Research report: A preliminary analysis of medical futility decisionmaking: law and professional attitudes

Judicial decisions reviewed in this article indicate that courts have taken two disparate approaches to disputes over futility of treatment. To explore whether a consensus on medical futility is developing among hospitals, the authors conducted a nationwide survey of health care professionals at hospitals. Respondents assigned importance ratings to factors used in recent futility decisions made at their institutions. The resulting importance ratings showed significant variation by characteristics of the institution (comparing respondents from for-profit, not-for-profit, and government hospitals) and by profession of the respondent (comparing physicians and nurses). The respondents' judgments endorsed three distinct strategies for making futility decisions (i.e., emphasis on the patient's decision preferences, providing for the patient and family, and adhering to objective medical and social norms). © 1998 John Wiley & Sons, Ltd.     

The social unconscious in persons,groups and societies,volume 1: Mainly theory,edited by Earl Hopper and Heim Weinberg

This paper looks at some instances of young children learning in a school setting, and suggests that ‘emotional learning’ is an integral part of the apparently ‘cognitive’ learning that takes place in school. The paper uses object relations psychoanalysis in order to explore some of the more-or-less hidden emotional states of mind that accompany difficulties and successes with school learning. Three extracts are presented from observations of young children coming to terms with reading and writing. Each of these is then discussed, with the aim of showing how learning always takes place in a dynamic, relational emotional context. From the theoretical perspective outlined in this article, all learning involves unconscious ‘object relating’. Things to be learnt about, and people requiring learning, or assisting with it, are the bearers of the learner's vivid unconscious ‘transferences’. Such transferences colour the learner's emotional experience of the people and things around him or her, constituting a dynamic, internally experienced, ‘emotional context’ for learning. While this emotional context may be partly subjective, it is also more or less affected by others' feeling states, pulling the learner into a shared learning environment which is emotionally complex and inter-subjective.     

Reversing the spiral toward futility

The most difficult task for the counselor is to find a way to reverse the spiral of the ′60's that has propelled black students toward futility. The committed counselor should communicate honesty and sincerity to the students, know the facts about the black experience, enlighten his administration about black students' needs, and have first-hand knowledge about students' feelings regarding their curriculum.     

Making Decisions About Life-Sustaining Medical Treatment in Patients With Dementia

The problem of decision-making capacity in patients with dementia, such as those with early stage Alzheimer's, can be vexing, especially when these patients refuse life-sustaining medical treatments. However, these patients should not be presumed to lack decision-making capacity. Instead, an analysis of the patient's decision-making capacity should be made. Patients who have some degree of decision-making capacity may be able to make a choice about life-sustaining medical treatment and may, in many cases, choose to forgo treatment.     

The felt presence of other minds: Predictive processing,counterfactual predictions,and mentalising in autism

The mental states of other people are components of the external world that modulate the activity of our sensory epithelia. Recent probabilistic frameworks that cast perception as unconscious inference on the external causes of sensory input can thus be expanded to enfold the brain’s representation of others’ mental states. This paper examines this subject in the context of the debate concerning the extent to which we have perceptual awareness of other minds. In particular, we suggest that the notion of perceptual presence helps to refine this debate: are others’ mental states experienced as veridical qualities of the perceptual world around us? This experiential aspect of social cognition may be central to conditions such as autism spectrum disorder, where representations of others’ mental states seem to be selectively compromised. Importantly, recent work ties perceptual presence to the counterfactual predictions of hierarchical generative models that are suggested to perform unconscious inference in the brain. This enables a characterisation of mental state representations in terms of their associated counterfactual predictions, allowing a distinction between spontaneous and explicit forms of mentalising within the framework of predictive processing. This leads to a hypothesis that social cognition in autism spectrum disorder is characterised by a diminished set of counterfactual predictions and the reduced perceptual presence of others’ mental states.     

The legal consensus about foregoing life-sustaining treatment: its status and its prospects

The legal consensus that has evolved through adjudication and legislation since the Karen Quinlan case in 1976 is founded on the premise that there is a bright line between passive euthanasia and active euthanasia. Indeed, the term passive euthanasia is often eschewed in favor of less emotionally-laden terminology such as "forgoing life-sustaining treatment" or "terminating life support" so as to further sever any possible connection with active euthanasia. Legal approval has been bestowed upon passive euthanasia under certain circumstances while active euthanasia is routinely condemned. This consensus was put to a test in 1990 when the United States Supreme Court ruled on the Cruzan case. However, the Court's narrow decision did not upset the consensus, and in the most significant appellate decisions handed down by state courts since Cruzan, there has been a reaffirmation--and possibly even an extension--of the consensus. Two other threats to the legal consensus about forgoing life-sustaining treatment have begun to manifest themselves: the increasing pressure for mercy killing and "futility" cases. Both of these challenge the fundamental premises on which the consensus is grounded.     

