Tag: suffering

Bioethics Blogs

Teaching Medical Anthropology by Ari Gandsman

In the decade since becoming a full time professor, medical anthropology has been one of my core courses. I have taught it seven times.  Although the basic structure of the course remains similar, emphases have shifted over time. Perhaps I can best highlight the evolution of the course through a discussion of readings I use since readings are the backbone of a syllabus.  Even though I generally do not follow texts closely since I see lectures as overlapping but also supplemental and complimentary to readings, I try to mirror topics that they will be reading about, often highlighting a general theoretical literature or approach while the students read a single illustration.

Starting from the beginning, my history of medical anthropology remains the same, focusing on when “medicine” was subsumed into broad and now antiquated anthropological categories of magic and witchcraft. I never stray far from Evans-Pritchard’s Witchcraft, Oracles & Magic Among The Azande, an apparent professional contractual obligation for meAlthough I have given them the entire ethnography [the abridged in print edition] to read twice in the past, I have more lately just given them a short excerpt, often “The Notion of Witchcraft Explains Unfortunate Events.” I once also used W.H. Rivers Medicine, Magic and Religion but, although fascinating and of historic importance, it proved esoteric for an undergraduate course.  When I first started teaching, I tried to include more on non-Western medical systems, including using ethnographies on Traditional Chinese Medicine or Tibetan medicine. More recent students may be disappointed that I do not delve further into non-Western medical systems, what many students with hazy ideas of the discipline may think a medical anthropology course should almost entirely consist of.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Luhrmann and Marrow’s Our Most Troubling Madness by Murphy Halliburton

Our Most Troubling Madness: Case Studies in Schizophrenia Across Cultures

T.M. Luhrmann and Jocelyn Marrow, editors

University of California Press, 2016, 304 pages

 

A key premise of this volume of ethnographic case studies is that schizophrenia, or the various conditions we label as schizophrenia and related psychoses, varies in crucial ways in terms of experience, prognosis and outcome in different sociocultural contexts. Tanya Luhrmann’s introduction to the volume, which features twelve articles presenting twelve individuals diagnosed with schizophrenia (including three cases presented by Luhrmann), casts doubt on the biomedical model of schizophrenia, or at least the strong biomedical model where an individual’s biology is the determining factor in the pathogenesis of schizophrenia. Support for this critique comes from within the fields of psychiatry, psychology and related disciplines, and not just from anthropology, the disciplinary home base of many of the authors in this compilation. This supports the volume’s efforts to speak to an audience beyond the contributors’ own disciplines and “serve as a positive catalyst for change” in how we treat psychosis, especially in European and North American settings (5).

The introduction also briefly traces the history of theories of schizophrenia in psychiatry and anthropology, including moments when the two fields overlapped as with Gregory Bateson’s theory that schizophrenia results from a “double bind” that develops in a person’s psyche from conflicting social cues. This theory, put forth by an anthropologist, had a significant place in psychiatrists’ understanding of pathogenesis until the rise of the medical model deflected the blame from families toward “random bad genetic luck” (16).

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Breakthrough Immunotherapies Seem Like a Dream Come True for Children with Leukemia

Guest Post: Nancy Jecker, Aaron Wightman, Abby Rosenberg, Doug Diekema

Paper: From protection to entitlement: selecting research subjects for early phase clinical trials involving breakthrough therapies

A breakthrough therapy to cure cancer in children suffering from acute lymphoblastic leukemia (ALL) is a dream for many families.  New immunotherapies appear to make this dream a reality. Such therapies use a person’s own immune cells to recognize and combat their disease. In the largest study to date of ALL patients treated with a form of immunotherapy known as Chimeric Antigen Receptor (CAR) T-Cell therapy, a 93% remission rate was reported. Such results are a glimmer of hope for those whose prognoses were previously considered very poor.

However, the good news is tempered by the fact this potentially lifesaving experimental therapy may not be available to everyone who might benefit. And demand is growing as word spreads. Since CAR T-cell therapy for ALL is available only through clinical trials, do patients have a right to participate? How should we choose among medically suitable candidates?

We have faced these questions before. Most recently, with ZMapp to treat Ebola Virus Disease, azidothymidine (AZT) to treat HIV and AIDS, and Immunitab (Gleevac) to treat Chronic Myleogenous Leukemia. Are patients suffering from devastating, life-threatening diseases entitled to breakthrough therapies?

In a recent paper, we argue that benefit is a continuum, from the complete uncertainty associated with standard research, to an intermediate stage where evidence of benefit mounts and reaches a peak, to a final stage of clearly demonstrated benefit that is sufficient to gain approval for clinical applications.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

A Bioethics View of Executions in Arkansas

by Craig Klugman, Ph.D.

This week the state of Arkansas had planned to execute 8 death-row inmates in 4, back-to-back killings using lethal injection over 10 days. The last execution in Arkansas was 12 years ago, so why the sudden rush? As part of the three-drug cocktail used by this state, their supply of midazolam—an anesthetic—is about to expire. If they do not use the drug by the expiration date, then they can’t use it and the company that makes the drug will not sell it to the state for this purpose.

