Journal of evaluation in clinical practice
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There has been a recent proposal by Gergel and Owen for introduction of legally enforceable self-binding directives for persons with bipolar affective disorder in the United Kingdom. The model is rooted in presence or absence of decision-making capacity, and the notion of capacity used is an expansion of the usual notion of capacity, in that it is individualized and diachronic. ⋯ I also raise concern that the diachronic notion of capacity leads to an authenticity type account, which fails to incorporate differences in individual prognosis. I then present a rough sketch of an alternative account, more in keeping with current mental health legislation, which uses an individualized notion of "risk to self" to justify self-binding directives in bipolar disorder.
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In recent years there has been growing attention to the epistemology of clinical decision-making, but most studies have taken the individual physicians as the central object of analysis. In this paper we argue that knowing in current medical practice has an inherently social character and that imaging plays a mediating role in these practices. We have analyzed clinical decision-making within a medical expert team involved in diagnosis and treatment of patients with pulmonary hypertension (PH), a rare disease requiring multidisciplinary team involvement in diagnosis and management. ⋯ Finally, we argue that images fulfill a mediating role in distributed knowing in 3 ways: first, as enablers or tools in acquiring information; second, as communication facilitators; and third, as pervasively framing the epistemic domain. With this study of clinical decision-making in diagnosis and treatment of PH, we have shown that clinical decision-making is highly social and mediated by technologies. The epistemology of clinical decision-making needs to take social and technological mediation into account.
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Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. ⋯ It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a "situated practice" rather than as a sequence of research-driven abstract decisions.
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We consider how conceptions of the self and identity from the philosophical literature can help us to understand identity disturbance in borderline personality disorder (BPD). We present 3 philosophical approaches: connectedness, narrative, and agency. ⋯ The connectedness approach is dominant in philosophy, and the narrative approach has been used by psychiatry, but we argue that the lesser-known agency approach provides a promising way to theorize some aspects of identity disturbance in BPD. It relates the 2 diagnostic criteria of identity disturbance and disinhibition and is consistent with evidence of memory deficits and altered self-processing in BPD patients.