Responding to reports of cases of personality change following deep brain stimulation, neuroethic... more Responding to reports of cases of personality change following deep brain stimulation, neuroethicists have debated the nature and ethical implications of these changes. Recently, this literature has been challenged as being overblown and therefore potentially an impediment to patients accessing needed treatment. We interviewed 16 psychiatrists, 16 patients with depression, and 16 members of the public without depression, all from the Midwestern United States, about their views on how three electroceutical interventions (deep brain stimulation, electroconvulsive therapy, and transcranial magnetic stimulation) used to treat depression might affect the self. Participants were also asked to compare the electroceuticals’ effects on the self with the effects of commonly used depression treatments (psychotherapy and pharmaceuticals). Using qualitative content analysis, we found that participants’ views on electroceuticals’ potential effects on the self mainly focused on treatment effective...
A number of reports have suggested that patients who undergo deep brain stimulation (DBS) may exp... more A number of reports have suggested that patients who undergo deep brain stimulation (DBS) 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.
Lawrence et al. (2019) conducted a qualitative study examining the beliefs of patients with treat... more Lawrence et al. (2019) conducted a qualitative study examining the beliefs of patients with treatment-resistant depression about deep brain stimulation (DBS). There have been only a small number of studies looking at patients’ perceptions of DBS for depression. One of the first (Leykin et al. 2011) examines the perceptions around risk, potential benefits, and therapeutic misconception of 31 participants considering DBS for major depression in two different clinical sites. They found that participants perceived the surgery itself as the riskiest study procedure, demonstrating reasonable perceptions of risks and benefits. Participants also recognized that DBS for depression was experimental, yet the authors also found evidence of therapeutic misconception, with participants incorrectly assessing the likelihood of personal benefit, the study’s purpose, and individualization of treatment. A more recent study by Klein and colleagues (Klein et al. 2016) examined perspectives of participants who have undergone DBS for depression or obsessive-compulsive disorder, with the goal of better understanding ethical challenges that might arise with the use of next-generation DBS. Among the four major themes found by this group were relationship effects, which have to do with the impact of DBS on relationships, and meaningful consent, which had to do with effective communication of complex information, framing of realistic expectations, and attention to cognitive and affective impairments. Lawrence and colleagues found that their participants were thoughtful and cautious about DBS for depression, with most showing minimal interest in the procedure. They also identify a number of concerns expressed by patients regarding efficacy and adverse effects, including possibly being worse off after the procedure. Their participants also voice concerns that their depression interfered with their ability to weigh the risks and benefits. Given the few studies examining patients’ beliefs about DBS for psychiatric, the study by Lawrence and colleagues is a needed addition; however, there are two points we find important to consider relevant to this study. The first one is connected to methodological issues; the second concerns suggestions as to how looking at public perceptions
OBJECTIVE The research required to establish that psychiatric treatments are effective often depe... more OBJECTIVE The research required to establish that psychiatric treatments are effective often depends on collaboration between academic clinical researchers and industry. Some of the goals of clinical practice and those of commercial developers of psychiatric therapies overlap, such as developing safe and effective treatments. However, there might also be incompatible goals; physicians aim to provide the best care they can to their patients, whereas the medical industry ultimately aims to develop therapies that are commercially successful. In some cases, however, clinical research may be aiming both at improved patient care and commercial success. It is in these cases that a conflict of interest (COI) arises. The goal of this study was to identify differences and commonalities regarding COIs between 2 kinds of somatic psychiatric interventions: pharmacological and neurosurgical. METHODS The authors conducted a study focused on professional concerns regarding pharmacological and neuro...
The Journal of medicine and philosophy, Jan 9, 2018
Arguments in favor of greater research-practice integration in medicine have tended to be ethical... more 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.
When the editorial to the first philosophy thematic edition of this journal was published in 2010... more When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human ...