Arkansas had planned to use a combination of 3 drugs in the execution, midazolam (an anesthetic), vecuronium bromide (a paralytic), potassium chloride (to stop the heart). This cocktail would be used to kill the 8 men.

I say “had planned” because last week, two of the prisoners had judges issue stays on their executions. This move is not unusual as there is often a flurry of court appeals and filings in the time before an execution. What is unusual is that over the weekend, another judge placed a stay on all executions on the request of drug companies and distributors—Pfizer, Fresenius, West-Ward Pharmaceuticals, and McKesson—who do not want their drugs to be used in an execution. McKesson’s concern is that when they learned the reason the state bought the vecuronium bromide, that they refunded the cost and asked for the drug to be returned. Drug manufacturers and distributors have come out against their products being used to kill prisoners. The association is unlikely to be good for sales or brand reputation.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Donald Trump’s Mental Health (again)

The speculation about Donald Trump’s mental health that was doing the rounds earlier in the year seems to have died down a bit.  That’s to be expected; like it or not, his Presidency is now part of normal life.  But I’ve been lagging in my blogging here, and so it’s only now that I’ve got a moment to mention in passing an op-ed article about Trump in the New Scientist that appeared just after I posted last on the topic.  (February.  I know, I know.)

It’s by Allen Frances, and it takes issue with what he calls “armchair diagnosis” of the president.  He’s right to say that there’s something disquieting about armchair diagnosis: “psychiatric diagnosis is already done far too casually and inaccurately in medical and mental health practice.  Armchair diagnosis further cheapens its currency.”  However, I do wonder whether we ought to pay some attention to whose armchair it is.  Often, it’s an armchair occupied by the genuinely ignorant, or the spiteful.  That’s the internet for you.  Accusing someone of being mentally ill or having a personality disorder on this account may be simply mistaken; or it may be intended as a jibe, the subtext of which is that there’s something shameful about having a mental health problem.  But not every armchair is the same: as Frances’ article admits, a letter with 35 signatories who work within the mental health field appeared in the New York Times.  That letter may be misguided, or ill-motivated.  But it is by people who, presumably, know a thing or two about the topic.  Their armchair is not my armchair.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Law Changes and Slippery Slopes

Apparently, there was a TV programme in Australia the other day in which a there was a discussion of assisted dying.  It got reported in The Guardian, largely on the basis that an 81-year-old audience member kept calling Margaret Somerville “darling” and then got mildly sweary.  I’ve only seen those clips from the programme that are linked in the Graun‘s report, so I’m not going to comment on the tone of the debate in particular.  Rather, I’m interested in one of the responses to the programme, from Xavier Symons, writing in The Conversation.

Symons takes the opportunity to unpick the idea of a slippery slope argument – in this case, the claim that allowing some forms of assisted dying will commit us to allowing… well, that’s open-ended, but it’s sufficient to say that it’d be terrible.  We’d want to avoid terrible things; therefore, the argument goes, we shouldn’t allow any of it.  This is well-worn stuff in the seminar room, but it’s a mode of argument that refuses to die.  Quite correctly, Symons points out that

there is a need for empirical evidence or sound inferential reasoning to support the claim that event B will necessarily (or probably) follow on from event A.  Without this evidence, the argument is invalid. I can’t just claim, for example, that the legalisation of medicinal marijuana leads to the legalisation of ice – I need to show some empirical or logical connection between the two.

So far, so standard.  (I’d say “unsound” rather than “invalid”, because the validity of an argument doesn’t depend on its evidence – or, at least, not in the same way; but that’s a small matter.)  He then makes another move, which is a bit more interesting:

But (and it’s a big but) there is such a thing as a good and valid slippery slope argument.  A good slippery slope argument demonstrates a causal or probable relationship between event A and B, such that event B can legitimately be expected to occur if event A is allowed to occur.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

VR and PTSD: Healing from trauma by confronting fears in virtual reality environments

By Katie Givens Kime
Image courtesy of Flikr

What are the ethical implications of therapeutically re-exposing patients to trauma via virtual reality technologies? Of the 2.7 million American veterans of the Iraq and Afghanistan wars, at least 20% suffer from depression and/or post-traumatic stress disorder (PTSD), and other studies peg that percentage even higher. As a chronic, debilitating mental illness, one PTSD symptom is hyperarousal, in which a person repeatedly re-experiences a trauma in the form of nightmares, panic attacks, and flashbacks.  One of the most long-trusted therapeutic approaches to PTSD is exposure therapy; now, virtual reality technology is increasingly being used to simulate exposure to traumatic events and to environments related to the traumatic event.


