The relevance of Rawls' principle of justice for research on cognitively impaired patients

An ethical conflict arises when we must performresearch in the interest of future patients,but that this may occasionally injure theinterests of today's patients.In the case of cognitively impaired persons, thequestion arises whether it is compatible withhumane healthcare not only to treat, but alsoto use these patients for research purposes.Some bioethicists and theologians haveformulated a general duty of solidarity, alsopertaining to cognitively impaired persons, as ajustification for research on these persons. Ifone examines this thesis from the theory ofjustice according to John Rawls, it is revealedthat such a duty of solidarity cannotnecessarily be extrapolated from Rawls'conception of justice. This is at least true ofRawls' difference principle, because accordingto the difference principle only those measuresare justifiable which serve the interest of therespective least well off. Those measures whichwould engender additional injury for the leastwell off could not be balanced by any utilityaccording to Rawls.However, John Rawls' difference principleis subordinate to the first principle,which is that each person has an equalright to the most extensive basic libertycompatible with the same liberty for others.These primary goods are determined by thefreedom and integrity of the person.This integrity of decisionally impaired personswould be in danger if one would abstain fromresearch and thus forego the increase inknowledge related to their disease. Thus onecould conclude, at least from Rawls' firstprinciple, that society must take on a duty toguarantee the degrees of freedom forcognitively impaired persons and thus alsosupport the efforts for their healing.     

Reasoning with Factors

The paper proposes an analysis and a formalisation of factor-based reasoning. After examining the relevance of factors in legal reasoning, binary and scalable factors (dimensions) are distinguished and the relations between them are discussed. An account of a fortiori reasoning with both types of factors is developed. This article reports ideas which are discussed and developed in Sartor (2005). We refer to the latter work for the theoretical framework in which our analysis of factors is embedded.     

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Volume Contents     

Betrayal And Paranoia: The Psychotherapist's Function as an Intermediary

We present an approach to the problem of structuring a therapeutic alliance with patients presenting paranoid symptoms, using both psychoanalytical and cognitive techniques. Initially, we focused on one of the main aspects of the paranoid worldview: the fear of being betrayed and the tendency to betray. This is a defense maneuver, through which patients deny their passivity, and the impotence in the relationship with their own internal needs and with the significant people in the external world, including the therapist. In our experience to build up a working relationship, both a psychoanalytical interpretation of unconscious conflicts and the cognitive analysis of dysfunctional beliefs are needed. Often, in more serious cases, the role of nonqualified object must be accepted at the beginning, due to the patient's need to be in control of the situation. Only then can a therapeutic phase begin, in most cases, through an integrated approach that includes pharmacological, psychodynamic, and cognitive modalities.     

Grandiose Fantasies and Low Self-Esteem: An Experimental Study

Grandiose states of mind could be an ineffective way to cope with low self-esteem. In fact, it is possible that grandiose fantasies would tend to induce doubts about personal worth and decrease self-esteem. This study explored whether grandiose fantasies help to cope with low self-esteem. The self-reported occurrence and unpleasantness of intrusive thoughts regarding the sense of exclusion, humiliation, and low self-esteem in non-clinical individuals were assessed during self-induced grandiose fantasies and self-induced relaxation. The occurrence and unpleasantness of low self-esteem intrusions were significantly higher during grandiose fantasies, suggesting that grandiose fantasy is ineffective at combating low self-esteem.     

Reliability of self-reported attachment style in patients with severe psychopathology

Little is known about whether severe psychopathology influences the assessment of self-reported attachment style. Fifty-eight randomly selected adult psychiatric inpatients completed the Experiences in Close Relationship questionnaire (ECR; Brennan, Clark, & Shaver, 1998) and were administered the 24-item Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993) and the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960) at both admission and discharge. The Structured Clinical Interview for DSM-IV (SCID-I; First, Spitzer, Gibbon, & Williams, 1996) was used to establish Axis I diagnoses. The ECR scales showed good internal consistency and absolute stability both in patients with (n = 24) and without (n = 34) a psychotic disorder. Relative stability was only fair among patients with psychotic disorders but good among patients without psychotic disorders. Neither higher BPRS or HDRS scores, nor the presence of a psychotic disorder, significantly reduced the retest reliability of the ECR scales. These findings suggest that self-report measures might provide a reliable assessment of attachment style in patients with severe psychopathology, except for the most severely impaired patients.     