Despite its potential hazards, the activity of questioning theoretical frameworks and proposing s... more Despite its potential hazards, the activity of questioning theoretical frameworks and proposing solutions is necessary if progress is even to be possible. Intellectual history has by no means ended, so we cannot expect to have all the answers, and from time to time the activity of critical questioning will be frustrating. But intellectual progress requires us to continue the process of asking fundamental questions. The alternative to thinking in this way is indeed unthinkable.
Background-Neuroimaging studies report that individuals with posttraumatic stress disorder show a... more Background-Neuroimaging studies report that individuals with posttraumatic stress disorder show abnormal responses in the amygdala and medial prefrontal cortex (mPFC)/anterior cingulate cortex (ACC) during exposure to traumatic reminders. However, neural responses arising in the early aftermath of a traumatic event have not been studied. Methods-Twenty-two motor vehicle-collision survivors and 12 non-traumatized controls participated. Regional cerebral blood flow (rCBF) was measured using [ 15 O]-H 2 O PET at rest and as subjects listened to scripts of traumatic and neutral events. Self-report measures rated emotional responses to the scripts; standardized assessments (Impact of Events-Revised) evaluated acute stress symptoms at scanning and at 3-month follow-up. Most subjects improved symptomatically. Results-At rest, trauma subjects showed hyperperfusion in right mPFC/ACC and hypoperfusion in right amygdala compared with controls. In trauma subjects, listening to trauma-scripts versus neutral-scripts resulted in decreased flow in the right amygdala and left amygdala/perirhinal cortex, and symptom scores correlated negatively with right hippocampal flow changes. Symptom improvement at 3 months correlated negatively with rCBF changes in right perirhinal cortex and hippocampus during the trauma versus neutral script contrast. Subjective disturbance during the trauma versus neutral contrast correlated positively with rCBF changes in right amygdala and left mPFC. Functional connectivity analyses of rCBF changes during trauma versus neutral scripts demonstrated left amygdala coupling with right ACC and bilateral anterior insula, and coupling between the amygdala and contralateral hippocampus. Conclusions-In recently traumatized subjects functional interactions between the amygdala, perirhinal cortex and ACC/mPFC that occur during exposure to traumatic reminders may underlie adaptive/recuperative processes.
The suggestion that at least some emotions are modular captures a number of our intuitions about ... more The suggestion that at least some emotions are modular captures a number of our intuitions about emotions: they are generally fast responses to a stimulus, they are involuntary, and they are easily distinguished (at least in most cases) from one another; we simply know that, for example, anger feels different than fear. Candidates for modular emotions are usually the so-called “basic” emotions - anger and fear are good examples of these. Defenders of emotion theories that focus on basic emotions, such as Paul Ekman in psychology and Paul Griffiths in philosophy, emphasize the advantages of theories that stress the evolutionary continuity of emotional expression and link emotions to the activity of neural circuits that are similar in human beings and other animals.In this paper, however, I will examine arguments for the discontinuity of emotions in human beings, as compared with other animals. Owing to a combination of cultural practices and neuroanatomy, both our emotional “wiring” ...
Evidence-based medicine (EBM) ranks different medical research methods on a hierarchy, at the top... more 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...
International Journal of Feminist Approaches to Bioethics, 2011
Jackie Leach Scully, Laurel E. Baldwin-Ragaven, and Petya Fitzpatrick, Feminist Bioethics: At the... more Jackie Leach Scully, Laurel E. Baldwin-Ragaven, and Petya Fitzpatrick, Feminist Bioethics: At the Center, on the Margins, Baltimore: The Johns Hopkins University Press, 2010, reviewed by Robyn Bluhm
Page 1. neurofeminism issues at the intersection of Feminist theory and cognitive science edited ... more Page 1. neurofeminism issues at the intersection of Feminist theory and cognitive science edited by robyn b|uhm, anneioopiacobson and heidi lene moibom New Directions in Philosophy and Cognitive Science JQ #1 it Page 2. ...
