Pluralism,philosophies of medicine and the varieties of medical ethics: A commentary on Thomasma and Pellegrino

Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, the project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety.     

Comorbidity of attention Deficit Hyperactivity Disorder and Post-Traumatic Stress Disorder

Attention Deficit Hyperactivity Disorder (ADHD) and Post-Traumatic Stress Disorder (PTSD) show a high degree of comorbidity in traumatized children. Two hypotheses may help explain this relationship: children with ADHD are at higher risk for trauma due to their impulsivity, dangerous behaviors, and parents who may have a genetic predisposition for impairment of their own impulse control; and hyperarousal induced by severe trauma and manifested by hypervigilance and poor concentration may impair attention to create an ADHD-like syndrome. Four illustrative cases are presented, and implications for treatment are discussed.     

A methodology for teaching ethics in the clinical setting: A clinical handbook for medical ethics

The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented?     

Religion and the Survival of 1010 Hospitalized Veterans

Objective: To examine the effects of religious affiliation and religious coping on survival of acutely-hospitalized medically-ill male veterans following discharge. Sample and Methods: Between 1987 and 1989, comprehensive psychosocial and physical-health evaluations were performed on a consecutive sample of 1010 patients ages 20–39 and 65–102 years admitted to the general medicine and neurology services of the Veterans Administration (VA) Medical Center in Durham, North Carolina. Religious affiliation and religious coping (the degree to which a patient relied on his religious faith for comfort and strength) were among the variables assessed. Subjects or surviving family members were contacted by telephone in 1996–97 to determine vital status; dates of death were confirmed by the Veterans Administration's Beneficiary Identification and Records Locator Subsystem (BIRLS), death certificate, or the National Death Index. Cox proportional-hazards regression was used to model the effects of religious variables on time to death, controlling for demographic, social, psychiatric, and physical-health covariates. Results: Follow-up was obtained on all 1010 patients. During the observation period, 673 patients died. While a higher proportion of conservative Protestants than members of other religious groups died during this time (70.5% vs. 64.3%, p = .04), the association disappeared once covariates were controlled. Religious coping was unrelated to survival in both bivariate and multivariate analyses (hazard ratio 1.00, 95% CI 0.99–1.01). Conclusions: Neither religious affiliation nor dependence on religion as a coping behavior predicted survival in this sample of medically-ill male veterans. Several reasons for the absence of an effect are explored, notably the fact that the mortality force exerted by age, medical diagnosis, and severity of physical-health problems overwhelmed the weaker effects of psychosocial variables.     

Trends in married couples' time use: Evidence from 1977–78 and 1987–88

Conflicting evidence regarding married couples' time use trends has recently emerged in the literature. A critical review of this literature suggests that variations in data quality and methodological approaches may be responsible for many of the observed differences. Capitalizing on the insights gained from this review, a trend analysis of couples' time use is presented in this paper. The analysis is based on two cross-sections of time diary data collected from two-parent, two-child households. The results suggest that the relationships between socioeconomic variables and couples' time use changed during the period from 1977–78 to 1987–88. On average, these changes lead to an increase of over seven hours per week in married women's productive work time (i.e., market work plus household work). Correspondingly, the productive work time of husbands increased by an average of three and one-half hours per week. Both increases came at the expense of time that was formerly spent in more leisure-oriented activities.Financial support for the collection of the data used in this study was provided by the Utah State Agricultural Experiment Station and the University of Utah Research Committee. A grant of computer time from the Utah Supercomputing Institute, which is funded by the State of Utah and the IBM Corporation, is greatfully acknowledged. Additional support has been provided by the Department of Home Economics and Consumer Education at Utah State University where Dr. Zick was on leave during the 1989–90 academic year. W. Keith Bryant, Ken R. Smith, and an anonymous reviewer each gave helpful comments on an earlier draft of this article.     

Laying medicine open: understanding major turning points in the history of medical ethics

At different times during its history medicine has been laid open to accountability for its scientific and moral quality. This phenonmenon of laying medicine open has sometimes resulted in major turning points in the history of medical ethics. In this paper, I examine two examples of when the laying open of medicine has generated such turning points: eighteenth-century British medicine and late twentieth-century American medicine. In the eighteenth century, the Scottish physician-philosopher, John Gregory (1724-1773), concerned with the unscientific, entrepreneurial, self-interested nature of then current medical practice, laid medicine open to accountability using the tools of ethics and philosophy of medicine. In the process, Gregory wrote the first professional ethics of medicine in the English-language literature, based on the physician's fiduciary responsibility to the patient. In the late twentieth century, the managed practice of medicine has laid medicine open to accountability for its scientific quality and economic cost. This current laying open of medicine creates the challenge of developing medical ethics and bioethics for population-based medical science and practice.     

The relationship between moral philosophy and medical ethics reconsidered

Medical ethics often is treated as applied ethics, that is, the application of moral philosophy to ethical issues in medicine. In an earlier paper, we examined instances of moral philosophy's influence on medical ethics. We found the applied ethics model inadequate and sketched an alternative model. On this model, practitioners seeking to change morality "appropriate" concepts and theory fragments from moral philosophy to valorize and justify their innovations. Goldilocks-like, five commentators tasted our offerings. Some found them too cold, since they had already abandoned applied ethics; others too hot, since they still find the applied ethics model to their taste. We reply that the appropriation model offers an empirically testable account of the historical relationship between moral philosophy and medical ethics that explains why practitioners appropriate concepts and fragments from moral philosophy. In contrast, the now fashionable common morality theory neither explains moral change nor why practitioners turn to moral philosophy.     

Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2

The nosology of chronic depression in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994) is highly complex and requires clinicians to differentiate among several chronic course subtypes. This study replicates an earlier investigation (J. McCullough et al., 2000; see record 2000-05424-007) that found few differences among Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R; American Psychiatric Association, 1987) categories of chronic depression. In the present study, 681 outpatients with chronic major depression, double depression, recurrent major depression without full interepisode recovery, and chronic major depression superimposed on antecedent dysthymia were compared. Few differences were observed on a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. The authors suggest that chronic depression should be viewed as a single, broad condition that can assume a variety of clinical course configurations.     

Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life

The effect of a grateful outlook on psychological and physical well-being was examined. In Studies 1 and 2, participants were randomly assigned to 1 of 3 experimental conditions (hassles, gratitude listing, and either neutral life events or social comparison); they then kept weekly (Study 1) or daily (Study 2) records of their moods, coping behaviors, health behaviors, physical symptoms, and overall life appraisals. In a 3rd study, persons with neuromuscular disease were randomly assigned to either the gratitude condition or to a control condition. The gratitude-outlook groups exhibited heightened well-being across several, though not all, of the outcome measures across the 3 studies, relative to the comparison groups. The effect on positive affect appeared to be the most robust finding. Results suggest that a conscious focus on blessings may have emotional and interpersonal benefits.