What Is Mental Effort: A Clinical Perspective.

Although mental effort is a frequently used term, it is poorly defined and understood. Consequently, its usage is frequently loose and potentially misleading. In neuroscience research, the term is used to mean both the cognitive work that is done to meet task demands and the subjective experience of performing that work. We argue that conflating these two meanings hampers progress in understanding cognitive impairments in neuropsychiatric conditions because cognitive work and the subjective experience of it have distinct underlying mechanisms. We suggest that the most coherent and clinically useful perspective on mental effort is that it is a subjective experience. This makes a clear distinction between cognitive impairments that arise from changes in the cognitive apparatus, as in dementia and brain injury, and those that arise from subjective difficulties in carrying out the cognitive work, as in attention-deficit/hyperactivity disorder, depression, and other motivational disorders. We review recent advances in neuroscience research that suggests that the experience of effort has emerged to control task switches so as to minimize costs relative to benefits. We consider how these advances can contribute to our understanding of the experience of increased effort perception in clinical populations. This more specific framing of mental effort will offer a deeper understanding of the mechanisms of cognitive impairments in differing clinical groups and will ultimately facilitate better therapeutic interventions.

Ethical principles and a practical approach to support policy making through the next phases of the COVID-19 pandemic and beyond.

There is an urgent need for an ethical framework to help us address the local and national challenges that we face as clinicians during the COVID-19 pandemic. We propose four key commitments from which a practical and consistent ethical approach can be derived. These commitments are to articulate the needs, rights and interests of the different stakeholders affected by any policy; to be accountable and transparent, recognising that people are autonomous individuals with values and concerns of their own; to consider the impact of our actions on the sustainability of the NHS, infrastructure, service demands and staff welfare; and to treat everybody equitably, with all deserving of consideration and care. Implementing these commitments will require a number of specific actions. We must put in place frameworks enabling clear advocacy for each competing objective; communicate policy and practice effectively to the public; promote integration of decision-making among social, primary, secondary and tertiary care and reduce or stop unnecessary or inefficient interventions; minimise health inequalities; and build spare capacity into the system.In this article, we expand on these actions, and note the legal context in which this would be delivered.

Too much medicine: not enough trust?

As many studies around the theme of 'too much medicine' attest, investigations are being ordered with increasing frequency; similarly the threshold for providing treatment has lowered. Our contention is that trust (or lack of it) is a significant factor in influencing this, and that understanding the relationship between trust and investigations and treatments will help clinicians and policymakers ensure ethical decisions are more consistently made. Drawing on the philosophical literature, we investigate the nature of trust in the patient-doctor relationship, arguing that at its core it involves a transfer of discretion. We show that there is substantial empirical support for the idea that more trust will reduce the problem of too much medicine. We then investigate ways in which trust can be built, concentrating on issues of questioning, of acknowledging uncertainty and of shouldering responsibility for it. We argue that offering investigations or treatments as a way of generating trust may itself be an untrustworthy way of proceeding, and that healthcare systems should provide the institutional support for facilitating continuity, questioning and the entrusting of uncertainty.

The Addict in Us all.

In this paper, we contend that the psychology of addiction is similar to the psychology of ordinary, non-addictive temptation in important respects, and explore the ways in which these parallels can illuminate both addiction and ordinary action. The incentive salience account of addiction proposed by Robinson and Berridge (1-3) entails that addictive desires are not in their nature different from many of the desires had by non-addicts; what is different is rather the way that addictive desires are acquired, which in turn affects their strength. We examine these "incentive salience" desires, both in addicts and non-addicts, contrasting them with more cognitive desires. On this account, the self-control challenge faced by addicted agents is not different in kind from that faced by non-addicted agents - though the two may, of course, differ greatly in degree of difficulty. We explore a general model of self-control for both the addict and the non-addict, stressing that self-control may be employed at three different stages, and examining the ways in which it might be strengthened. This helps elucidate a general model of intentional action.