In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further (...) questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

Ethical concerns have been raised about the quality of informed consent by participants in phase 1 oncology trials. Interview surveys indicate that substantial proportions of trial participants do not understand the purpose of these trials—evaluating toxicity and dosing for subsequent efficacy studies—and overestimate the prospect of therapeutic benefit that they offer. In this article we argue that although these data suggest the desirability of enhancing the process of information disclosure and assessment of comprehension of the implications of study participation, they (...) do not necessarily invalidate consent by phase 1 trial participants. (shrink)

: The "therapeutic misconception," described by Paul Appelbaum and colleagues more than 20 years ago, refers to the tendency of participants in clinical trials to confuse the design and conduct of research with personalized medical care. Although the "therapeutic misconception" has become a term of art in research ethics, little systematic attention has been devoted to the ethical significance of this phenomenon. This article examines critically the way in which Appelbaum and colleagues formulate what is at stake in the therapeutic (...) misconception, paying particular attention to assumptions and implications that clinical trial participation disadvantages research participants as compared with receiving standard medical care. After clarifying the ethical significance of the therapeutic misconception with respect to the decision making of patients, we offer policy recommendations for obtaining informed consent to participation in clinical trials. (shrink)

In two recent studies we have examined the prose rhythms in the clausulae of late imperial Latin authors. We found two clausular systems to be prevalent, the cursus and the cursus mixtus. The cursus involves the use of accentual rhythms and consists of three basic cadences: planus, tardus, and velox. The cursus mixtus has been defined by modern scholars as a type of prose rhythm in which the clausula is structured along both accentual and metrical lines, that is by the (...) combination of one of the three forms of the cursus with one of the standard metrical forms derived from Cicero's system — cretic-spondee, dicretic, cretic-tribrach, or ditrochee. (shrink)

Robert Nozick's adherence to Locke's puzzling doctrine about punishment can seem strange. Why does Nozick follow Locke in claiming that individuals in a state of nature have a right to punish any wrongdoer?Here reflection on this question proceeds by stages to a conclusion that Nozick as well as any other state-of-nature theorist of similar stripe should find disturbing. For, as we shall see, what Nozick describes as the general right of a minimal state to punish cannot arise within a state (...) of nature from the more plausible right of individuals to punish only those who harm them. (shrink)

We argue that cognitive empathy and other instances of mental state attribution are a byproduct of self-awareness. Evidence is brought to bear on this proposition from comparative psychology, early child development, neuropsychology, and abnormal behavior.

In several recent studies we have developed precise statistical methodologies which have demonstrated that the cursus mixtus was the dominant rhythmical system for final clausulae in Latin prose from the third century a.d. to the fifth. The cursus mixtus consisted of four standard metrical forms derived from the richer variety of Cicero's Asiatic tradition – cretic-spondee, dicretic, cretic-tribrach and ditrochee –, which were structured according to three accentual patterns – planus, tardus and velox. The latter are differentiated by the number (...) of unstressed syllables intervening between and following two accented syllables. The planus has two unaccented syllables between two word accents and one after the last accent. The tardus has two between two accents and two after the last accent. The velox has four between two accents and one after the last accent. The four metrical forms are contained within the parameters of the accentual cadences. The planus contains either the cretic-spondee or the ditrochee ; the tardus either the dicretic or the cretic-tribrach ; the velox either the ditrochee or the cretic-spondee (nimium videbatur. Authors who used the cursus mixtus, however, preferred to effect an exact coincidence between the accent and ictus, and as a result evinced primarily the following standard rhythmical forms: planus/cretic-spondee; tardus/dicretic or cretic-tribrach; and velox/ditrochee. So far now we have examined only the rhythmical properties of final clausulae, but it is appropriate also to investigate for rhythm at internal positions within the sentence. (shrink)

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict or (...) come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

We argued last year in this journal that extensive integration of research and care is a worthy goal of health system design, and we second the call from Ruth Faden and colleagues to move toward learning health care systems. As they recognize, learning health care systems demand the coordination of research and medical ethics—two sets of normative commitments that have long been considered distinct. In offering a novel ethics framework for such systems, Faden et al. advance the scholarly debate about (...) how best to do this and challenge us to think more deeply about its practical implications. However, we believe that at least three issues they raise require additional attention. First, the research‐care distinction has more normative bite than they are willing to concede. Second, the role for independent oversight requires clarification. Finally, they neglect the concept of stewardship as a guiding obligation of learning health care systems. (shrink)

We argued last year in this journal that extensive integration of research and care is a worthy goal of health system design, and we second the call from Ruth Faden and colleagues to move toward learning health care systems. As they recognize, learning health care systems demand the coordination of research and medical ethics—two sets of normative commitments that have long been considered distinct. In offering a novel ethics framework for such systems, Faden et al. advance the scholarly debate about (...) how best to do this and challenge us to think more deeply about its practical implications. However, we believe that at least three issues they raise require additional attention. First, the research‐care distinction has more normative bite than they are willing to concede. Second, the role for independent oversight requires clarification. Finally, they neglect the concept of stewardship as a guiding obligation of learning health care systems. (shrink)

This article focuses on mirror self-recognition, the ability to recognize one's own image in a mirror. It presents the result of the first experiment on mirror self-recognition which showed that chimpanzees are able to learn that the chimps they see in the mirror are not other chimps, but themselves, as evidenced by self-directed behaviour. It reviews evidence for neural network for self-recognition and self-other differentiation and cites evidence that frontal cortex and cortical midline structures are implicated in self-recognition tasks. It (...) also suggests that the mirror self-recognition ability correlates to large brain size relative to the animal's body size. (shrink)

