Early developmental issues reconsidered: commentary on Pine's ideas on symbiosis

The concept of symbiosis is a powerful one expressing a significant emotional experience for many individuals. However, the concept needs to be differentiated from infant-stage symbiosis, Margaret Mahler's second stage of normal development. The latter idea, according to Pine (2004), was of "central" importance to Mahler. Although Pine acknowledges the influence of research findings and some critical challenges to this idea, he maintains nonetheless that it "remains quite valuable" and reports what he suggests are manifestations of symbiotic experiences in the infant-mother relationship. His recognition of infant observational data has led him to feature the idea of "moments" of merger between mother and infant. Empirical data, however, challenge both the idea of a more broadly defined stage of infantile symbiosis and the more narrowly conceived "moments." A different understanding of development in the presence of early-stage symbiosis is provided.     

Current issues in theory construction: A commentary on Waters and Sroufe

The view of competence proposed by Waters and Sroufe remains faithful to a kind of theorizing about human personality which emphasizes its unitary and universal properties. Developments in other areas of inquiry, however, are redirecting theoretical efforts toward a more pluralistic and contextualistic view of human nature and development. Implications for future theories of development are discussed.     

Anticruelty care: commentary

The anticruelty policy is a best-interests test for treatment plans including decisions to forgo life-sustaining therapy for certain incompetent patients. In connection with specific proposed therapy, the policy requires no reference to the patient's unknowable values, subjective experiences, or quality of life. The decision to undertake a treatment plan derives from the caregiver's knowledge of burdens and benefits of that treatment when used in caring for the competent or for those incompetents capable of growth or repair. The caregiver should weigh the potentially cruel effects of treatment against the likelihood of reducing suffering or encumbrance with the treatment. The terms "burden" and "benefit," in fact, are replaced by the terms "cruelty" and "beneficence," as the relevant opposing outcomes that must be weighed. Thus, the anticruelty policy shifts our scrutiny from experiences of the patient that we cannot evaluate to the proposed actions of the competent decision makers and caregivers. Notably, it is a protreatment policy when the goals of medicine are attainable; and it is an anticruelty policy when they are not. The policy does evaluate the world of the patient to the extent that it requires a judgment based upon external appearances about patient pleasure or happiness in living. It presumes to universalize larger societal values about cruelty, beneficence, compassionate concern for the helpless, and certain rights of individuals. And it presumes to universalize on the patient's behalf specific medical values about hopeless injury, timely death, the goals of medicine, and cruelty, which should remain open to societal discussion and revision. The presented definition of hopeless injury does not require brain death, coma, or persistent vegetative state. Specifically, the policy holds that death is timely for a patient with hopeless injury, and that prevention of death for such patients is not a goal of medicine but a cruelty.     

Conceptual and methodological issues in the study of Internal Representation: A commentary on Infant Mental Health Journal,volume 10.3

This commentary raises issues about the current state of research on internal representation, using the Special Issue of the Infant Mental Health Journal on “Internal Representation and Parent-Infant Relationships” as a point of departure. Current research is praised for its emphasis on subjectivity and intersubjectivity in relationships, for integrating viewpoints from a variety of disciplines, and for the development of innovative investigatory approaches. At the same time, however, an overemphasis on quantitative methods is cited as possibly raising the risk of prematurely limiting an investigation of these issues that is broad-based enough to reflect their intricacy in actual experience. Instead, a more varied approach is sought, in which operationalizability is viewed as one of many potential sources of methodological validity rather than as the most important one. More purely clinical and theoretical approaches are particularly appropriate to the study of internal representation and intrafamilial relationships because access to personal, interior experience must rely on such forms as language and the techniques of clinical inquiry.     

Hermeneutical clinical ethics: A commentary

Essays by Thomasma and ten Have recommend hermeneutical clinical ethics. The use Thomasma makes of hermeneutics is not radical enough because it leaves out basic interpretation of clinical practice and focuses narrowly on ethical principles and rules. Ten Have, while failing to notice that the hyperreality of clinical ethics is a feature of all language, rightly distinguishes four characteristic parameters of a thoroughgoing interpretive clinical ethics: experience, attitudes and emotions, community, and ambiguity. Suggestions are made for implementing hermeneutical ethics in clinical teaching.     

