Scientists seem to have decoded what happens in our brains when we have to choose between political candidates. According to the latest study, the lateral orbitofrontal cortex (LOFC) region of the brain must function fully and normally to enable us to make sound decisions based on all the pieces of information we have with us. The findings of this study are sure to whet interest in the functioning of the LOFC region. After all, understanding why we choose the way we do would interest many different quarters, from politicians to marketers.

The LOFC and decision-making

Functional neuroimaging studies of the human brain provide a clear picture of how the LOFC is involved in the decision-making process.

According to one study, the LOFC region executes a number of distinct functions that cumulatively make up the decision-making process. The LOFC helps us evaluate the affective worth of stimuli as they hit our senses and figure out the chances (if any) of garnering rewards by acting upon the stimuli. These encoding processes taking place in the brain in response to stimuli also guide us to eventually make a decision by helping us assess the values of several different courses of action. When we can evaluate the potential risks and rewards of an action plan, it helps us choose a specific course.

Further studies have corroborated the findings from earlier experiments on the role of the LOFC in the decision-making process. According to them, the damage to the orbitofrontal cortex (OFC) region of the brain may impede the decision-making process in several ways. This can render the individual incapable of making complex decisions after comparing the relative values of diverse bits of information.

The role of the LOFC in political decision-making

Making a knowledgeable decision depends greatly on our ability to weigh the pros and cons of disparate pieces of information and string them together to perceive the big picture. The role of the LOFC region in facilitating this complex executive function is evident from the findings of study carried out on subjects who were asked to evaluate the merits of several political candidates.

The subjects comprised healthy individuals, patients with damage to their LOFC regions, and patients with damaged frontal portions but healthy LOFC regions. All subjects were shown photographs of real-life electoral candidates, but they did not know anything about the candidates, so they could guess the competence and attractiveness of the candidates only from the photographs. Healthy subjects made their voting decisions based on perceived competence and attractiveness. Those subjects who had damaged frontal regions but healthy LOFCs also based their voting decisions on the competence and attractiveness ratings of the candidates. But those with damaged LOFCs based their decisions only on the attractiveness ratings of the candidates.

The above experiment indicates that damage to the LOFC impairs a person’s ability to analyze information from varied sources before making a political decision. However, scientists point out that damage to this region may not affect a person’s ability to evaluate social traits based on perceived attractiveness.

The findings of the above study prove what scientists had been guessing for all these years — in the absence of details, people tend to choose political leaders based on a complex set of factors that go beyond the mere attractiveness quotient of the electoral candidates.

According to one study, after just looking at photographs, people tend to vote for unknown candidates who they think share positive characteristic traits with them. The perceived characteristic traits of the candidates that get most nods are openness and transparency, emotional stability, and likeability. This study indicates the far-reaching influence of first impressions.

Political leaders with an eye on power and position may want to take note of the findings of another study. People who have suffered damage to the OFC region of their brains tend to be morally harsher and more inflexible than healthy people. The people with damaged OFC regions tend to exhibit “hypermoral” tendencies. These people punish offenders more harshly than those with healthy OFC regions for crimes committed under similar circumstances and with identical degrees of severity. So political leaders, you know what to do; make sure that you have an impeccable public image and behave honorably in your personal life.

OFC and economic decision-making

Scientists have now decoded the neural mechanism of decision-making. They have also discovered that the OFC has a role to play even when we are in the shopping mall or the grocery store. The economic decision-making process is a complex one where the individual has to assess the relative values (read: rewards) of various goods and figure out how much money they are willing to part with to buy a specific item. So marketers are probably looking towards scientists to figure out how exactly the human brain computes future rewards and why they are willing to pay more for certain goods than others.

However, apart from the knowledge that the LOFC plays a role in complex decision-making processes, scientists are still unclear about the exact roles of the other regions of the brain in calculating the value of various action pathways and decision options. Once they do, therapists, counselors, and psychiatrists hope that they will be able to predict human behavior more accurately, especially in persons who have suffered brain damage.

