decision-making, saying that each is the product of a separable neural system. Later formulations emphasize that emotions are also involved in cognitive processing. I argue that, given the acknowledgement that emotions inform cognitive decision-making, a single-process (...) theory can explain all of the data that have been cited as evidence for Greene’s theory. The emotional response to the thought of causing harm may differ in degree, but not in kind, from other emotions influencing moral decision-making. (shrink)
Feminist bioethics is committed to recognizing the way that power differentials arising from differences in social location shape health and health care, and also to ensuring that women's experiences inform bioethical analyses (Sherwin 1992, 1998; Scully et al. 2010). Yet there may be a tension between these two points of emphasis, not because they are incompatible but because they require very different perspectives. In this article, I argue that feminist analyses of the relationship between gender and mental disorder have tended (...) to emphasize the effects of women's relative lack of social power, with the result that women who experience mental disorders tend to be viewed as passive victims of oppression. I then .. (shrink)
Timothy Brown invites us to think about the ways in which people who are being treated with deep brain stimulation might come to interact with their devices. He suggests that a framework of relational agency can help us to understand both the benefits and the challenges of DBS because DBS systems are, while not full fellow agents, more than mere props; users must sometimes "negotiate and collaborate with their stimulators". We agree that it is important to develop conceptual frameworks that (...) both do justice to the ways that individuals respond to using DBS and give them new ways to think about the device, their relationship to it, and its role in their lives. In this commentary, we consider three... (shrink)
Feminist Bioethics: At the Center, on the Margins is a collection of essays that “reflect on the positioning of feminist bioethics” (xi). The volume editors suggest that the discipline of feminist bioethics, twenty years after it began, faces tension between becoming incorporated into mainstream bioethics, which would mean that it has greater influence on bioethics as a whole, and remaining “on the margins,” where it can perhaps better continue its critical project of drawing attention to the ways in which “dominant (...) ways of doing bioethics” are gendered and “thus contribute to culturally inscribed oppressive practices” (3). The volume includes papers with diverse theoretical and methodological approaches and .. (shrink)
The first volume in the rapidly growing field of philosophy of medicine to focus on the relationship between knowledge and clinical practice and policy.
This book explores the central questions and themes lying at the heart of a vibrant area of philosophical inquiry. Aligning core issues in psychiatry with traditional philosophical areas, it presents a focused overview of the historical and contemporary problems dominating the philosophy of psychiatry. -/- Beginning with an introduction to research issues, it addresses what psychiatry is and distinguishes it from other areas of medical practice, other health care professions and psychology. With each section of the companion corresponding to a (...) philosophical subject, contributors systematically relate themes in philosophy of psychiatry to topics in philosophy of mind, phenomenology, philosophy of science, ethics, social and political philosophy, metaphysics, epistemology, and philosophy of medicine. Looking ahead to new research directions, chapters address recent issues including the metaphysics of mental disorders, gender and race in psychiatry and psychiatric ethics. -/- Featuring discussion questions, suggestions for further reading and an annotated bibliography, The Bloomsbury Companion to Philosophy of Psychiatry is an accessible survey of the debates and developments in the field suitable for undergraduates in philosophy and professional philosophers new to philosophy of psychiatry. (shrink)