How can we take history seriously as real and relevant? Despite the hazards of politically dangerous or misleading accounts of the past, we live our lives in a great network of cooperation with other actors; past, present, and future. We study and reflect on the past as a way of exercising a responsibility for shared action. In each of the chapters of Full History Smith poses a key question about history as a concern for conscious participants in the sharing of (...) action, starting with “What Is Historical Meaningfulness?” and ending with “How Can History Have an Aim?” Constructing new models of historical meaning while engaging critically with perspectives offered by Ranke, Dilthey, Rickert, Heidegger, Eliade, Sartre, Foucault, and Arendt, Smith develops a philosophical account of thinking about history that moves beyond postmodernist skepticism. Full History seeks to expand the cast of significant actors, establishing an inclusive version of the historical that recognizes large-scale cumulative actions but also encourages critical revision and expansion of any paradigm of shared action. (shrink)

To the French critics who originally labelled certain films noir it seemed that a class of Hollywood products had gone darker during the war years – as though a dark filter had been placed over the lens. Films were not designed or marketed as noir, and retrospectively noir's status as a genre is still unsettled. Yet there is widespread interest today in experiencing diverse films as noir, and even in using a Noir Filter in Instagram and video games. Pursuing the (...) filter clue, the noir experience can be thought of as subjection to a dark filtering of narrative. Image filtering styles can help to resolve not only the puzzle of noir's quasi-genre status but also an issue of general interest in aesthetic experience. The use of image filters makes a distinctively powerful contribution to the experience of a work or genre, or to the cultural dominance of an aesthetic regime, due to the unobtrusive formative role it plays in the economy of experience. (shrink)

: Originally presented during Ethic Rounds at the Dana-Farber Cancer Institute, this commentary on the case of a patient treated for life-threatening cancer explores the responsibilities of health care providers when addressing the patient's desire to adopt a child.

Explores the basic forms of responsibility that we willingly assume and the collaborative fulfillment that we find in each.

This book focuses on the political thought of American statesmen. These statesmen have had consistent and comprehensive views of the good of the country and their actions have been informed by those views. The editors argue that political life in America has been punctuated by three great crises in its history-the crisis of the Founding, the crisis of the House Divided, and the crisis of the Great Depression. The Second World War was a crisis not just for America but for (...) the whole of Western Civiliation and, in the wake of that war, a new crisis arose which came to be called the "Cold War." Just when that gave the appearance of being resolved, the world reached a new juncture, a new crisis, which Samuel P. Huntington dubbed the "clash of civiliations." The statesmen having political responsibility in confronting the first three crises in America's history came as close to philosophic grasp of the problems of liberal democracy as one could demand from those embroiled in the active resolution of events. Their reflection of political philosophy in the full sense informed their actions. Since we cannot confidently explain the future, Aristotle warned us to call no man happy while he still lives. Thus the book, in its third edition, keeps to its settled pattern of dealing with settled matters. The preface to the third edition confronts the three later crises and, to the extent consistent with truth, attempts to relate them to the first three. Morton J. Frisch was professor emeritus of political science at Northern Illinois University. He was the author or editor of several books, including Selected Writings and Speeches of Alexander Hamilton; Alexander Hamilton and the Political Order; and Franklin D. Roosevelt: The Contribution of the New Deal to American Political Thought and Practice. Richard G. Stevens retired from National Defense University as professor of political science in 1994. Since then he has taught as an adjunct professor of government at American University. He is co-editor with Matthew J. Franck of Sober as a Judge: The Supreme Court and Republican Liberty, and the author of The American Constitution and Its Provenance; Reason and History in Judicial Judgment: Felix Frankfurter and Due Process; and Political Philosophy: An Introduction. (shrink)

: Medical research is widely thought to have a fundamentally therapeutic orientation, in spite of the fact that clinical research is thought to be ethically distinct from medical care. We need an entirely new conception of clinical research ethics—one that looks to science instead of the doctor-patient relationship.

Past research has found that skin colouration, particularly facial redness, influences the perceived health and emotional state of target individuals. In the current work, we explore several extensions of this past research. In Experiment 1, we manipulated facial redness incrementally on neutral and angry faces and had participants rate each face for anger and health. Different red effects emerged, as perceived anger increased in a linear manner as facial redness increased. Health ratings instead showed a curvilinear trend, as both extreme (...) paleness and redness were rated as less healthy than moderate levels of red. Experiment 2 replicated and extended these findings by manipulating the masculinity of both angry and neutral faces that varied in redness. The results found the effect of red on perceived anger and health was moderated by masculine face structure. Collectively, these results show that facial redness has context dependent effects that vary based on facial expression, appearance, and differentially impact ratings of emotional states and health. (shrink)

Medical research is widely thought to have a fundamentally therapeutic orientation, in spite of the fact that clinical research is thought to be ethically distinct from medical care. We need an entirely new conception of clinical research ethics—one that looks to science instead of the doctor‐patient relationship.

In ancient times, when persuasion played the role of public force, eloquence was necessary. Of what use would it be today, when public force has replaced persuasion. One needs neither art nor metaphor to say such is my pleasure. Jean Jacques Rousseau.