References

Fellows LK (2007). The role of orbitofrontal cortex in decision making: a component process account. Annals of the New York Academy of Sciences, 1121, 421-30 PMID: 17846161

Koppensteiner, M., & Stephan, P. (2014). Voting for a personality: Do first impressions and self-evaluations affect voting decisions? Journal of Research in Personality, 51, 62-68 DOI: 10.1016/j.jrp.2014.04.011

Mimura M (2010). [Role of the orbitofrontal cortex in moral judgment]. Rinsho shinkeigaku = Clinical neurology, 50 (11), 1007-9 PMID: 21921545

O’DOHERTY, J. (2007). Lights, Camembert, Action! The Role of Human Orbitofrontal Cortex in Encoding Stimuli, Rewards, and Choices Annals of the New York Academy of Sciences, 1121 (1), 254-272 DOI: 10.1196/annals.1401.036

Plassmann, H., O’Doherty, J., & Rangel, A. (2007). Orbitofrontal Cortex Encodes Willingness to Pay in Everyday Economic Transactions Journal of Neuroscience, 27 (37), 9984-9988 DOI: 10.1523/JNEUROSCI.2131-07.2007

Xia, C., Stolle, D., Gidengil, E., & Fellows, L. (2015). Lateral Orbitofrontal Cortex Links Social Impressions to Political Choices Journal of Neuroscience, 35 (22), 8507-8514 DOI: 10.1523/JNEUROSCI.0526-15.2015

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Prices have fallen as cloud storage has gained popularity. Google Drive now offers 15 GB data storage for free, 100GB for $1.99 monthly or $9.99 monthly for 1 TB. For software developers Google also offers Google Cloud Storage. Amazon claims to offer unlimited data storage for $60 a year.

The cloud has existed in basic form for decades, it is really no more than a metaphor used to refer to a network of remote servers which store, manage and process data. Yahoo, Hotmail and Flickr, for example therefore technically make up some of the most popular early providers of cloud data storage.

When email started to become widely used, some users opted to not only save their important emails in their inbox but also to print them. Some of us saved them in word processor formats which later were saved to a data CD, USB or external hard disc.

Now it seems somewhat old fashioned to try to save our files such as emails or photos in printed copies not only due to the extra cost, physical space and weight of storage, but also because of the increasing number of files and photos we produce in our everyday lives, and increasing accessibility of online storage.

But is it better to use the cloud than saving our files using our own data storage devices?

Many people still do not believe so. Saving our data on the cloud has its own risks. To some it feels like giving your safe deposit box to someone, a third party to look after it. That someone runs a database located somewhere else in the world, probably using hundreds of data servers. Your data is seemingly vulnerable to a host of issues which might afflict the servers, from damage or fire to hacking.

Also, let’s bear in mind that internet legislation is still blurry. If the server owner decides to change its policies, your data might be affected by such changes.

In theory, we should be aware of the existing policies regarding the storage of data. How many of us actually read the small print when signing up to such a service? The rights and freedoms with respect to the processing of your personal data may vary, and it is up to us to keep tabs on these.

The rules regarding the privacy of your data might vary depending on the country where that data is kept and/or your cloud storage provider and their own policies and regulation.

However, in practice, it is doubtable whether most users of cloud services would even be aware of the continent where their data is located.

The main issues afflicting cloud storage clearly relate to reliability and security. While keeping our data in the cloud might have many advantages, it is always advisable to keep a backup of our precious files on a personal storage device, just in case.

References

Wang, Cong. (2010-03–1) Privacy-Preserving Public Auditing for Data Storage Security in Cloud Computing. , 1-9. DOI: 10.1109/INFCOM.2010.5462173

Image via Dusit / Shutterstock.

However, this does not always occur and patients are continually at risk because of errors made by health care professionals. Medical malpractice in the psychiatric fields is as common as other medical fields and often involves more than just the traditional doctor or patient.