Sadomasochism, sexual excitement, and perversion

Sadomasochism, an ingredient of infantile sexuality, is an essential part of normal sexual functioning and love relations, and of the very nature of sexual excitement. Sadomasochistic elements are also present in all sexual perversions. Sadomasochism starts out as the potential for erotic masochism in both sexes, and represents a very early capacity to link aggression with the libidinal elements of sexual excitement. Sexual excitement may be considered a basic affect that overcomes primitive splitting of love and hatred. Erotic desire is a more mature form of sexual excitement. Psychoanalytic exploration makes it possible to uncover the unconscious components of sexual excitement: wishes for symbiotic fusion and for aggressive penetration and intermingling; bisexual identifications; the desire to transgress oedipal prohibitions and the secretiveness of the primal scene, and to violate the boundaries of a teasing and withholding object. The relation between these wishes and the development of erotic idealization processes in both sexes is explored in the context of a critical review of the pertinent psychoanalytic literature.     

Epinephrine,Arousal, and Emotion: A New Look at Two-factor Theory

Ever since William James, psychologists of emotion have tended to view affective states as intrinsically conscious. We argue that nonconscious affect also exists, and focus specifically on the possibility of unconscious "liking". We present evidence that positive and negative affective reactions can be elicited subliminally, while a person is completely unaware of any affective reaction at all (in addition to being unaware of the causal stimulus). Despite the absence of any detectable subjective experience of emotion, subliminally induced unconscious "liking" can influence later consumption behaviour. We suggest that unconscious "liking" is mediated by specific subcortical brain systems, such as the nucleus accumbens and its connections. Ordinarily, conscious liking (feelings of pleasure) results from the interaction of separate brain systems of conscious awareness with those core processes of unconscious affect. But under some conditions, activity in brain systems mediating unconscious core "liking" may become decoupled from conscious awareness. The result is a genuinely unconscious emotion.     

Psychodynamische Aspekte der Ged?chtnisfunktionen

Based on Freud??s early thinking this paper tries to give an overview about the current state of the art related to psychodynamic aspects of memory functions. Freud began with the investigation of retrieval alterations, especially keeping content away from the experiencing ego to avoid unpleasurable states. Under the influence of new knowledge about war neuroses he tried to tackle the question of what might happen to the memory system if in the encoding situation the protecting shield is broken down through the impact of the stimuli. He came to the conclusion that such situations might lead to an omnipresence of the destructive content which could no longer be subsumed under the pleasure principle. Their permanent presence and the defense against them form the difference between traumatic disturbances and those based on unconscious conflicts. Most processes cannot be subsumed under repression but as a change of reality perception. It is shown that the models explaining the change from one state to the other is still not satisfactory. The analysis of peritraumatic states make it clear that they alone, like dissociative states, have an influence but posttraumatic experiences are just as decisive for the future development leading either to a pathogenic unconscious conflict or long-term posttraumatic disturbances with all kinds of comorbid states or healing.     

MOURNING THE LOSS BUILDS THE BOND: PRIMAL COMMUNICATION BETWEEN FOSTER,ADOPTIVE, OR STEPMOTHER AND CHILD

In this article, a particular source for the gifts and agonies of non-biological mothering bonds will be examined, namely the losses both mother and child bring to the new bond-building endeavor. As many women choose non-biological parenting because they are unable to have children of their own, the degree to which they grieve their loss is a factor in their capacity to fully attach with foster, step or adoptive children. On the other side of the connection, many agonies that mothers endure result from the use of projective identification by the child to communicate the devastating feelings due to losses experienced prior to engaging with this new caretaker. The child, too, needs to make peace with these losses, to have them acknowledged so that s/he can move on to new developmental pains and gains. On neither side of the interaction can the attachment process be taken for granted: both mother and child have to work at belonging to one another. Often the feelings which permeate the intersubjective space between mother and newly-claimed child seem like insurmountable obstacles because of their unconscious, primitive or preverbal nature.The mother may be called upon to contain and bear witness to the child's profound distress, which can undermine her confidence as a mother. Similarly the child may be subject to the mother's unconscious fantasies about the child she wished she'd had, and experience the futility of living up to such expectations.This piece is an attempt to delineate the pitfalls, due to not-yet-mourned losses, on the way to mutual recognition on the part of mother and child in non-biological bonds.     