Responding to reports of cases of personality change following deep brain stimulation, neuroethic... more Responding to reports of cases of personality change following deep brain stimulation, neuroethicists have debated the nature and ethical implications of these changes. Recently, this literature has been challenged as being overblown and therefore potentially an impediment to patients accessing needed treatment. We interviewed 16 psychiatrists, 16 patients with depression, and 16 members of the public without depression, all from the Midwestern United States, about their views on how three electroceutical interventions (deep brain stimulation, electroconvulsive therapy, and transcranial magnetic stimulation) used to treat depression might affect the self. Participants were also asked to compare the electroceuticals’ effects on the self with the effects of commonly used depression treatments (psychotherapy and pharmaceuticals). Using qualitative content analysis, we found that participants’ views on electroceuticals’ potential effects on the self mainly focused on treatment effective...
A number of reports have suggested that patients who undergo deep brain stimulation (DBS) may exp... more A number of reports have suggested that patients who undergo deep brain stimulation (DBS) 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.
Lawrence et al. (2019) conducted a qualitative study examining the beliefs of patients with treat... more Lawrence et al. (2019) conducted a qualitative study examining the beliefs of patients with treatment-resistant depression about deep brain stimulation (DBS). There have been only a small number of studies looking at patients’ perceptions of DBS for depression. One of the first (Leykin et al. 2011) examines the perceptions around risk, potential benefits, and therapeutic misconception of 31 participants considering DBS for major depression in two different clinical sites. They found that participants perceived the surgery itself as the riskiest study procedure, demonstrating reasonable perceptions of risks and benefits. Participants also recognized that DBS for depression was experimental, yet the authors also found evidence of therapeutic misconception, with participants incorrectly assessing the likelihood of personal benefit, the study’s purpose, and individualization of treatment. A more recent study by Klein and colleagues (Klein et al. 2016) examined perspectives of participants who have undergone DBS for depression or obsessive-compulsive disorder, with the goal of better understanding ethical challenges that might arise with the use of next-generation DBS. Among the four major themes found by this group were relationship effects, which have to do with the impact of DBS on relationships, and meaningful consent, which had to do with effective communication of complex information, framing of realistic expectations, and attention to cognitive and affective impairments. Lawrence and colleagues found that their participants were thoughtful and cautious about DBS for depression, with most showing minimal interest in the procedure. They also identify a number of concerns expressed by patients regarding efficacy and adverse effects, including possibly being worse off after the procedure. Their participants also voice concerns that their depression interfered with their ability to weigh the risks and benefits. Given the few studies examining patients’ beliefs about DBS for psychiatric, the study by Lawrence and colleagues is a needed addition; however, there are two points we find important to consider relevant to this study. The first one is connected to methodological issues; the second concerns suggestions as to how looking at public perceptions
OBJECTIVE The research required to establish that psychiatric treatments are effective often depe... more OBJECTIVE The research required to establish that psychiatric treatments are effective often depends on collaboration between academic clinical researchers and industry. Some of the goals of clinical practice and those of commercial developers of psychiatric therapies overlap, such as developing safe and effective treatments. However, there might also be incompatible goals; physicians aim to provide the best care they can to their patients, whereas the medical industry ultimately aims to develop therapies that are commercially successful. In some cases, however, clinical research may be aiming both at improved patient care and commercial success. It is in these cases that a conflict of interest (COI) arises. The goal of this study was to identify differences and commonalities regarding COIs between 2 kinds of somatic psychiatric interventions: pharmacological and neurosurgical. METHODS The authors conducted a study focused on professional concerns regarding pharmacological and neuro...
The Journal of medicine and philosophy, Jan 9, 2018
Arguments in favor of greater research-practice integration in medicine have tended to be ethical... more 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.
When the editorial to the first philosophy thematic edition of this journal was published in 2010... more When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human ...