Common forms of psychiatric negligence

• Failure to conduct a proper suicide risk assessment. The standard of care requires physicians to conduct a proper risk of suicide assessment on every potentially suicidal patient. If a doctors fails to properly assess the patient considering all the relevant factors such as patient history, age, gender, sexual orientation, employment and living standards, then he is at risk for potential litigation.
• Failure to prevent a patient’s suicide. If a proper suicide risk assessment has been performed and it has been determined there is a legitimate risk of suicide, a doctor must take steps to prevent that suicide from occurring. If he fails in this task, he could be judged guilty of malpractice.
• Improper diagnosis or treatment. While some people believe that many psychiatric diagnoses are ill-defined, this is simply not the case. Any mental health professional should be able to come to a definitive diagnosis assuming the proper patient assessment has occurred. However, if an improper diagnosis is made or if a doctor prescribes the incorrect treatment, a patient or their family have a strong case for malpractice against the doctor or mental health professional.
• Failure to warn. Extending further from the traditional doctor and patient relationship, courts have ruled that if a patient makes threats during sessions against another person, the clinician has a duty to warn this person of the potential threat if they believe it is credible. This can often be a difficult determination for the clinician as he/she must balance doctor/patient confidentiality versus their responsibility for the safety of others. If a patient acts on these threats, the victim’s families have a reasonable malpractice case to pursue.
• Boundary violations. It has been established there must exist a boundary between the healthcare professional and their patients. If the professional violates these boundaries or attempts to use his/her position as a means to, for example, illicit sexual encounters with their patients, he/she are guilty of malpractice and maybe even other felony crimes.
• False repressed memories. One of the most common treatments patients undergo is the process of revealing past memories that have been repressed. Many psychiatric health care professionals believe these memories to be the source of the mental health problems for many patients. If false memories are revealed and it causes irreparable harm to the patient or other individuals, the mental health care professional can be held liable for creating these false memories.

Malpractice case studies

Prosenjit Poddar, a student from Bengal, India, was rebuffed by Tatiana Tarasoff who wanted to see other men.  Poddar withdrew and became increasingly antisocial. Tarasoff left for South America and Poddar began to improve even seeing a psychologist. During his sessions, he confided in his psychologist revealing a plan to murder Tarasoff. When she returned, he stopped seeing his psychologist and carried out the plan he had told him about. Neither Tarasoff or her family received any warnings about the threat.

Tarasoff’s parents later sued the psychologist and other employees of the University of California. The court found that that a mental health professional has a duty to not just the patient, but also any individuals that have been threatened by the patient.

In Syracuse, New York, Joe Mazella, a well respected and popular high school coach, committed suicide after spending three years in the care of physicians and being prescribed antidepressants. After his death, his widow filed a lawsuit against the doctors treating him. Attorneys for the widow argued that Mazella would not have wanted to end his own life and the combination of negligence and low quality of care by the doctors along with three years on antidepressants that are known to cause suicide led to the beloved coach taking his own life.

The Supreme Court of the state of New York found that both doctors who treated Mazella were negligent and held one of the doctors liable for his death awarding the widow $800,000 for the loss of her husband’s income, $200,000 to his youngest daughter and $100,000 to each of his oldest daughters. In addition, $324,000 in interest was added to bring the total to $1.524 million.

Conclusion

Courts are increasingly recognizing the standard of care required for mental health care professionals and, in some areas, their responsibilities can extend far beyond just their patients. These cases represent just a small part of the malpractice cases facing mental healthcare professionals.

It is important for every mental health care professional to provide the highest standard of care possible at all times and to maintain the safety of not only their patients but any individuals that have been threatened by the patient. Failure to provide this type of care is grounds for malpractice and mental health care professionals should and are often held liable for these mistakes.

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The exchange of nude or semi-nude photos is amongst the most common ways of sexting, and is regarded as a form of auto-pornography. According to some researchers, people claim to do it “for fun”, “as a present”, as a form of foreplay or – especially among the young – as a result of peer pressure.

Sexting has been a matter of much debate in recent years and some governments have introduced specific laws regarding it. Part of the problem is that amongst the young population, sexting is increasingly common and in an attempt to explore their sexuality, they could be contributing to the production and possession of child pornography.

But sexting is not only a practice amongst the young. Adults of all ages are also increasingly engaging in sexting. In the media it is a common topic, and glossy magazines encourage women to send sexts to their partners to “spice up the relationship” and provide tips as to how to send “dirty messages” via smartphones. But adults are not exempt from the risks of putting themselves in dangerous situations by sexting.