Response to Erich Loewy: commentary

The capacity to suffer, the vulnerability with respect to suffering, confers on all animals with that capacity (not just human beings) a prima facie right not to be caused suffering. Nurturing in order to stave off such suffering is the first act of the community toward the individual, primarily in infancy. Hence for Loewy, autonomy, the gradual growth of self-determination in individuals, is grounded in a broader moral commitment of the community, that of beneficence. This is the critical point in his argument, for it represents a wholesale critique of modern libertarianism. Libertarians, in contrast to Loewy's argument, seem to ground the nature of the community in the prima facie right of autonomy. For Loewy, the community not only has an obligation to refrain from harming individuals (nonmaleficence), but it also has an active duty to ameliorate and prevent, as far as possible, the suffering of its members. Thus, if there is a social contract, it is one of nurturing one another to overcome the vulnerability of suffering, not primarily one of protecting autonomy. This is most significant for clinical ethics as well. Once the primary obligation to ameliorate suffering is no longer necessary, when the individual loses or does not have the primary moral worth prompted by the capacity to suffer, then secondary and symbolic obligations emerge. Loewy is thereby able to suggest a "calculus" of moral worth, wherein our obligations to individuals in a permanent vegetative state or to anencephalics (almost always the individual will have lost the capacity to suffer through some cerebral event) must be weighed against other primary obligations. Although Loewy admits that grounding clinical ethics in the capacity to suffer might be "thin," it nevertheless prompts serious discussion about the nature of the "good" in good clinical ethics decisions.     

Natural resources for morality: commentary

Loewy makes an extraordinary and audacious claim. He does not only reject virtue ethics, casuistry, the "Kantian injunction of respect for persons based on their capacity for self-legislation," and the utilitarian greatest good as possible groundings for clinical ethics. He even offers another grounding that he qualifies explicitly as "universally acceptable." Of course we have to analyze what it is that he offers. But prior to that, we must analyze what he means by "grounding." Grounding suggests an evidence that can neither be rationally grounded again nor rationally questioned but that other concepts can be rationally grounded upon. And it is at least doubtful whether the alternatives he quotes are groundings in that strict sense....     

Short-term memory: A brief commentary

Over the years, a metatheoretical view of short-term memory has developed. This view, closely related to the “modal” model from the 1960s, is supported by an increasing base of neurophysiological data, and a wide variety of empirical findings. It treats short-term memory as (1) the temporary, above threshold, activation of neural structures (related in not-too-well-specified ways to various recency effects); (2) a work space for carrying out virtually all cognitive operations involved in human cognition; and (3) the source of capacity limitations, accounting for certain memory limitations and most attentional limitations. The main problem with this view is the fact that it encompasses virtually everything that we are concerned with in human cognition—asuccessful model would almost be a general model of cognition, something the field has not yet approached. This situation is not grounds for despair. Progress is being made on many fronts, notwithstanding the fact that the most successful models are focused on specific task domains. Recent advances include an increasing awareness of the necessity for detailed models of short-term retrieval, a theme reflected in a number of articles in the present collection.     

Suffering and interpersonal meaning: commentary

I would like to suggest that to describe suffering as a psychological phenomenon is still too general. It leaves the door open to the belief that suffering is an individual phenomenon, experienced because of dynamics arising out of the individual psyche as the pain arises out of the individual body. Instead of describing suffering as a psychological phenomenon, we should describe it as an interpersonal, even communal phenomenon....If the task of reestablishing, continuing, and creating interpersonal meaning within the context of suffering is accepted, the problem often arises concerning how the health professional can accomplish this task with the patient under the extraordinary circumstances that pain and illness, as well as the health-care environment, provide. Beyond sensitive and thoughtful dialogue, we may have to return to a sense of ceremony within health care, especially since the rationalistic naiveté of nineteenth-century positivism did so much to encourage the belief that the best health care is the one that does things efficiently and "unceremoniously"....