Moral enhancement, at the peak of pharmacology and at the limit of ethics.

The debate over the improvement of moral capacity or moral enhancement through pharmacology has gained momentum in the last decade as a result of advances in neuroscience. These advances have led to the discovery and allowed the alteration of patterns of human behavior, and have permitted direct interventions on the neuronal structure of behavior. In recent years, this analysis has deepened regarding the anthropological foundations of morality and the reasons that would justify the acceptance or rejection of such technology. We present a review of proposals for pharmacological interventions directed directly towards moral enhancement. In addition, we identify the ethical dilemmas that such interventions may generate, as well as the moral assessment of the authors of these studies. There is a moderate consensus on the risks of any intervention on the intimate structure of the human condition, its autonomy and identity, but there are large differences in explaining the reasons for this concern and especially in justifying such interventions. These findings show that it is necessary to investigate the moral assessment of authors and the ethical dimension within the field of pharmacology in order to identify future trends.

Nudging in nursing.

Nudging is a concept in behavioural science, political theory and economics that proposes indirect suggestions to try to achieve non-forced compliance and to influence the decision making and behaviour of groups and individuals. Researchers in medical ethics are currently discussing whether nudging is ethically permissible in healthcare. In this article, we examine current knowledge about how different decisions (rational and pre-rational decisions, major and minor decisions) are made and how this decision-making process pertains to patients. We view this knowledge in light of the nursing project and the ongoing debate regarding the ethical legitimacy of nudging in healthcare. We argue that it is insufficient to discuss nudging in nursing and healthcare in light of free will and patient autonomy alone. Sometimes, nurses must take charge and exhibit leadership in the nurse-patient relationship. From the perspective of nursing as leadership, nudging becomes a useful tool for directing and guiding patients towards the shared goals of health, recovery and independence and away from suffering. The use of nudging in nursing to influence patients' decisions and actions must be in alignment with the nursing project and in accordance with patients' own values and goals.

Ethical considerations for sleep intervention in organizational psychology research.

Over the past several years, interest into the role of sleep in the workplace has grown. The theoretical shift from research questions examining sleep as an outcome to placing sleep as the independent variable has increased experimental approaches to manipulating sleep in organizational studies. This is an exciting trend that is likely to continue in the organizational sciences. However, sleep experimentation can also pose special challenges for organizational researchers unaccustomed to sleep science. In this commentary, I discuss five ethical considerations of conducting negative sleep interventions in organizational psychology research. I also provide recommendations for organizational researchers-or even other researchers in disciplines outside of sleep science-who wish to implement sleep interventions in their studies.

'Autism and the good life': a new approach to the study of well-being.

Medical, psychological, educational and social interventions to modify the behaviour of autistic people are only justified if they confer benefit on those people. However, it is not clear how 'benefit' should be understood. Most such interventions are justified by referring to the prospect that they will effect lasting improvements in the well-being and happiness of autistic people, so they can lead good lives. What does a good life for an autistic person consist in? Can we assume that his or her well-being is substantively the same as the well-being of non-autistic individuals? In this paper, we argue that, as it stands, the current approach to the study of well-being is for the most part unable to answer these questions. In particular, much effort is needed in order to improve the epistemology of well-being, especially so if we wish this epistemology to be 'autism-sensitive'. Towards the end of the paper, we sketch a new, autism-sensitive approach and apply it in order to begin answering our initial questions.

US state variation in autism insurance mandates: balancing access and fairness.

This article examines how nations split decision-making about health services between federal and sub-federal levels, creating variation between states or provinces. When is this variation ethically acceptable? We identify three sources of ethical acceptability-procedural fairness, value pluralism, and substantive fairness-and examine these sources with respect to a case study: the fact that only 30 out of 51 US states or territories passed mandates requiring private insurers to offer extensive coverage of autism behavioral therapies, creating variation for privately insured children living in different US states. Is this variation ethically acceptable? To address this question, we need to analyze whether mandates go to more or less needy states and whether the mandates reflect value pluralism between states regarding government's role in health care. Using time-series logistic regressions and data from National Survey of Children with Special Health Care Needs, Individual with Disabilities Education Act, legislature political composition, and American Board of Pediatrics workforce data, we find that the states in which mandates are passed are less needy than states in which mandates have not been passed, what we call a cumulative advantage outcome that increases between-state disparities rather than a compensatory outcome that decreases between-state disparities. Concluding, we discuss the implications of our analysis for broader discussions of variation in health services provision.

Surrogate partner therapy: ethical considerations in sexual medicine.