Is it safe?

Sexting is widely considered as risky behaviour and a growing problem that can cause serious embarrassment and have undesirable social or even legal consequences. For example, sexting can pose a risk for extortion or “sextortion”, harassment and can lead to bullying in the young.

In specific situations, such as harassment after sexting, the law can enforce criminal charges and this has already resulted in criminal prosecutions. If sexting involves a young person, the legal consequences can be very severe as the content may constitute child pornography. However, the laws are not clear in many countries and it can be difficult to use multimedia material to prove accusations.

Bullying among the young is also a delicate matter related to sexting, which has proved difficult to tackle.

Sexting can be a form of intimacy in a relationship and if this intimacy is broken by the partner through sharing with third parties, there can be severe consequences. There have been reported cases of young people committing suicide after their nude photographs had been distributed to others.

These events can also affect the professional opportunities of the people implicated, since they can damage personal reputations.

In a society in which the use of technology is implicated in our most private behaviours, it is necessary to stay informed and educate the young about the possible consequences of sexting.

Once we post material online we relinquish control over it. This content can truly end up anywhere. For this reason, sexting cannot truly be considered safe under any circumstances.

References

Ferguson, C. (2010). Sexting Behaviors Among Young Hispanic Women: Incidence and Association with Other High-risk Sexual Behaviors Psychiatric Quarterly, 82 (3), 239-243 DOI: 10.1007/s11126-010-9165-8

Mitchell KJ, Finkelhor D, Jones LM, & Wolak J (2012). Prevalence and characteristics of youth sexting: a national study. Pediatrics, 129 (1), 13-20 PMID: 22144706

Image via Champion Studio / Shutterstock.

Race is a slippery concept, and an uncomfortable one, because it is related to the marking of differences and divisions among human beings in a society that is supposed to be advanced enough to acknowledge the importance of equality.

Its use is an act of classification that immediately sets boundaries between people and defines an environment in which discrimination can occur. For many, race is a concept based on stereotypical, perceived differences of language, body or ancestry which have their roots in colonialist views.

For example, the “Hispanic race” is a product of the power and influence of Spanish colonisers over the dominated groups in America, while the “African American race” is a label related to the migrants who were taken to America often as a result of the slave trade.

If race is considered as a product of domination and inequality, then we should avoid the term. But we can’t, because it is still a big issue in the so-called “developed world”, as can be seen with the recent unrest in the US. If we do not refer to race or the racialization of groups, as an unresolved issue related to discriminatory practices and inequality, then how can we address it?

Even in the field of neuroscience, and as an attempt to be inclusive, most scientific studies regarding genetics and biological psychiatry choose to identify the “race” of the participants.

The simple act of identifying someone’s race is an act of marking differences and consolidating the use of the concept itself. The use of race has often been replaced by the use of other concepts to classify people, such as “culture”. Such terms possess complex problems of their own since they are also broad and require interpretation.

For some scientists the only way of dealing with the concept of race is avoiding it entirely but some speculate that this will merely leave them in a state of denial. Others suggest that it may create functional limitations which are at least bureaucratically useful.

Some scientists such as Heinz are optimistic in this regard and state that genetic research will soon provide such detailed, personalized information that classifications such as race may come to be regarded as increasingly cumbersome and relatively meaningless.

References

Morning, A. (2006) ‘On Distinction’, Is Race Real? Accessed 20 March 2010.

Heinz A, Müller DJ, Krach S, Cabanis M, & Kluge UP (2014). The uncanny return of the race concept. Frontiers in human neuroscience, 8 PMID: 25408642

Image via Nickolya / Shutterstock.

The recent Senate Intelligence Committee report detailing the CIA’s use of enhanced interrogation techniques (EITs) like waterboarding has reinvigorated debate over the appropriateness of such methods for counterterrorism efforts. Many protest the use of EITs on moral or legal grounds, citing the inhumanity of the physical and emotional pain imparted by these tactics. Further corroborating protesters’ arguments is ample scientific evidence demonstrating that the aversive effects of exposure to stressors like those involved in EITs are not limited to the duration of those experiences. Instead, enduring high stress circumstances can lead to life-long struggles with post-traumatic stress disorder (PTSD), anxiety, and depression, effects that are likely mediated by physiological changes in the amygdala, an area of the brain that processes emotional information.