BDNF serum levels in subjects developing or not post-traumatic stress disorder after trauma exposure

Post-traumatic stress disorder (PTSD) is a syndrome resulting from exposure to a severe traumatic event that poses threatened death or injury and produces intense fear and helplessness. The neural structures implicated in PTSD development belong to the limbic system, an important region for emotional processing. Brain-derived neurotrophic factor (BDNF) is a neurotrophin that serves as survival factor for selected populations of central nervous system (CNS) neurons and plays a role in the limbic system by regulating synaptic plasticity, memory processes and behavior. Impaired BDNF production in the brain can lead to a variety of CNS dysfunctions including symptoms associated with PTSD. However, so far fewer studies have investigated this neurotrophin in patients with PTSD. Furthermore, given the multiple role of BDNF in various CNS disorders, it cannot be excluded that traumatic events per se may influence neurotrophin levels, without a direct association to the PTSD syndrome.     

Consumer behaviour and the toilet: Research on expulsive and retentive personalities

During the last five decades, a number of studies have attempted to draw from psychoanalytic theory to examine the relationship between evacuation disorders and a person's character. According to Freud's original conceptualization, early or harsh toilet training leads children to develop an anal retentive personality, characterized by the tendency to control their bowels as well as their material possessions; by contrast, liberal toilet training leads children to develop an anal expulsive personality, characterized by the tendency to excessively relieve faeces, as well as be being careless, messy, and inclined to dispose of old products and buy new ones. Although toilet training may not be responsible, these sets of traits do cohere. To empirically examine these hypotheses, we studied the personality traits and consumption habits of people suffering from different bowel disorders. By means of semistructured interviews, we analysed the personality characteristics, sociodemographic backgrounds, and peculiar consumption habits of people suffering from constipation and diarrhoeic syndromes. The results show that constipated people tend to be obstinate, excessively concerned with hygiene, and inclined toward retaining possessions, whereas diarrhoeic people tend to be careless, disorganized, and disposed to share their possessions with others. We discuss the theoretical and practical implications of these results and indicate avenues for future research.     

Switching from reaching to navigation: differential cognitive strategies for spatial memory in children and adults

Navigational and reaching spaces are known to involve different cognitive strategies and brain networks, whose development in humans is still debated. In fact, high‐level spatial processing, including allocentric location encoding, is already available to very young children, but navigational strategies are not mature until late childhood. The Magic Carpet (MC) is a new electronic device translating the traditional Corsi Block‐tapping Test (CBT) to navigational space. In this study, the MC and the CBT were used to assess spatial memory for navigation and for reaching, respectively. Our hypothesis was that school‐age children would not treat MC stimuli as navigational paths, assimilating them to reaching sequences. Ninety‐one healthy children aged 6 to 11 years and 18 adults were enrolled. Overall short‐term memory performance (span) on both tests, effects of sequence geometry, and error patterns according to a new classification were studied. Span increased with age on both tests, but relatively more in navigational than in reaching space, particularly in males. Sequence geometry specifically influenced navigation, not reaching. The number of body rotations along the path affected MC performance in children more than in adults, and in women more than in men. Error patterns indicated that navigational sequences were increasingly retained as global paths across development, in contrast to separately stored reaching locations. A sequence of spatial locations can be coded as a navigational path only if a cognitive switch from a reaching mode to a navigation mode occurs. This implies the integration of egocentric and allocentric reference frames, of visual and idiothetic cues, and access to long‐term memory. This switch is not yet fulfilled at school age due to immature executive functions.