INTRODUCTION: Surrogate partner therapy (SPT) is a controversial and often misunderstood practice. AIM: The aim of this study was to review the history and evidence-based literature regarding SPT, describe and provide a model for ethical SPT practice, and present two case examples illustrating ethical concerns. METHODS: Literature review and report of clinical experience were the methods used. MAIN OUTCOME MEASURE: Results of literature review and clinical experience were assessed for this study. RESULTS: Sex therapy pioneers Masters and Johnson introduced surrogacy in sex therapy; however, there is a lack of published evidence supporting treatment efficacy and ethico-legal questions have limited the practice from becoming a common intervention. SPT can be an effective intervention that may enhance sexual medicine practice. However, SPT must be offered according to legal, professional, and ethical standards. CONCLUSIONS: Sexual medicine practitioners should consider SPT based on the ethical paradigms offered, and sex therapy practices utilizing SPT should collect and publish outcome data.

Trauma and diverse child populations.

It has been estimated that as many as two-thirds of American youth experience a potentially life-threatening event before 18 years of age and that half have experienced multiple potentially traumatic events. Race, ethnicity, and culture influence the frequency and nature of these traumas and also the ways in which children react to traumatic events. The authors discuss the varied influences of cultural background on these reactions to trauma, the varying presentations of diverse children experiencing troubling reactions, and the need to provide treatment to children and their families in a fashion that is culturally sensitive and acceptable to diverse families.

ACOG Committee Opinion No. 422: at-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice.

Drug and alcohol abuse is a major health problem for American women regardless of their socioeconomic status, race, ethnicity, and age. It is costly to individuals and to society. Obstetrician-gynecologists have an ethical obligation to learn and use a protocol for universal screening questions, brief intervention, and referral to treatment in order to provide patients and their families with medical care that is state-of-the-art, comprehensive, and effective. In this Committee Opinion, the American College of Obstetricians and Gynecologists' Committee on Ethics proposes an ethical rationale for this protocol in both obstetric and gynecologic practice, offers a practical aid for incorporating such care, and provides guidelines for resolving common ethical dilemmas related to drug and alcohol use that arise in the clinical setting.

The HIM (Health for Izhevsk Men) trial protocol.

BACKGROUND: Russia is one of the very few industrialised countries in the world where life expectancy has been declining. Alcohol has been implicated as a major contributor to the rapid fluctuations observed in male life expectancy since 1985 that have been particularly marked among working-age men. One approach to reducing the alcohol problem in Russia is 'brief interventions' which seek to change views of the personal acceptability of excessive drinking and to encourage self-directed behaviour change. There is limited understanding in Russia of the salience and applicability of Motivational Interviewing (MI), a well-defined brief intervention commonly used to target alcohol-related behaviour, but MI may have important potential for success within the Russian context. METHODS/DESIGN: The study will be an individually randomised two-armed parallel group exploratory trial. The primary hypothesis is that a brief adaptation of MI will be effective in reducing self-reported hazardous drinking at 3 months. The secondary hypothesis is that it will be effective in reducing self-reported past week beverage alcohol consumption, alcohol dependence and related problems at 3 months and at 12 months. MI will also be effective at 12 months in reducing self-reported hazardous drinking, alcohol dependence and related problems, proxy reported hazardous drinking, and recent alcohol use as indicated by bio-markers. Participants are drawn from the Izhevsk Family Study II, with eligibility determined based on proxy reports of hazardous drinking in the past year. All participants undergo a health check, with MI subsequently delivered to those in the intervention arm. Signed consent is obtained from those in the intervention arm at this point. Both groups are then invited for 3 and 12 month follow ups. The control group will not receive any additional intervention. TRIAL REGISTRATION: ISRCTN82405938.

Sujeitos em terapia: um estudo sócio-antropológico das práticas homeopáticas e psicanalíticas / People in Therapy: a social-anthropological study about Homoeopathics and Psycoanalytics clinical practices

Esta tese é fruto de um trabalho de pesquisa de campo desenvolvido ao longo de uma década. Insere-se no campo das Ciências Humanas e da Saúde através da linha de pesquisa Racionalidades Médicas e Práticas de Saúde, coordenada por Madel T. Luz. A partir de um enfoque sócio-antropológico, realiza-se um estudo comparativo entre a prática clínica da racionalidade médica homeopática e da psicanálise. Buscamos compreender os sentidos e significados atribuídos aos processos de adoecimento erecuperação da saúde; bem como os valores culturais, subjacentes a estas práticas, presentes em segmentos da classe média carioca, que levam determinados sujeitos a procurarem estas formas terapêuticas, para aplacarem seus sofrimentos. Para tanto criamos a categoria sociológica: sujeitos em terapia, que inclui a percepção de estados positivos, que chamamos de saúde e seu estado ideal denominado cura; a percepção de estados indicativos de um movimento desestabilizador, nomeado adoecimento; uma perspectiva terapêutica de respeito às singularidades e à pertinência temporal das intervenções possíveis, de acordo com as circunstâncias globais de cada paciente; e, o que ao nosso ver é a maior distinção destas propostas terapêuticas, uma relação terapeuta-paciente única, desafiadora, instigante, onde a sintonia se faz necessária para que o processo caminhe, numa direção que não se sabe a priori qual é, mas que é fruto desta interação. Trabalhamos com a análise das representações sociais dos homeopatas e psicanalistas acerca do sujeito (ou quem se trata), da saúde (ou o sujeito saudável), da cura(ou momento da alta) e da doença (ou o sujeito doente); agregando a esta análise a percepção da dinâmica das consultas homeopáticas e das sessões psicanalíticas referidas por estes profissionais, bem como aquilo que eles valorizam no processo terapêutico que desenvolvem com seus pacientes...

