The physician and social renewal: Julius B. Richmond as role model

We live in an age of “high tech” medicine which affects both health care recipients and physicians who are taught its many wonders and uses. It is easy in this atmosphere of specialization for clinicians, professors and medical students to become isolated and to ignore social issues which affect health care in its broadest sense. Individuals who are committed to the “common good” are the ones historically who have been effective change agents. It would be tragic simply to stand back and allow the cynical and greedy to dominate any profession which deals with the poor, the uninsured and the homeless. It is imperative for physicians to take a broad view of today's problems in health care delivery systems, for they can have an enormous impact on the kind of world our children will inherit. It is essential for physicians to become involved in social concerns, and in improving health care delivery, at all levels in their practice. Given their power and prestige, it is crucial for physicians and aspiring physicians to have positive role models. Dr. Julius B. Richmond provides an admirable example of a physician who cares about his profession, his patients and his nation. Through his research, his public service and his teaching, Dr. Richmond has demonstrated the difference a single individual can make in improving the quality of life for all Americans.     

Die Bindungstheorie als Basis psychotherapeutischer Interventionen in der Terminalphase

Recent attachment research has shown that every person develops, already in early childhood, special attachment strategies activated in cases whenever the person cannot cope on his own with dangers. These strategies are classified into four categories: “secure”, “insecure-avoidant”, “insecure-ambivalent/enmasked” and “disoriented/disorganized” attachment patterns. The death of a next person represents a situation of a unique and final separation causing psychical disturbances for the patient himself and his relatives. It is, therefore, an especially effective trigger for the activation of the attachment system. This article aims on relating attachment theory to an attachment-oriented therapy, that would open, particularly in the field of palliative medicine, possibilities of application which have been neglected. Case studies illustrate how these insights may be applied during the psychotheraputic care for patients and their relatives. As dying patients generally are brought by their family to the clinic, physicians have a particularly favourable situation to observe the attachment patterns in the family and integrate these informations into their treatment strategy: for example in case of “avoidant” attachment patterns, to bring cautiously the denied emotions into the communication and to support hopes for the fulfilment of needs for affection and protection; or in case of so-called “ambivalent/entangled” attachment patterns to help to disentangle too close relationships; or in case of “disorganized” attachment patterns to support emotional regulation and help to clear the relationships. It is obvious that this approach based on attachment theory and offering alleviations during the process of dying, is not only on a palliative board relevant, but may be applied with success in the medical care of dying patients and their relatives.     

Informed consent: An overview

Over the past 25 years, obtaining informed consent for the performance of many medical procedures has become part of the practice of medicine. As opposed to the “duty to warn” that is enforced by the law, informed consent should be a cornerstone of a fully collaborative decision-making process, the elements of which are presented in this paper. The responsibility for this process rests upon health care institutions and financing arrangements, as well as upon physicians and courts. In response to emergencies, patient preferences, and public interests, the consent process is justifiably abbreviated. However, as presently articulated, the consent process treats communication too simplistically, is distorted by the way it is enforced in litigation, is inattentive to social justice issues, and is not integrated into the moral commitment of physicians.     

Rethinking Professional Ethics in the Cost-Sharing Era

Changes in healthcare financing increasingly rely upon patient cost-sharing to control escalating healthcare expenditures. These changes raise new challenges for physicians that are different from those that arose either under managed care or traditional indemnity insurance. Historically, there have been two distinct bases for arguing that physicians should not consider costs in their clinical decisions—an “aspirational ethic” that exhorts physicians to treat all patients the same regardless of their ability to pay, and an “agency ethic” that calls on physicians to be trustworthy advisors to their patients. In the setting of greater patient cost-sharing, physicians' aspiration and agency roles increasingly conflict. Satisfactorily navigating the new terrain of consumer-driven healthcare requires physicians to consider these two roles and how they can best be reconciled so as to maximize quality of care while respecting the heterogeneity of patients' financial resources and willingness to pay.     

Le juge,le médecin et le détenu. Regard critique sur la suspension de peine pour raison médicale

The purpose of the article is to give a critical view of the “suspension médicale” (a kind of compassionate release), which is often considered as a “humanist” law. Based on a research conducted on the experience of prisoners at the end of their lives, it appeared that many more or less objective criteria are involved in the decision-making process. In this context, physicians and magistrates try to articulate their actions according to expertise. The decision of granting or refusal also depends on the perception of the prisoner's personality. The application of the law thus reflects the tensions and alliances between medicine and justice in the treatment of a deviant and vulnerable population.     

Troubles du comportement et adolescence. Problématiques d'accès aux soins et modalités de réponses nouvelles

The psychopathology of adolescence requires particular adaptation of treatments. This article presents the specific organization of psychiatric treatment for adolescents developed in a mental ward. It works in collaboration with paediatric services, school medicine, community homes for adolescents, parents and attending physicians. Going towards adolescents signalled by those partners, we make easier the access to treatment, the “out of walls reception”. Reciprocal therapeutic commitment, worked with the adolescent, allows him to access to a variety of special cares: consultations, therapeutic groups, hospitalisation, “indirect treatments”. Results from three years allows us to stress the relevance of such a specific organization namely for tricky clinical situations.     

