“Advice to the medical students in my service”: the rediscovery of a golden book by Jean Hamburger,father of nephrology and of medical humanities

Jean Hamburger (1909–1992) is considered the founder of the concept of medical intensive care (réanimation médicale) and the first to propose the name Nephrology for the branch of medicine dealing with kidney diseases. One of the first kidney grafts in the world (with short-term success), in 1953, and the first dialysis session in France, in 1955, were performed under his guidance. His achievements as a writer were at least comparable: Hamburger was awarded several important literary prizes, including prix Femina, prix Balzac and the Cino del Duca prize (1979), awarded, among others, to Jorge Luis Borges and Konrad Lorenz.Here we would like to offer a selected reading of a “golden” book, “Conseils aux étudiants en medicine de mon service” (“Advice to the Medical Students in my Service”), the first book dedicated to patient-physician relationship in Nephrology, written when dialysis and transplantation were becoming clinical options (1963). The themes include: the central role of the patient, who should be known by name, profession, life style, and not by disease; the importance of the setting of the care; the need for truth-telling and for leaving hope; the role of research not only in the progression of science, but also in the daily clinical practice.     

The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

Introduction

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called “moral foundations.” The objective of this study was to determine if “harm” and “fairness” intuitions can explain physicians’ judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to “purity”, “authority” and “ingroup” in cost-related judgments.

Methods

We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care.

Results

1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values?>?0.05). Agreement with cost-containment was associated with higher mean “harm” (3.6) and “fairness” (3.5) intuitions compared to “in-group” (2.8), “authority” (3.0), and “purity” (2.4) (p?<?0.05). In multivariate models adjusted for age, sex, region, and specialty, both “harm” and “fairness” were significantly associated with judgments about cost-containment (OR?=?1.2 [1.0-1.5]; OR?=?1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR?=?1.2 [1.0-1.4]; OR?=?0.9 [0.7-1.0]).

Conclusions

Moral intuitions shed light on variation in physician judgments about cost issues in health care.

     

Neuroethics,confidentiality, and a cultural imperative in early onset Alzheimer disease: a case study with a First Nation population

The meaningful consideration of cultural practices, values and beliefs is a necessary component in the effective translation of advancements in neuroscience to clinical practice and public discourse. Society’s immense investment in biomedical science and technology, in conjunction with an increasingly diverse socio-cultural landscape, necessitates the study of how potential discoveries in neurodegenerative diseases such as Alzheimer disease are perceived and utilized across cultures. Building on the work of neuroscientists, ethicists and philosophers, we argue that the growing field of neuroethics provides a pragmatic and constructive pathway to guide advancements in neuroscience in a manner that is culturally nuanced and relevant. Here we review a case study of one issue in culturally oriented neuroscience research where it is evident that traditional research ethics must be broadened and the values and needs of diverse populations considered for meaningful and relevant research practices. A global approach to neuroethics has the potential to furnish critical engagement with cultural considerations of advancements in neuroscience.     

The place of words and numbers in psychiatric research

In recent decades, there has been widespread debate in the human and social sciences regarding the compatibility and the relative merits of quantitative and qualitative approaches in research. In psychiatry, depending on disciplines and traditions, objects of study can be represented either in words or using two types of mathematization. In the latter case, the use of mathematics in psychiatry is most often only local, as opposed to global as in the case of classical mechanics. Relationships between these objects of study can in turn be explored in three different ways: 1/ by a hermeneutic process, 2/ using statistics, the most frequent method in psychiatric research today, 3/ using equations, i.e. using mathematical relationships that are formal and deterministic. The 3 ways of representing entities (with language, locally with mathematics or globally with mathematics) and the 3 ways of expressing the relationships between entities (using hermeneutics, statistics or equations) can be combined in a cross-tabulation, and nearly all nine combinations can be described using examples. A typology of this nature may be useful in assessing which epistemological perspectives are currently dominant in a constantly evolving field such as psychiatry, and which other perspectives still need to be developed. It also contributes to undermining the overly simplistic and counterproductive beliefs that accompany the assumption of a Manichean “quantitative/qualitative” dichotomy. Systematic examination of this set of typologies could be useful in indicating new directions for future research beyond the quantitative/qualitative divide.     

The dilemma of localizing language: John Abercrombie's unexploited evidence

John Abercrombie (1780-1844) was considered the most eminent Scottish physician of his time. In his Pathological and Practical Researches on the Diseases of the Brain and Spinal Cord (1836, Edinburgh: John Carfrae and Son, 3rd ed.) he described the cases of 140 patients with cerebral disorders, 48 of whom suffered from language disturbances. Despite the overwhelming clinical and neuropathological evidence of a close association between language disorder and right-sided hemiparesis or diseases of the left hemisphere, and in spite of his great interest in language disorders, he made no attempt to localize the aphasic syndrome to a specific brain area.     

Schooling and traditional collaborative social organization of problem solving by Mayan mothers and children.

Traditional indigenous social organization in the Americas has been characterized as involving horizontal multiparty engagements, in contrast with schooling, which often relies on hierarchy and division of labor. This study examined whether the social organization of problem solving of Guatemalan Mayan indigenous mothers and children varied with the mothers' extent of experience with school. We observed 47 mothers as they constructed a puzzle with 3 children (ages 6-12 years). Mayan mothers with little schooling (0-2 grades) were involved more in horizontal, multiparty engagements, whereas Mayan mothers with extensive experience with schooling (12 or more grades) were involved more in hierarchical, division-of-labor engagements with the children. The results suggest that Western formal schooling contributes to the reshaping of traditional collaborative social organization among indigenous Mayan people.     

A 9-YEAR-OLD WITH CONVERSION DISORDER, SUCCESSFULLY TREATED WITH PSYCHOANALYSIS

This paper outlines the successful psychoanalytic treatment of a latency-aged boy with severe conversion disorder. Details of clinical treatment are presented. As no tested treatment has yet been found that reliably treats chronic conversion in children, this case is of importance in demonstrating the usefulness of psychoanalysis as treatment for severe psychopathology. The patient's unconscious fantasy constellations that gave rise to this syndrome are highlighted.     

School Effectiveness Findings 1979–2002

The London studies of school effectiveness in the 1970s provided evidence that the qualities of schools made a significant difference to pupil progress, after taking account of the characteristics and backgrounds of the pupils at the time of school entry. The purpose of this article is to review the further evidence that has accumulated since then in order to assess how far the findings have been confirmed or refuted, what new questions have arisen and what key challenges remain. The continuing areas of research and debate include school effects on behavioral outcomes, the effects of class size, the importance of parental involvement, the impact of intake mix, peer influences, and level of resources. There has been greater agreement on the many features fostering school effectiveness. However, questions remain on how to bring about desired changes. The paper concludes by drawing attention to 10 largely unanswered questions that matter for policy and practice.     

Inferentialism and Communicative Action: Robust Conceptions of Intersubjectivity

Brandom's inferentialism provides a semantics that complements Habermas's theory of communicative action without sacrificing its intersubjectivist insights. Pace Habermas, Brandom's conception of communication is robustly intersubjective. At the pragmatic level, interlocutors inherit each other's commitments and entitlements and must justify their claims when challenged; at the semantic level, anaphora show how the web of meaning is knit together, connecting expressions of the language as well as interlocutors. Finally, Habermas's thesis that there are three irreducible types of validity claim is preserved by linking claims to truth and rightness with mutually irreducible patterns of inference.