Given the harm associated with EITs, it is perhaps important to assess whether EITs provide the desired outcome of enhancing national security. Indeed, harming an individual to spare no one is morally distinct from harming an individual to save many. Though we may determine that neither case is acceptable, the former case is clearly less acceptable than the latter.

Unfortunately, the actual impact of EITs is not clear. Defenders of EITs claim that EITs are critical tactics that have helped the United States thwart terrorist attacks, while opponents argue that the techniques have not significantly contributed to actionable intelligence. Because there are few data that can be used to address the efficacy of EITs as they are currently employed, it may be helpful to draw upon behavioral science research to identify any potential for these EITs to fulfill their stated goal of extracting valuable information.

Are Enhanced Interrogation Techniques Effective?

What are the critical brain processes that determine whether a prisoner will divulge constructive information to his interrogators?

Memory – To convey accurate information, memory must be intact.

Some arguments against the efficacy of EITs have focused on the deleterious effects of stress and sleep deprivation on memory and have pointed to imaging studies that suggest that people suffering from PTSD have different patterns of activation in areas of the brain involved in memory compared to those without the disorder. These arguments emphasize the potential for those undergoing EITs to supply false information.

Much of the literature on the effects of stress and sleep deprivation on memory actually show that these factors influence working memory and diminish the ability to learn new information. However, it is possible that memories of the past could also be affected, particularly if those memories are complex or not stably encoded in the brain. Nonetheless, it is unlikely for stress to demolish highly engrained information. Given that such information, such as the names of family members or close friends, may be valuable for counterterrorism, arguments against the efficacy of EITs that are built on the impact of stress on memory are perhaps not highly convincing.

Executive Functions – The surrender of withheld information may be facilitated by disruption of executive functioning.

The scientific research that is probably most relevant to the efficacy of EITs is that addressing the effects of stress on executive functions. Stress significantly affects the prefrontal cortex (PFC), which is critical for these functions. Executive functions that are likely relevant for those undergoing EITs are the disciplined control over behavior and the ability to keep track of different versions of fact sets.

When the PFC is damaged, people have a harder time regulating their behavior and tend to resort to behavior that is more habitual and less goal-oriented. Thus, it could be argued that the stress-induced diminution of discipline could increase the likelihood that withheld information becomes shared. Nonetheless, there is no evidence to suggest that the extreme measures that appear to accompany EITs are necessary to induce the type of stress needed for this effect.

Motivation – Choosing to share information requires that one deem the value of sharing that information as higher than the value of not sharing that information.

If we consider the effects of EITs on motivation and valuation, the argument of their effectiveness begins to crumble. Stressful circumstances, particularly those that may be interpreted as life threatening, elicit what is known as the fight or flight response, in which the body’s physical and mental resources are focused on escaping or demolishing the perceived threat. In the case of EITs, these responses likely manifest as instincts to survive and to avoid pain.

Some researchers have suggested that those enduring EITs are motivated to talk because time spent talking is time where interrogation, and the associated stress and pain, are avoided. These researchers further claim that there is little correlation between the accuracy of information provided and the degree of pain endured. When this is the case, there is clear incentive to talk but no added value of providing truthful information. Even if we could articulate how EIT practices could incentivize the sharing of accurate information, the argument for the justification of EITs would still suffer from our inability to illustrate how these practices are superior to others that would be considered more civilized.

How Can We Ensure National Security Without EITs?

Behavioral science suggests that the potential for EITs to lead to the acquisition of accurate actionable intelligence is limited. Thus, there is great potential to develop a new system for procuring desired information that is superior to current EITs in both a moral sense and a practical sense.