Definition and the Question of “Woman”

Within recent feminist philosophy, controversy has developed over the desirability, and indeed, the possibility of defining the central terms of its analysis—"woman,”“femininity,” etc. The controversy results largely from the undertheorization of the notion of definition; feminists have uncritically adopted an Aristotelian treatment of definition as entailing metaphysical, rather than merely linguistic, commitments. A “discursive” approach to definition, by contrast, allows us to define our terms, while avoiding the dangers of essentialism and universalism.     

Yearning for certainty and the critique of medicine as “science”

A debate has simmered concerning the nature of clinical reasoning, especially diagnostic reasoning: Is it a “science” or an “art”? The trend since the seventeenth century has been to regard medical reasoning as scientific reasoning, and the most advanced clinical reasoning is the most scientific. However, in recent years, several scholars have argued that clinical reasoning is clearly not “science” reasoning, but is in fact a species of narratival or hermeneutical reasoning. The study reviews this dispute, and argues that in a theoretical sense, the dispute rests upon a naïve—but very popular—caricature of what constitutes “science reasoning.” But, if the dispute rests upon just such a caricature, why is it so persistent? The study concludes by suggesting that we, as patients and as physicians, have deep psychological tendencies that incline us to adopt the very naïve “science” concept/model of diagnostic reasoning, even if (or when) we understand its inaptness.     

Ethical Dilemmas at the End of Life: Islamic Perspective

Many Muslim patients and families are often reluctant to accept fatal diagnoses and prognoses. Not infrequently, aggressive therapy is sought by the patient or his/her family, to prolong the life of the patient at all costs. A series of searches were conducted of Medline databases published in English between January 2000 and January 2015 with the following Keywords: End-of-life, Ethics and Islam. Islamic law permits the withdrawal of futile treatment, including all kinds of life support, from terminally ill patients leaving death to take its natural course. However, such decision should only take place when the physicians are confident that death is inevitable. All interventions ensuring patient’s comfort and dignity should be maintained. This topic is quite challenging for the health care providers of Muslim patients in the Western World.     

L’abord de la sexualité par les professionnel·le·s de santé en oncologie : une revue de la littérature

The improvement in medical techniques has drastically modified the practice of care in oncology. Supportive care, geared towards supporting patients with chronic illnesses, now occupies a greater place alongside treatments aimed at survival. These changes have conducted some health care professionals to be more interested in patients’ quality of life and, in particular, to the impact of cancer on sexuality. Repercussions on sexuality are actually one of the most problematic aspects of patients’ quality of life post cancer. The aim of this paper is to draw up a review of the English and French literature on this “new” concern which still seems to raise many challenges in practice. Our review emphasizes that despite the recognition of the importance of addressing sexuality issues post cancer in oncology, in their practices, physicians as the nurses alike find it difficult to address. In addition, it underlines that the dominant social representations of sexuality – in terms of gender, sexual orientation and age – have permeated health care professionals’ subjectivities and, at the same time, influence how sexuality is address and interfere with a systematic discussion of these issues throughout the care process. Our discussion tackles the lack of psychologists, both in research and clinic, regarding these issues. Finally, our conclusion highlights the contributions of psychology facing issue posed by sexuality in oncology.     

L’expertise médicale au temps des pandémies : l’exemple des cancers

Medical law suits were interrupted during the COVID-19 pandemia and judicial process will come shortly back to the normal. Pandemia induced delays in the cancer diagnosis and treatment. These modifications were validated by expert consensus from the medical societies. However in the coming years it is highly possible that patients think they were victims of a “loss of chance” and ask for a compensation. The various situations in which physicians can be involved are described and recommendations for the management of medical charts are discussed.     

Pain Sensitivity: An Unnatural History from 1800 to 1965

Who was truly capable of experiencing pain? In this article, I explore ideas about the distribution of bodily sensitivity in patients from the early nineteenth century to 1965 in Anglo-American societies. While certain patients were regarded as “truly hurting,” other patients’ distress could be disparaged or not even registered as being “real pain.” Such judgments had major effects on regimes of pain-alleviation. Indeed, it took until the late twentieth century for the routine underestimation of the sufferings of certain groups of people to be deemed scandalous. Often the categorizations were contradictory. For instance, the humble status of workers and immigrants meant that they were said to be insensitive to noxious stimuli; the profound inferiority of these same patients meant that they were especially likely to respond with “exaggerated” sensitivity. How did physicians hold such positions simultaneously? Pain-assignation claimed to be based on natural hierarchical schemas, but the great Chain of Feeling was more fluid than it seemed.     