This thesis results from fieldwork research developed along one decade. It belongs to the domain of Humanities and Health Sciences in the line of research Medical Rationalities and Health Practices, coordinated by Madel T. Luz.From a social-anthropological perpective, a comparative study is carried out involving the clinical practice of the homeopathic medical rationality and psychoanalysis. The aim of the study is to understand the meaning and sense attributed to the processes ofsickening and recovery as well as the cultural values underlying the aforementioned practices, present in segments of Rio de Janeiro’s middle class, which lead certain subjectsto seek these therapeutic modes to ease their suffering. In order to develop such a study, a sociological category was created – people in therapy –, which includes the perception of positive states, which we deem health and its ideal state called cure; the perception ofstates indicative of a destabilizing movement, named sickening; a therapeutic perspective respectful of singularities and of the temporal adequacy of the possible interventions,according to the global circumstances of each patient; and, what in our opinion is the main distinction between these therapeutic proposals, namely, a unique, challenging and instigating therapist-patient rapport, in which being in tune with one another is necessaryfor the process to take place, albeit in a direction which no one knows beforehand which will be, but which depends on this interaction.We have worked with the analysis of social representations of homeopaths and psychoanalysts of the subject (or the one in treatment), of health (or the healthy subject), of healing (or the moment of release) and of sickness (or the sick subject); adding to theseanalyses the observations around the dynamics of homeopathic and psychoanalytic sessions as related by...

An ethical viewpoint: the role of veterinarians and behaviourists in ensuring good husbandry for cats.

Cat owners commonly consider their pets to be members of their families, and many factors contribute to a high level of owner attachment to their cats. Suppression of a cat's emotional needs in favour of the emotional requirements of the owner may produce a less satisfactory relationship for the owner, and usually for the cat as well. Owners' failure to comprehend their cat's true demands of life, and their false expectation of their ability to fulfil human psychological demands lies at the heart of many feline behaviour problems.

Sexual modification therapies: ethical controversies, philosophical disputes, and theological reflections.

Knowing, either by the light of natural reason or by the light of Christian revelation, that homosexuality is a disordered condition is not sufficient for its being ethically permissible to direct self-identified homosexual persons toward just any treatment that aims to modify sexual orientation. For example, such an undertaking would be morally impermissible in cases where the available "treatments" are known to be both futile and potentially damaging to persons undertaking them. I, therefore, introduce this edition of Christian Bioethics by reflecting on (a) the position of homosexuality in our current psychiatric nosology, (b) problems with drawing causal inferences from the outcomes of psychotherapy studies, and (c) the advantages and disadvantages of appealing to traditional categories of sexual orientation in this discussion, all with an eye toward more deeply elucidating core ethical concerns involving the intentional psychotherapeutic modification of sexual orientation.

Sexual reorientation therapy: an orthodox perspective.

This article evaluates the phenomenon of sexual reorientation therapy from the standpoint of Orthodox Christian theology. It is argued that homosexual desire is the product of the fall of mankind and cannot be considered "normal." At the same time, however, reorientation therapies, whether secular or Christian, are inherently reductionistic and fail to address the underlying spiritual pathologies involved in homosexual desire (or any other deep-seated passion). The purpose of therapeia in the Orthodox Church is the psycho-somatic transfiguration of the whole person into the image of Christ, not merely the cessation of homosexual activity or the "reidentification" of one's "lifestyle."

Is continence enough?

The ideal of virtue demands not only right choice and right behavior but also right desire in the emotions. Homosexual desire, then, even if it does not result in overt homosexual behavior, is contrary to virtue, and the completion of virtue demands right desire. If a homosexual has no plan to marry, then right desire implies only the removal of homosexual desire and not the revival of heterosexual desire at which reorientation therapy aims. On the other hands, if a homosexual is married or plans to marry, then right desire includes heterosexual desire for one's spouse. If homosexual desire is viewed as an emotional disorder, and not merely as a moral defect, then it may require reorientation therapy to bring about heterosexual desire. The pursuit of virtue, then, may recommend reorientation therapy, but even this recommendation is fairly limited, since reorientation therapy may be burdensome and may not be that effective. In conclusion, married homosexuals or homosexuals planning to marry may have a limited moral obligation to pursue reorientation therapy.