Despite its potential hazards, the activity of questioning theoretical frameworks and proposing s... more Despite its potential hazards, the activity of questioning theoretical frameworks and proposing solutions is necessary if progress is even to be possible. Intellectual history has by no means ended, so we cannot expect to have all the answers, and from time to time the activity of critical questioning will be frustrating. But intellectual progress requires us to continue the process of asking fundamental questions. The alternative to thinking in this way is indeed unthinkable.
Background-Neuroimaging studies report that individuals with posttraumatic stress disorder show a... more Background-Neuroimaging studies report that individuals with posttraumatic stress disorder show abnormal responses in the amygdala and medial prefrontal cortex (mPFC)/anterior cingulate cortex (ACC) during exposure to traumatic reminders. However, neural responses arising in the early aftermath of a traumatic event have not been studied. Methods-Twenty-two motor vehicle-collision survivors and 12 non-traumatized controls participated. Regional cerebral blood flow (rCBF) was measured using [ 15 O]-H 2 O PET at rest and as subjects listened to scripts of traumatic and neutral events. Self-report measures rated emotional responses to the scripts; standardized assessments (Impact of Events-Revised) evaluated acute stress symptoms at scanning and at 3-month follow-up. Most subjects improved symptomatically. Results-At rest, trauma subjects showed hyperperfusion in right mPFC/ACC and hypoperfusion in right amygdala compared with controls. In trauma subjects, listening to trauma-scripts versus neutral-scripts resulted in decreased flow in the right amygdala and left amygdala/perirhinal cortex, and symptom scores correlated negatively with right hippocampal flow changes. Symptom improvement at 3 months correlated negatively with rCBF changes in right perirhinal cortex and hippocampus during the trauma versus neutral script contrast. Subjective disturbance during the trauma versus neutral contrast correlated positively with rCBF changes in right amygdala and left mPFC. Functional connectivity analyses of rCBF changes during trauma versus neutral scripts demonstrated left amygdala coupling with right ACC and bilateral anterior insula, and coupling between the amygdala and contralateral hippocampus. Conclusions-In recently traumatized subjects functional interactions between the amygdala, perirhinal cortex and ACC/mPFC that occur during exposure to traumatic reminders may underlie adaptive/recuperative processes.
The suggestion that at least some emotions are modular captures a number of our intuitions about ... more The suggestion that at least some emotions are modular captures a number of our intuitions about emotions: they are generally fast responses to a stimulus, they are involuntary, and they are easily distinguished (at least in most cases) from one another; we simply know that, for example, anger feels different than fear. Candidates for modular emotions are usually the so-called “basic” emotions - anger and fear are good examples of these. Defenders of emotion theories that focus on basic emotions, such as Paul Ekman in psychology and Paul Griffiths in philosophy, emphasize the advantages of theories that stress the evolutionary continuity of emotional expression and link emotions to the activity of neural circuits that are similar in human beings and other animals.In this paper, however, I will examine arguments for the discontinuity of emotions in human beings, as compared with other animals. Owing to a combination of cultural practices and neuroanatomy, both our emotional “wiring” ...
Evidence-based medicine (EBM) ranks different medical research methods on a hierarchy, at the top... more 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...
International Journal of Feminist Approaches to Bioethics, 2011
Jackie Leach Scully, Laurel E. Baldwin-Ragaven, and Petya Fitzpatrick, Feminist Bioethics: At the... more Jackie Leach Scully, Laurel E. Baldwin-Ragaven, and Petya Fitzpatrick, Feminist Bioethics: At the Center, on the Margins, Baltimore: The Johns Hopkins University Press, 2010, reviewed by Robyn Bluhm
Page 1. neurofeminism issues at the intersection of Feminist theory and cognitive science edited ... more Page 1. neurofeminism issues at the intersection of Feminist theory and cognitive science edited by robyn b|uhm, anneioopiacobson and heidi lene moibom New Directions in Philosophy and Cognitive Science JQ #1 it Page 2. ...
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