A significant weakness of EITs is that they are not conducive to scientifically rigorous experimentation. Ethical considerations prevent us from conducting controlled human studies on the impact of EIT implementation, which precludes optimization of these approaches. However, research from a number of disciplines, including neuroscience, computer science, psychology, and economics provide considerable insight into how to affect decision making. If we apply this knowledge to build new innocuous systems for interrogation, we have the opportunity to collect data and optimize these systems accordingly.

In addition to providing general information on the efficacy of specific negotiation tactics, this type of research could also uncover details on how to customize interrogation to individual cases. For example, neuroscience research demonstrates that stress differentially affects male and female decision making tendencies, suggesting that different coercive approaches could be strategically targeted to men and women.

Conclusion

It is difficult to condone EITs given that the aversive neural effects do not appear to be accompanied by significant societal benefits. Further, even if we could establish moral grounds for EITs, our focus should be on how to effectively obtain the information we need to keep our citizens safe. EITs are not conducive to science-backed optimization because they do not allow for controlled experimental manipulations. On the other hand, other persuasive tactics, which may be equivalent or superior to EITs in their efficacy, can be experimentally tested and improved upon as more data are collected. Employing the scientific method to understand specific effects of different coercive techniques could allow us to more effectively acquire the information needed to keep our nation secure.

References

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On April 20, 1999, as news stations across the country broke through regularly scheduled programs, shots continued to ring out at Columbine High School in Colorado. Still reeling from the devastating consequences of this mass shooting, exactly one month later, the echo of gunfire was heard, this time at Heritage High School in Georgia.

Since this time, the violence has continued in what appears to be a cancer spreading across the United States, the effects of which have gun control advocates and civil rights advocates at odds with each other. As legislators struggle to find a cure to this malevolent disease, managing gun control laws in relation to individuals suffering from mental illness has quickly becoming a focal point of the debate.

Over a decade after the Columbine shooting, Americans were faced with the loss of more lives in the mass shooting at Virginia Tech on April 16, 2007. The tragedy resulted in the deaths of 32 students and faculty members along with 17 non-lethal injuries. Gun violence would continue through the years with little progress made in controlling this vicious cycle, until America was once again slammed in the face with another mass shooting on a school campus. This was not just any school, but an elementary school. On December 14, 2012, the quiet town of Newton, Connecticut would lose 20 children and six adults in what some speculate as an avoidable tragedy.

The general rhetoric of the NRA and other political supporters holding the line against stricter gun legislation lobby that the real issue is keeping guns out of the hands of the mentally ill. Yet, there is evidence that suggests this line of thought is inaccurate. Studies reveal that individuals with severe mental illnesses, a small percentage in overall comparison, perpetrate approximately one in 20 violent crimes.

It is not as though American political leaders have never passed legislation in an attempt to control the availability of guns to the mentally ill. Congress passed the Gun Control Act in 1968, making it illegal for individuals that had been committed, involuntarily, to a mental hospital or that had been determined mentally “defective” (a term commonly used during that time) to purchase a gun.

Later, legislation via the 1994 Brady Violence Prevention Act, extended the 1968 Gun Control Act exclusionary clauses regarding mental illness (along with initially the same verbiage), and added provisions to include a waiting period to purchase a handgun in hope of better ensuring proper background checks of potential buyers.

The insinuation that placing stronger reporting mandates on mental health clinicians alone will drastically reduce the number of violent acts committed using a gun, is simply unsubstantiated. Also, the totality of legislation, such as the New York Secure Ammunition and Firearms Enforcement Act of 2013, focuses on past, current, and future individuals seeking mental health services. The law mandates mental health professionals to report patients that may potentially harm others as well as themselves.

The outcome of such action could prove to be less of a deterrent to gun violence and more harmful to individuals with mental illnesses. It has the potential of leading to wrongful identification of potentially violent patients and a systematic response whereby individuals who need mental health services withdraw from treatment or forego treatment out of fear of being reported as mentally unstable. Further, it simply violates doctor-patient’s confidentiality as well as the overall privacy of patients.

Many gun rights advocates and political leaders often quote the Second Amendment to the Constitution as evidence supporting the right to bear arms. Yet, there seems to be little concern by the same individuals regarding breaching patient confidentiality also afforded to individuals, including psychiatric patients, provided under the protection of the Health Information Portability and Accountability Act (HIPAA). Still, the push for more stringent gun control legislation focusing on individuals with mental health illnesses is one that is supported by both advocates of gun rights and gun control.

