Ethical and Public Health Considerations for Integrating Physicians with Mental Disability into the Physician Workforce.

Stigma against mental disability within the medical field continues to impose significant barriers on physicians and trainees. Here, we examine several implications of this stigma and propose steps toward greater inclusion of persons with mental disabilities in the physician workforce.

Biases in the evaluation of self-harm in patients with disability due to spinal cord injury.

INTRODUCTION: Suicide is a global problem and accurate assessment of risk for self-harm is critical. Even morally principled clinicians can manifest bias when assessing self-harm in patients with physical disabilities such as spinal cord injury (SCI). Assessment of self-harm is an obligation for health care clinicians and overestimating or underestimating risk may undermine a patient's trust in their care, possibly leading to less engagement, increased apathy about having an interest in living, and less adherence to healthy treatment options. CASE PRESENTATION: Introduces readers to three biases that can impact decision-making regarding a patient with a disability when assessing the patient's risk for self-harm: (1) ineffectual bias, (2) fragile friendliness bias, and (3) catastrophe bias. These preconceptions are derived from a mix of paternalism, projection, low expectations, pity, and infantilization. In this paper, we explain how each bias can affect clinical decision-making regarding diagnosis, treatment, prognosis, and prevention for patients with SCI within a common case scenario. Readers can employ personal reflection and potential self-application when they encounter individuals with SCI in and outside clinical settings. DISCUSSION: Unchecked biases toward the disabled and patients with SCI can undermine ethical caregiving. Biases are habits of mind and thoughtful clinical and education interventions can improve clinical practice. The literature on health care bias with other minority groups is instructive for investigating biases related to patients with disabilities, and especially for clinicians outside of rehabilitation medicine.

From disability to human flourishing: how fourth wave psychotherapies can help to reimagine rehabilitation and medicine as a whole.

Aim: With disabled patients, clinicians are often mechanistically oriented, limiting goals to bodily improvements of perceived deficits back to species-typical functioning. Psychological goals, when present at all, are often pessimistically narrow, or phenomenologically shallow. Recent research on fourth wave psychotherapies helps broaden clinical concepts of healing and treatment beyond mere deficit remediation, and helps match clinical goals with the richness of human flourishing and the layered complexity of the patient's evolving experience of meaning.Method: This article draws from first-hand accounts of the experience of disability and adjustment to impairment, along with a synthesis of recent theoretical and experimental work in clinical psychology and psychotherapy, to present recommendations for more accurate and ethical notions of rehabilitation for clinical practice.Results: We explain the clinical value of "flourishing": the psychological, social, cultural, existential, moral, spiritual and religious dimensions of the patient in the context of their dynamic narrative existence in meaningful relationship and ritual formation. This approach allows clinicians to personalize and humanize caregiving in line with human strengths, move beyond an aim of mere recovery, more accurately characterize perceived impairments, goals of care, and successful treatment outcomes. These more capacious and experientially-attuned clinical concepts and aims help the clinician accompany and empower patients by understanding what is at stake throughout the illness experience.Conclusions: This flourishing model helps to reimagine the clinician-patient relationship, and the methods and entire purpose of rehabilitation medicine, and clinical medicine more broadly. The condition of blindness is presented as an illustrative case.Implications for rehabilitationAmidst vast medical and technological advances in diagnosis and treatment of disabilities, modern health systems often still approach rehabilitation of disability via species-typical standards of bodily or mental homeostasis as the standard of sound health, without considering the perspectives and experiences of flourishing that are unique to the individual who is sufferingPsychological, social scientific, and religious traditions uniquely explore the inner experiences of individuals and their relationships, and can be used to help patients find individualized paths to recovery, healing, and flourishingFourth-wave psychotherapies, utilizing existential, humanistic, and spiritual/religious philosophies, have resources clinicians can use to help patients aim beyond mere recovery, and allow for the possibility of "ultrabilitation"Attention to the psychological, social, cultural, existential, moral, spiritual, and religious dimensions of the patient in the context of their dynamic existence can promote ultrabilitationDedicated focus on compassion, virtue, dignity, gratitude, contemplative wisdom, and transcendence can enable one to conceptualize flourishing in a way independent or complementary to bodily outcomes in recovery, and sometimes even when illness or disability persists.

The psychology of coordination and common knowledge.

Research on human cooperation has concentrated on the puzzle of altruism, in which 1 actor incurs a cost to benefit another, and the psychology of reciprocity, which evolved to solve this problem. We examine the complementary puzzle of mutualism, in which actors can benefit each other simultaneously, and the psychology of coordination, which ensures such benefits. Coordination is facilitated by common knowledge: the recursive belief state in which A knows X, B knows X, A knows that B knows X, B knows that A knows X, ad infinitum. We test whether people are sensitive to common knowledge when deciding whether to engage in risky coordination. Participants decided between working alone for a certain profit and working together for a potentially higher profit that they would receive only if their partner made the same choice. Results showed that more participants attempted risky coordination when they and their prospective partner had common knowledge of the payoffs (broadcast over a loudspeaker) than when they had only shared knowledge (conveyed to both by a messenger) or private knowledge (revealed to each partner separately). These results support the hypothesis that people represent common knowledge as a distinct cognitive category that licenses them to coordinate with others for mutual gain. We discuss how this hypothesis can provide a unified explanation for diverse phenomena in human social life, including recursive mentalizing, performative speech acts, public protests, hypocrisy, and self-conscious emotional expressions.

Emerging perspectives on adolescents and young adults with high-functioning autism spectrum disorders, violence, and criminal law.

As the prevalence of autism spectrum disorders (ASDs) has increased, attention has shifted toward consideration of ASDs in adolescence and adulthood, as well as public health repercussions for this population. Since the social and emotional deficits within ASDs may be salient during incidents of unintended criminal or violent behavior, one area of focus is involvement of adolescents and young adults with ASD in the criminal justice system. Without a thorough understanding of how and why individuals with ASDs may exhibit criminal behavior, judicial and legislative state systems have begun to develop policies lacking a substantial evidence base. In this article, we attempt to synthesize the literature on one type of ASD (high functioning) and criminal behavior. Three specific deficits characteristic of individuals with ASDs (theory of mind, emotion regulation, and moral reasoning) are examined as potential confluent forces leading to criminal behavior among individuals with ASDs. Legal and policy recommendations are presented.

Dehumanization in Medicine: Causes, Solutions, and Functions.

Dehumanization is endemic in medical practice. This article discusses the psychology of dehumanization resulting from inherent features of medical settings, the doctor-patient relationship, and the deployment of routine clinical practices. First, we identify six major causes of dehumanization in medical settings (deindividuating practices, impaired patient agency, dissimilarity, mechanization, empathy reduction, and moral disengagement). Next, we propose six fixes for these problems (individuation, agency reorientation, promoting similarity, personification and humanizing procedures, empathic balance and physician selection, and moral engagement). Finally, we discuss when dehumanization in medical practice is potentially functional and when it is not. Appreciating the multiple psychological causes of dehumanization in hospitals allows for a deeper understanding of how to diminish detrimental instances of dehumanization in the medical environment.