A Legacy of Silence: Bioethics and the Culture of Pain

For over 20 years the medical literature has carefully documented the undertreatment of all types of pain by physicians. During this same period, as the field of bioethics came of age, the phenomenon of undertreated pain received almost no attention from the bioethics literature. This article takes bioethicists to task for failing to recognize the undertreatment of pain as a major ethical, and not merely a clinical, failing of the medical profession. The nature and extent of the problem of undertreated pain is examined, as well as possible reasons for its disregard by bioethicists. The factors contributing to undertreated pain in the clinical setting are considered, as well as the hazards posed by recent failures to address ethically questionable clinical practices. Finally, suggestions are offered for refocusing the attention of bioethicists to this significant problem.     

Deterrence, Opportunity, and Choice

Traditional studies of deterrence have focused on punishment with less regard for the rewards of both crime and noncrime. Influenced by work in economics and behavioral psychology, more recent studies have departed from tradition by incorporating rewards for crime. To this extent, they should be regarded as advances over the more traditional approaches. Notwithstanding these advances, variations in both the probability and magnitude of reward for noncrime have not been systematically included in these more recent theories of choice. In an attempt to determine whether opportunities for noncrime are either central or trivial to the criminal decision-making process, the present study fitted two alternative models to experimental data involving risk-taking: (a) the economic utility model employed by Piliavin, Gartner, Thornton, and Matsueda (1986) in their study of criminal choice; and (b) the satisfaction balance model developed by Gray and Tallman (1984). Results showed that while both models explained significant amounts of variation in the dependent variable, the Gray-Tallman model provided a substantially better fit of the data. Despite limitations inherent in experimental studies as, for example, limitations surrounding the issue of external validity, the findings strongly suggest that opportunities for noncrime are as important as rewards and costs for crime in the process by which criminal decisions are made.     

“Not with me you don't”: A story of narrative practice and dissociative disorder

This paper discusses issues relating to therapeutic practice based upon the narrative metaphor. A case of someone suffering the effects of Dissociative Identity disorder is used to illustrate the difficulties that clients can experience with the “expert” knowledge conception of therapy. The value of the “respectful” and “non-expert” emphasis of Narrative Practice emerges even when the therapist believes that he or she lacks expertise in the client's apparent “condition.” Three themes emanating from the case form the basis for the discussion: the client's experience of being recruited into accepting the diagnostic label of Dissociative Identity Disorder; the effects of being forced to accept a contract to eliminate self-abusive behaviour; and the therapist's dealing with a gun in the therapy room.     

Perceiving geographical slant

People judged the inclination of hills viewed either out-of-doors or in a computer-simulated virtual environment. Angle judgments were obtained by having people (1) provide verbal estimates, (2) adjust a representation of the hill’s cross-section, and (3) adjust a tilt board with their unseen hand. Geographical slant was greatly overestimated according to the first two measures, but not the third. Apparent slant judgments conformed to ratio scales, thereby enhancing sensitivity to the small inclines that must actually be traversed in everyday experience. It is proposed that the perceived exaggeration of geographical slant preserves the relationship between distal inclination and people’s behavioral potential. Hills are harder to traverse as people become tired; hence, apparent slant increased with fatigue. Visually guided actions must be accommodated to the actual distal properties of the environment; consequently, the tilt board adjustments did not reflect apparent slant overestimations, nor were they influenced by fatigue. Consistent with the fact that steep hills are more difficult to descend than to ascend, these hills appeared steeper when viewed from the top.     

Evidence that blocking is due to associative deficit: Blocking history affects the degree of subsequent associative competition

Rats were trained on an appetitive discriminated operant procedure according to a blocking design, in which training with a compound stimulus (A + B) was given with or without prior training with A alone. Stimulus B was then presented in compound with a new stimulus (B + C compound). The ability of Stimulus B to block acquisition of control by Stimulus C was decreased by B having itself been blocked by A during the prior training. The results imply that the mechanism of blocking during the initial blocking procedure was a reduced association between Stimulus B and the reinforcer, and not a performance deficit such as that postulated by comparator models of learning.     

Racial differences in behavior disorders of children

This study compared black and white children on the Behavior Problem Checklist. Data on 1,162 white and 614 black children were obtained from school records and from teachers and were analyzed using multiple regression analysis of variance. Blacks were judged to have a greater frequency of behavior disorders than whites. A number of interactions of race with other variables were found, and their meanings were discussed.     

The changing pattern of perceptual analytic strategies and response selection with practice in a two-choice reaction time task

In the experiment reported here the primary hypothesis proposed, which was supported by the data, was that subjects performing a two-choice self-paced serial RT task would learn to change their strategy of perceptual analysis of signals presented to them as they became progressively more practised. Early in practice each signal is identified as a particular state of the display and an appropriate response is then made. Well practised subjects, however, select their responses by reference to the change or constancy between successive displays. This strategy implies that the assumptions made by the generally accepted simple S-R connectionist model of two-choice serial RT may be quite misleading, since the choice of any particular response must be determined not only by the display state but also by what the previous response had been.     

Alphanumeric category effects: Evidence against the sufficiency of a localization explanation

The Hatfield Polytechnic, Hatfield, Herts ALIO 9AB, England The experiment utilized a serial choice reaction time (RT) paradigm in which only one alphanumeric stimulus was presented per trial, and the target set consisted of a single identified item. The categorical relationship between the target and nontarget items was varied as a property of blocks of trials. Target and nontarget RTs were smaller when the specified target item (e.g., the number 6) was categorically distinct from the nontargets (e.g., letters) than when it was from the same category (e.g., digits). The processing of catch-trial stimuli (items from the alternate category to the nontargets) and homographie category-ambiguous items was inhibited only in the former, between-category, condition. The results are contrasted with those obtained in visual search tasks. They suggest that a “locational-cue” explanation of alphanumeric category effects is inadequate.     

Sharing behavior and racial preference in children

Three groups of white children, 43 preschoolers and first-graders, 46 third-graders, and 44 fifth-graders, were asked to choose either a white child or a black child as a recipient of sharing and also as a companion for several social interaction situations ordered for social distance. The preschoolers and first-graders preferred to share and interact socially with the white child. The third-graders and the fifth-graders displayed a weaker preference for the white child over the black child on the sharing task, no preference in situations of high social distance, and a preference for the white child in situations of low social distance. The results from ancillary measures suggested that the choices of the younger children were motivated by a generalized color preference but that the choices of the older children were guided by an awareness of the social meaning of racial categories.The investigation was supported by the Research Advisory Council of East Tennessee State University.     

An instrumented method for assessment and remediation of stuttering: A single-subject case study

A single-subject experimental design was used to investigate the feasibility of applying non-invasive laboratory instrumentation for examining speech physiology to assessment and biofeedback-based remediation of stuttering. Physiologic assessment facilitated the development of behavioral goals directed at changing respiratory and phonatory behaviors for this subject. Visual biofeedback therapy produced reduction in respiratory discontinuities and increased phonatory continuity, concomitant with reduced perceivable molar dysfluency. Methods used in this case illustrate a variety of options and problems related to clinical use of instrumentation. Results suggest that signals which represent respiratory, phonatory, and articulatory physiologic events may be clinically practical for evaluating and altering perceivable dysfluency.