Image courtesy of Flikr

Last month’s Neuroethics and Neuroscience in the News event featured the recent research and observations of Barbara O. Rothbaum, who is the Paul A. Janssen Chair in Neuropsychopharmacology at the Emory University School of Medicine and Director of the Emory Veterans Program & Trauma and Anxiety Recovery Program. Rothbaum outlined the way in which exposure therapy (with or without the aid of virtual reality technology) is based on principles of learning and also discussed reliable findings with animals and phobic disorders (Foa & Kozak, 1986). The underlying premise of such therapy is that repeated and prolonged exposure to feared but realistically safe stimuli leads to habituation, and eventually to extinction.

The virtual reality exposure therapy (VRE) combat environments for “Virtual Vietnam” (developed by Georgia Tech and Emory Universities) includes a virtual Huey helicopter, a “fly” over the jungles of Vietnam, a “walk” in clearings near jungles and swamps, and other imaginal immersions in Vietnam-related stimuli.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

The ethnographic case: series conclusion by Emily Yates-Doerr

Editors note: This entry concludes the series “The Ethnographic Case” which ran every other Monday between June 2015 and July 2016. The bookCase, which holds 27 cases, can be accessed here.

One day, early on in the series, we received two submissions. Their similar anatomy was striking. Each featured a medical waiting room. Someone entered the space with a gift for the clinical personnel, the gift was accepted, and something shifted in the resulting care.

In Aaron Ansell’s case, set within gardens of an informal clinic in Piauí, Brazil, the gift was a small satchel of milk. Rima Praspaliauskiene’s was set in a Lithuanian public hospital and the gift was a rich chocolate cake. Aaron, who works and teaches on legal orders, analyzed the exchange as a challenge to hospital norms of equalitarianism. He helped us to see how the give-and-take of milk interrupts the requirements of a deracinated liberal democracy, offering instead the warm sociality of personal affinity. Rima, who focuses on medical care and valuing, used the object of the cake to query the social scientist’s impulse to explain why people do what they do. She shows us how this impulse may rest upon the linearity and equivalence of rational calculation, uncomfortably treating sociality as a commodity.

The juxtaposition of these submissions is emblematic – a case, if you will – of something we have seen throughout this series: the art of ethnographic writing resides in a relation between what is there and what is done with it.

Beginnings

We might trace the origin of the series to a business meeting at the AAAs, when we offered the idea of “the ethnographic case” for a Somatosphere series.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Lincoln in the Bardo in the Bardo/ by Russell Teagarden

Russell Teagarden is an Editor of the NYU Literature Arts and Medicine Database and helped lead the Medical Humanities elective at the School of Medicine this past winter. In this blog post, he experiments with creating a text collage from recent reviews of George Saunders novel, Lincoln in the Bardo.

Author’s note:
George Saunders is well known for his inventive and affecting short stories. Lincoln in the Bardo is his first novel, and as described by Charles Baxter in his review in the April 20, 2017 issue of The New York Review of Books, it “doesn’t resemble any of his previous books…nor does it really resemble anyone else’s novel, present or past. In fact, I have never read anything like it.” The story is told by a chorus of spirits or ghosts in a “bardo,” which is a Tibetan limbo of a sort for souls transitioning from death to their next phase. Saunders rarely gives any individual spirit more than 2 or 3 lines of dialog, and he intersperses short snippets from historical textsasome real, some notato provide contextual background. Of particular interest to the medical humanities community will be the focus on the well-trodden subject of grief through this experimental approach. The book has attracted the attention of many serious critics, so many in fact, that they can be assembled into a chorus to derive a review of the book in the book’s format. I have thus taken excerpts from published reviewsamost real, a few notato produce a review that covers how the book is laid out (I), how the bardo works (II), how the story flows (III), and how it’s critically received (IV) as can be told by a chorus of reviewers in a bardo of their own.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

A Lesson in Humanism to Medical Students Prompted by a Mass Casualty Event

by Sergio Salazar, MD, MBE

The purpose of this editorial is to reveal how one of the most tragic events in our nation’s history helped teach future medical providers the influence that humanistic actions can have on relieving suffering and forward healing.

On June 12, 2016 the largest mass shooting incident in our nation’s history claimed the lives of forty-nine innocent victims at the Pulse night club in Orlando. The Pulse night club was frequented by the Latino LGBTQ community. The shooter was identified as a terrorist with extremist religious beliefs adding intolerance for alternative lifestyles and race to the massive loss of life.    Due to the emotional turmoil experienced by everyone in the community, a session was prepared to provide a platform for discussion and closure for our students. Some students had been directly or indirectly involved in the care of the victims. The majority were like the rest of us, bystanders trying to come to grips with the senseless loss of life.

The longitudinal curricular themes (LCT) at the University Of Central Florida College Of Medicine include Ethics and Humanities. As with other aspects of medicine, learning becomes enhanced when the context of a lesson is presented as a real life scenario. After the mass casualty event known as the “Pulse” event, it was evident to everyone that the student body needed the opportunity to express their feeling regarding this tragedy.  To meet this need, the faculty devoted one of the ethics and humanities LCT sessions to facilitate discussion using an expert panel format.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.