In sickness and in health: An exploration of some of the unconscious processes involved in the decision by family caregivers to place a family member with dementia in residential care

This paper explores the feelings, conscious and unconscious, evoked by the difficult decision to place a family member with dementia into residential care. In an exploratory study I interviewed five people who had made this decision with a view to exploring some of the unconscious processes involved in their decision-making. The interviews were interpreted paying attention to my understanding of the transference and my countertransference feelings and as triangulated by a psychodynamic supervision group.

Intimate contact with ageing and death evokes fears about mortality and activates primitive anxieties. The progress of dementia may amplify primitive or psychotic states of functioning, particularly those involving evacuatory projection, and family carers may resort to splitting off unbearable feelings of anxiety which such projections can evoke and may contribute to their decision to look for residential care.

Once placed in residential care different dynamics evolve and further difficult questions arise: how often to visit; whether and when to dispose of the person's possessions and ultimately how to grieve. The focus of this paper is, as far as it is possible, on the partner without dementia as an individual and the impact of their relative's dementia on their lives.     

Autonomy and the refusal of life-prolonging therapy

Conclusion Autonomous decision-making over therapy options is not reducible to the refusal of unwanted medical intervention. This is a myth that has been imported from questionable assumptions in political economy, and is of little benefit to medical practice and the sometimes agonizing decisions which have to be taken by patients and their relatives. An individual's right to therapy abatement can be protected from abuse only in the context of a full understanding of autonomous choice; not merely the right to refuse, but the opportunity to receive assistance and consider alternatives. Limits are also required on the role of the surrogate in the refusal of therapy. Policies endorsing therapy abatement and exercise of the right to forego life-sustaining therapy should carry cast iron guarantees that they will not be disadvantageous to the poor and undereducated members of society. It should also be noted that fears of unlimited life-prolongation have been greatly exaggerated. In an atmosphere of governmental indifference to the plight of the sick, with the notion of welfare tuned to market forces, there is a danger that self-determination can have a restricted meaning; the option of death in the context of an underfunded health service. This may not be the time to campaign for the right to refuse therapy, but rather the time to campaign for improvements to existing therapy.     

Unravelling socioeconomic school composition effects on higher education enrollment: the role of students’ individual and shared feelings of futility and self-efficacy

Despite the massification of higher education, social inequality in higher education outcomes still persists. It is known that secondary schools’ socioeconomic composition is at least partly responsible for this social inequality. Nevertheless, the mechanisms by which socioeconomic composition affects higher education enrollment are still poorly understood. Based on the attribution theory, this study expects students’ feelings of academic self-efficacy and sense of futility to act as underlying mechanisms. Additionally, given that individual self-efficacy beliefs and individual sense of futility are shared among students within schools — that is, schools have different self-efficacy and futility cultures — we investigate whether these cultures are consequential for higher education enrollment and program choice. Results of binomial logistic multilevel analyses on the data of the International Study of City Youth (www.iscy.org) in Ghent, consisting of 1214 Flemish students across 29 schools, indicated that students in low socioeconomic composition schools are less likely to enroll in higher education because these schools are characterized by high futility cultures. In contrast, high self-efficacy and self-efficacy cultures are positively associated with the choice for academic bachelor programs, but they did not explain socioeconomic composition effects. We conclude that educational policies should aim at increasing a sense of control over academic outcomes in order to improve social equality in higher education outcomes.

     

Clinical psychology in medical settings: Psychology's role in health care

The number of clinical psychologists working in medical settings has grown along with the range of services provided by psychologists to patients with a multitude of medical problems across the lifespan. Medical care cost savings brought about by these psychological interventions is highlighted along with issues of public policy and specialization of training. The opportunity for ongoing development of clinical psychology in medical settings is described as unlimited and the mission of the newJournal of Clinical Psychology in Medical Settings is presented as supporting that growth.     

Transgender people in Australia's Northern Territory

While research has provided a significant picture of the lived experiences of transgender and sex/gender diverse (TSGD) Australians, it remains incomplete because population samples rarely include TSGD people from Australia's Northern Territory. The Northern Territory is twice the size of France but is populated by only 210,000 people. The territory's environmental and demographic features make it very distinct from Australia's other six states and mainland territory. Most notably, it possesses a "frontier" mentality and is considered to be one of Australia's most homophobic states and territories. This paper publishes the results of an online survey conducted as part of an ongoing research project into the health needs of TSGD individuals, such as availability of medical and support services that specialize in, and are "friendly" to, TSGD people, especially in remote areas of the territory, colloquially referred to as out bush.     