Evidenzbasierte Psychotherapie der Depression

Depressive disorders are among the most frequent reasons for utilizing the health care system. Despite the availability of efficacious treatments and further advances throughout the last years, there is still a need for improving diagnostic and therapeutic procedures. A promising approach is the implementation of evidence- and consensus-based guidelines. The German “Nationale VersorgungsLeitlinie Unipolare Depression” are evidence- and consensus-based clinical practise guidelines for patients with unipolar depression. All relevant stakeholders have been involved in its development and have passed the final version at the end of 2009 to foster compliance throughout. The available evidence allows the derivation of differentiated treatment recommendations, also with regard to concomitant antidepressant medication or as alternative treatment options. In acute therapy watchful waiting over 14 days is recommended for mild depression and psychotherapy after persistence of symptoms. In cases of moderate depression, psychotherapy and pharmacotherapy are equally recommended, in cases of severe depression a combination of both is recommended.     

GENOCIDAL MUTATION AND THE CHALLENGE OF DEFINITION

Abstract: The optimum definition of the term “genocide” has been hotly contested almost since the term was coined. Definitional boundaries determine which acts are covered and excluded and thus to a great extent which cases will benefit from international attention, intervention, prosecution, and reparation. The extensive legal, political, and scholarly discussions prior to this article have typically (1) assumed “genocide” to be a fixed social object and attempted to define it as precisely as possible or (2) assumed the need for a fixed convention and sought to stipulate the range of events that should be denoted by the term. Even if its meaning is a matter of convention, however, “genocide” is not a fixed object but varies by context and evolves in methods and forms over time. In fact, as relevant laws, legal interpretations, and political commitments develop, so do would‐be perpetrators modify what genocide is in order to avoid political and legal consequences. This article advances an approach to a definition of “genocide” that allows even legal definitions to keep pace with this evolutionary process.     

La loi no 2016-87 du 2 février 2016 créant de nouveaux droits en faveur des malades et des personnes en fin de vie : un nouvel équilibre décisionnel ?

Adopted after a tumultuous legislative process, the Act of 2 February 2016 complete the “Leonetti” law of April 22, 2005. Without going to legalize active help to die, this law does include some notable developments. It increases patient autonomy, including the consecration of mandatory advance directives and extends the right to refuse care. It specifies the role of the support person in the decision process and extends the scope of the collegiate procedure. Finally, it recognizes a right to care for the suffering and diversified palliative care modalities, particularly through the introduction of continuous deep sedation until death. Some aspects of the law relating to the mandatory advance directives or the process of sedation are however asked to be specified by regulation.     

Making the Case for Primary Care and Mandated Suicide Prevention Education

During its 2012 legislative session, Washington State passed ESHB 2366, otherwise known as the Matt Adler Suicide Assessment, Treatment, and Management Act of 2012. ESHB 2366 is a significant legislative achievement as it is the first law in the country to require certain health professionals to obtain continuing education in the assessment, treatment, and management of suicide risk as a requirement to obtain and maintain licensure. However, ESHB 2366 does not apply to primary care providers, an important next step for legislation that has as its goal “to help lower the suicide rate in Washington.” This commentary addresses objections raised against the law and potential responses as Washington considers strengthening its own law to include primary care providers and as other states consider similar legislation.     

From “Longshot” to “Fantasy”: Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail

Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from “longshot” to “fantasy” is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.     

Emotional Processing Therapy for post traumatic stress disorder

While prolonged exposure is considered one of the “gold standard” and recommended treatments for post traumatic stress disorder (PTSD), it has been poorly utilised in clinical practice. Individuals with PTSD often find it too distressing to confront memories, and therapists may be uncomfortable using the therapy. A new Emotional Processing Therapy is described in which an emotional approach to prolonged exposure provides individuals with a new insight into how trauma is processed. A conceptual analysis of exposure suggests that it is exposure to distressing emotional experiences which is a key element. Viewing it as an emotion-based therapy, allows the creative addition of new emotional elements. Through exploring the individual’s emotional processing style, previously learned and unhelpful patterns can be addressed, and the addition of an “emotional preparation” phase helps them understand why it is important to face emotionally distressing memories before exposure sessions begin. Emotional Processing Therapy is intuitive and makes sense to those affected by PTSD. It is framed in an emotional context and is presented as part of a lifestyle change that may reduce the likelihood of psychological problems developing in the future.     

Is psychoanalysis alive and well at 85? A rejoinder

Psychoanalysis has declined in public interest and scientific validity. It has become a “dead science” and an anachronistic system of beliefs. Its goal of total personality reconstruction is frustrating and futile. Psychoanalytic practice became a form of “exclusive salvationism,” and unconscionable, when it excluded the spouse from participation in the total treatment plan. More frequent interviews over a longer period of time do not produce a therapeutic effect that is “deeper,” and there is no reason to believe that fewer interviews are superficial, or temporary, and that prolongation of an analysis is more likely to produce better therapeutic results. Research studies do not produce any clear-cut winners when psychotherapies are compared. Psychoanalytic theories rest more on argument than on scientific evidence. The patient’s needs seldom, if ever, correspond to the therapist’s theoretical preoccupations, system of beliefs, and indoctrination. Research psychologists, philosophers of science, and eclectic psychiatrists have expressed their dissatisfaction with unproven psychoanalytic doctrines and the concept of “mental energy.” Psychoanalysis is not a pseudoscience, but a “half-science,” whose poetic mythology requires translation into the prose of science.