Engagement and suffering in responsible caregiving: On overcoming maleficience in health care

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as ‘clinical phronesis,’ i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of ‘virtue ethics,’ yet one that is informed by the exigencies of moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their “disengaged” form (reflecting the malaise of “modern medicine”). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the ‘silent world of doctor and patient’ — provides may deny or refuse any ‘given’ connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of ‘calculative reasoning’ only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can ‘save the life of medical ethics’ — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can ‘prevent the death of medical ethics.’     

An ethical excursion through labeling the mentally retarded

Review of a representative body of research data concerning the effects of the “mentally retarded” (MR) label on parents, teachers, college students, nonretarded children, communities, and persons labeled fails to support the extravagant claim of some investigators that the labeling process has psychologically damaging effects upon the individuals labeled as well as society. Negative reactions to labels could be minimized by extensive public education and counseling. Labels should be retained as formal instruments essential to establishing the eligibility of the retarded for special assistance, and for maintenance of communication within and between disciplines, without which contemporary society could not operate. An argument for the judicious use of labels is fashioned, recommending replacement of the MR label by “AD” (adaptively deficient), in keeping with the modern view of mental retardation as a psychosocial challenge deemphasizing IQ and requiring adjustment of the whole personality to demands of a complex environment (e.g., coping skill, motivation). Parents, teachers, friends, employers, and public officials could support the AD's struggle to effectively participate in community life by promoting the perennial values of respect for human dignity, fairness, equality, autonomy, and compassion. As a result of monitoring the success of such programs in all settings, public policy administrators could formulate rational approaches to improvement of service programs in the national interest.     

Cross-modal and intra-modal binding between identity and location in spatial working memory: The identity of objects does not help recalling their locations

In this study we tested incidental feature-to-location binding in a spatial task, both in unimodal and cross-modal conditions. In Experiment 1 we administered a computerised version of the Corsi Block-Tapping Task (CBTT) in three different conditions: the first one analogous to the original CBTT test; the second one in which locations were associated with unfamiliar images; the third one in which locations were associated with non-verbal sounds. Results showed no effect on performance by the addition of identity information. In Experiment 2, locations on the screen were associated with pitched sounds in two different conditions: one in which different pitches were randomly associated with locations and the other in which pitches were assigned to match the vertical position of the CBTT squares congruently with their frequencies. In Experiment 2 we found marginal evidence of a pitch facilitation effect in the spatial memory task. We ran a third experiment to test the same conditions of Experiment 2 with a within-subject design. Results of Experiment 3 did not confirm the pitch–location facilitation effect. We concluded that the identity of objects does not affect recalling their locations. We discuss our results within the framework of the debate about the mechanisms of “what” and “where” feature binding in working memory.     

On the nature of intuitive and delusional thought: Its implications in clinical work with psychotic patients

The author tries to differentiate intuitive imagination from delusional imagination and hypothesises that psychosis alters the system of intuitive thinking, which consequently cannot develop in a dynamic and selective way. Scholars of different disciplines, far removed from psychoanalysis, such as Einstein, Hadamard or Poincar, believe that intuitive thinking works in the unconscious by means of hidden processes, which permit a creative meeting of ideas. Thanks to Bion's work, psychoanalysts have begun to understand that waking thinking is unconsciously intertwined with dream‐work. The delusional construction is similar to a dreamlike sensorial production but, unlike a real dream, it remains in the waking memory and creates characters which live independently of the ‘dreamer's’ awareness. It is a dream that never ends. On the contrary, the real dream disappears when it has brought its communicative task to an end. In the analysis of psychotic patients it is very important to analyse the delusional imagination which dominates the personality and continuously transforms the mental state, twisting emotional truth. The delusional imagination is so deeply rooted in the patient's mental functioning that, even after systematic analysis, the delusional world, which had seemed to disappear, re‐emerges under new configurations. The psychotic core remains encapsulated; it produces unsteadiness and may induce further psychotic states in the patient. The author reports some analytic material of a patient, who, after a delusional episode treated with drugs, shows a vivid psychotic functioning. Some considerations are added on the nature of the psychotic state and on the therapeutic approach used to transform the delusional structure. This paper particularly deals with the difficulty in working through the psychotic episode and in ‘deconstructing’the delusional experience because of the terror connected with it. In the reported case, the analytic work changed the delusional construction into a more benign one characterised by phobic qualities. The analysis of the psychotic transference allowed the focus to be on the hidden work which had been continuously influencing the transferential picture of the analyst and the patient's psychic reality.     

Violence and Latin‐American preadolescents: A study of social brain function and cortisol levels

The present study investigated exposure to violence and its association with brain function and hair cortisol concentrations in Latin‐American preadolescents. Self‐reported victimization scores (JVQ‐R2), brain imaging (fMRI) indices for a social cognition task (the ‘eyes test’), and hair cortisol concentrations were investigated, for the first time, in this population. The eyes test is based on two conditions: attributing mental state or sex to pictures of pairs of eyes (Baron‐Cohen, Wheelwright, Hill, Raste, & Plumb, 2001). The results showed an association among higher victimization scores and (a) less activation of posterior temporoparietal right‐hemisphere areas, in the mental state condition only (including right temporal sulcus and fusiform gyrus); (b) higher functional connectivity indices for the Amygdala and Right Fusiform Gyrus (RFFG) pair of brain regions, also in the mental state condition only; (c) higher hair cortisol concentrations. The results suggest more exposure to violence is associated with significant differences in brain function and connectivity. A putative mechanism of less activation in posterior right‐hemisphere regions and of synchronized Amygdala: RFFG time series was identified in the mental state condition only. The results also suggest measurable effects of exposure to violence in hair cortisol concentrations, which contribute to the reliability of self‐reported scores by young adolescents. The findings are discussed in light of the effects of exposure to violence on brain function and on social‐cognitive development in the adolescent brain. A video abstract of this article can be viewed at https://www.youtube.com/watch?v=qHcXq7Y9PBk