Unwittingly Recapitulating Freud: Searle's Concept of a Vocabulary of the Unconscious

This paper aims to show that the pivotal notion in John Searle's account of the unconscious, despite his representation of Freud's position, is found in Freud's work as part of a very similar view of the issues surrounding the concept of the unconscious. The pivotal notion in question consists in treating the concept of the unconscious as a vocabulary without ontological commitment which Searle claims we must do for the following reason: to reconcile what he considers to be the dualistic concept of the unconscious with an ontology of the mental which recognises no states but conscious states and states of the neurophysiology with the capacity to cause them. The role of the concept in Searle's account is explained. Then his representation of Freud is challenged: firstly, by explicating how Freud accepted that the concept of the unconscious entailed no ontological commitment and, secondly, by showing how this fitted into his wider thinking on how the concept of the unconscious could be understood in terms of a vocabulary, leading ultimately to a justification of the concept of the unconscious in terms of explanatory power. On the basis of this exposition, Searle's charge of dualism against Freud is disputed     

‘If they didn’t support me,I most likely wouldn’t be here’: Transgender young people and their parents negotiating medical treatment in Australia

Abstract

Background: It is increasingly recognized that transgender young people require affirming medical care, however the provision of such care may be mitigated by the availability of services and the views of parents.

Aims: This study aimed to explore the views of Australian transgender young people (aged 11–17) and their parents with regards to medical treatment.

Methods: Ten qualitative interviews were conducted with parent-child dyads in two Australian states. Thematic analysis was undertaken on responses to interview questions related to family relationships, views about medical treatment (specifically hormone blockers and hormones), and the relationship between medical treatment and sense of self.

Results: Themes developed focused on the importance of strong supportive parent-child relationships, the meaning of and access to hormone blockers, and the meaning of and access to hormones.

Discussion: The paper concludes by discussing the implications of the findings for clinical services, particularly in relation to supporting parents to be affirming of a transgender child, the need to prepare transgender young people and their parents for the passage of time in regards to medical treatment, and the need to focus on expectations in regards to sense of self in relation to medical treatment.     

Religious,Ethical and Legal Considerations in End-of-Life Issues: Fundamental Requisites for Medical Decision Making

Religion and spirituality have always played a major and intervening role in a person’s life and health matters. With the influential development of patient autonomy and the right to self-determination, a patient’s religious affiliation constitutes a key component in medical decision making. This is particularly pertinent in issues involving end-of-life decisions such as withdrawing and withholding treatment, medical futility, nutritional feeding and do-not-resuscitate orders. These issues affect not only the patient’s values and beliefs, but also the family unit and members of the medical profession. The law also plays an intervening role in resolving conflicts between the sanctity of life and quality of life that are very much pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the inherent ethical and legal dilemmas needs to be sensitive not only to patients’ varying religious beliefs and cultural values, but also to the developing legal and ethical standards as well. There is a need for the medical profession to be guided on the ethical obligations, legal demands and religious expectations prior to handling difficult end-of-life decisions. The development of comprehensive ethical codes in congruence with developing legal standards may offer clear guidance to the medical profession in making sound medical decisions.     

II Spatial metaphors and somatic communication: the embodiment of multigenerational experiences of helplessness and futility in an obese patient

This paper explores the analysis of an obese woman who came to experience her flesh as a bodying forth of personal and multigenerational family and cultural experiences of helplessness. The paper discusses the ideas and images that formed the basis of how I engaged with these themes as they presented countertransferentially. My thesis is that clinical approaches which draw on spatial metaphors for the psyche offer valuable tools for working with people whose inner world expresses itself somatically because such metaphors can be used to engage simultaneously with the personal, cultural, and ancestral dimensions of these unconscious communications. The paper builds on Jung's view of the psyche as comprised of pockets of inner otherness (complexes), on Redfearn's image of psyche as landscape‐like and on Samuels’ thinking on embodied countertransference and on the political psyche. It also draws on Butler's work on the body as a social phenomenon and on the theme of being a helpless non‐person or nobody as explored in Tom Stoppard's play Rosencrantz and Guildenstern are Dead which retells Shakespeare's Hamlet from the perspective of two of the play's ‘bit’ characters.