Casuistry as methodology in clinical ethics

This essay focuses on how casuistry can become a useful technique of practical reasoning for the clinical ethicist or ethics consultant. Casuistry is defined, its relationship to rhetorical reasoning and its interpretation of cases, by employing three terms that, while they are not employed by the classical rhetoricians and casuists, conform, in a general way, to the features of their work. Those terms are (1) morphology, (2) taxonomy, (3) kinetics. The morphology of a case reveals the invariant structure of the particular case whatever its contingent features, and also the invariant forms of argument relevant to any case of the same sort: these invariant features can be called topics. Taxonomy situates the instant case in a series of similar cases, allowing the similarities and differences between an instant case and a paradigm case to dictate the moral judgment about the instant case. This judgment is based, not merely on application of an ethical theory or principle, but upon the way in which circumstances and maxims appear in the morphology of the case itself and in comparison with other cases. Kinetics is an understanding of the way in which one case imparts a kind of moral movement to other cases, that is, different and sometimes unprecedented circumstances may move certain marginal or exceptional cases to the level of paradigm cases. In conclusion, casuistry is the exercise of prudential or practical reasoning in recognition of the relationship between maxims, circumstances and topics, as well as the relationship of paradigms to analogous cases.     

Chronic pain,compensation and clinical knowledge

The nosological status of the putative clinical entity of compensation neurosis and the relationship of chronic pain complaints to compensation are explored. It is concluded that, using the traditional criteria of diagnostic validity, there is no support for the view that a specific type of psychiatric disorder related to compensation or litigation can be demonstrated. Although it has been generally considered that chronic pain complaints reflect an underlying disease state, recent evidence has shown that in the medico-legal setting the nature of the compensation system and the level of available benefits have a marked influence on both the rate of chronic pain complaints and the duration of pain related work incapacity.     

CURRENT TRENDS IN THE PHILOSOPHY OF MEDICINE

Abstract. The philosophy of medicine, a developing discipline, is defined as critical reflection on the activity of medicine. The clinical encounter is both its central aspect and the focus for philosophical analysis. The most systematic example of this discipline employs a mixture of empiricism and phenomenology. Systems thought presents an organizing schema by which the philosophy of medicine can move toward a more comprehensive and fundamental analysis of its own agenda, which includes four main topics: understanding the patient-physician interaction, concepts of health and disease, foundations of medical ethics, and the dialogue between medicine and the larger culture.     

A Sequential Analysis of Depressive Behaviors Within Adolescent Peer Interactions

This study examined depressive and positive patterns of interactions among clinical and nonclinical adolescent peers within an interpersonal context. Ten clinical dyads with a depressed partner and 10 nonclinical dyads engaged in 16-min audiotaped conversations under positive and negative task instructions discussing positive and negative experiences. Conversations were unitized and coded according to depressive, aggressive, positive, and neutral behaviors. The clinical dyad-group demonstrated over two times more depressive behaviors than did the nonclinical dyad-group. Both dyad-groups exhibited increased depressive interactions during negative task instructions and increased positive interaction during positive task instructions. The loglinear approach to sequential analysis demonstrated significant overall bidirectional influence in the adolescents' dyadic interaction. Specifically, we found that the depressed adolescents' depressive behaviors decreased the likelihood of partners' aggressive behaviors, and increased the likelihood of partners' positive behaviors. Clinical and nonclinical dyad-groups showed reliable patterns of positive interaction sequences. Results demonstrate that depressive and positive behaviors are functional in adolescent dyadic interaction.     

循证医学与临床实践

循证医学是９０ 年代诞生的新兴医学科学。其要点是将临床医学领域的研究结果进行系统、全面的综合评价,为临床医疗实践、科研、卫生决策和医学教育提供可靠的科学证据。在发达国家的运用表明它已经对临床实践产生了重大而深远的影响,并将继续在临床医学领域发挥重要的作用。     

Cultural Issues in Psychopharmacology: Integrating Medication Treatment with Lakota Sioux Traditions

Psychologists may soon be entering into the practice of pharmacologic treatment of mental illness. Although there has been some investigation of biologic differences in drug response among various ethnic and racial groups, very little attention has been paid to the nonbiologic differences. Cultural definitions of health, healing, and illness and specific cultural practices are likely to have a significant impact on various aspects of treatment, compliance, and interaction effects. This article addresses the issue of culture and the impact of cultural practices on the use of psychotropic medications with the Lakota (Sioux) people of the Northern Plains. Specific examples of traditional Lakota ceremonies and their potential interactions with psychotropic medications are presented with recommendations to prescribers for handling these situations in a culturally responsive manner. Emphasis is placed on creating collaborative relationships between prescribers and traditional spiritual healers in the care of Native American clients. Recommendations for future research are discussed.     

The Biomedical Disciplines and the Structure of Biomedical and Clinical Knowledge

The relation between biomedical knowledge and clinicalknowledge is discussed by comparing their respectivestructures. The knowledge of a disease as a biologicalphenomenon is constructed by the interaction of factsand theories from the main biomedical disciplines:epidemiology, diagnostics, clinical trial, therapydevelopment and pathogenesis. Although these facts andtheories are based on probabilities andextrapolations, the interaction provides a reliableand coherent structure, comparable to a Kuhnianparadigma. In the structure of clinical knowledge,i.e. knowledge of the patient with the disease, notonly biomedical knowledge contributes to the structurebut also economic and social relations, ethics andpersonal experience. However, the interaction betweeneach of the participating ``knowledges' in clinicalknowledge is not based on mutual dependency andaccumulation of different arguments from each, as inbiomedical knowledge, but on competition and partialexclusion. Therefore, the structure of biomedicalknowledge is different from that of clinicalknowledge. This difference is used as the basis for adiscussion in which the place of technology,evidence-based medicine and the gap between scientificand clinical knowledge are evaluated.     

Exercise Stage of Change and Self-Efficacy in Primary Care: Implications for Intervention

Multiple chronic diseases are caused or complicated by a sedentary lifestyle. Thus, an important and challenging application of psychology in clinical settings is changing the behavior of sedentary primary care patients. This study focused on exercise stage of change and self-efficacy in a sample of adult family practice patients recruited while waiting for their scheduled physician appointment. Regarding exercise stage of change, 15% of respondents were in the Precontemplation stage, 26% in the Contemplation stage, 50% in the Preparation stage, 7% in the Action stage, and 13% in the Maintenance stage. Mean self-efficacy scores for exercise were significantly higher among respondents in the Action and Maintenance stages of change. These cross-sectional data are consistent with the hypothesis that movement through the exercise stages of change could be encouraged by clinical interventions that increase exercise self-efficacy. The identification of multiple personal opportunities for increasing exercise self-efficacy may be clinically useful in this context. Recommendations for psychologists in primary care settings in their work with physicians are offered.