As the battle continues to ensue over protecting the rights of gun owners and protecting the health and safety of innocent citizens, there is little doubt that something must be done to reduce the overwhelming statistics relating to gun violence. Most professionals within the mental health field support continued efforts to effectively reduce the risks of gun violence at the hands of a severely mentally ill individual. It is through this support that the mental health community believes more doors will open providing greater opportunities in the funding and treatment of individuals suffering from many forms of mental illness.

References

Fazel S, & Grann M (2006). The population impact of severe mental illness on violent crime. The American journal of psychiatry, 163 (8), 1397-403 PMID: 16877653

Friedman, R (17 December, 2012). In Gun Debate, a Misguided Focus on Mental Illness. The New York Times.

Swanson J (2013). Mental illness and new gun law reforms: the promise and peril of crisis-driven policy. JAMA : the journal of the American Medical Association, 309 (12), 1233-4 PMID: 23392291

Webster, D. and Vernick, J. (2013). Reducing Gun Violence in America: Informing Policy with Evidence and Analysis. Baltimore, Maryland: The Johns Hopkins University Press, 2013. ISBN 10: 1-4214-1110-5.

Image via Sandra Matic / Shutterstock.

Since the enactment of the ACA in March 2010, there have been approximately 40 attempts to overturn the piece of legislation. One of the most recent attempts came in September 2013, as Republican Party members vowed, once again, to retaliate with a government shutdown. This constant battling between political parties has led to approximately seven bills within the Act to either be repealed completely or altered in some manner.

In its initial stages, the ACA promised hope in providing quality healthcare to every citizen in the United States. This included psychiatric care, a component in many health insurance policies that is included more as an afterthought than a viable program within the policy. Efforts were made to streamline ICD and CPT diagnostic and billing codes, as well as increase Medicare Advantage payments to insurers by 2014. Yet the battle continues surrounding whether to increase or decrease these payments.

Still, many hold out hope that the ACA will indeed, provide expansion and improved care to the most vulnerable people in the country. As there is a higher prevalence of mental illness among individuals in lower income brackets, expanded coverage should greatly improve medical outcomes for these individuals. The ACA is set to expand eligibility for Medicaid as well as provide federally subsidized health insurance benefits for those living up to 138% of the federal poverty line.

The Department of Veteran Affairs is well aware of the growing need to provide not only medical care but also consistent mental health services to its growing number of veterans and service members. Enhanced medical services are provided to veterans through the VA healthcare system. These services are provided for up to five years after discharge from active duty. Although many veterans are still eligible for services, active duty personnel are considered first priority, leaving many veterans seeking treatment outside VA centers or going without treatment.

The ACA is designed to expand coverage through Medicaid for veterans who are uninsured. Reports indicate that approximately half of the 1.3 million veterans that are uninsured will be eligible for Medicaid expanded coverage along with an addition 40% that will qualify for subsidized coverage due to the ACA.

Proponents of the ACA suffered somewhat of a loss in the delaying of the mandated employer provided health insurance. Originally set to roll out in 2014, employers were given another year to make necessary preparations in offering and providing health insurance options to full-time employees if the business had 50 or more full-time employees on its payroll. Currently, the mandate is set to take effect in 2015, leaving many employees who thought they would be provided health insurance through their employer, scrambling to make other arrangements.

There is some relief provided through the Health Insurance Marketplace — scheduled to roll out October 1, 2013. The website provided by healthcare.gov offers information relating to locating each individual state’s health insurance marketplace/exchange, health insurance options, information for businesses, and how to make the program work the best for each individual. In the coming months, this website will prove to be a much-needed resource as more individuals struggle to meet and comply with the health insurance mandate resulting from the enactment of the ACA and the fall out of the continued dissention among political parties.

References

Chretien JP, & Chretien KC (2013). Coming home from war. Journal of general internal medicine, 28 (7), 953-6 PMID: 23435767

Golberstein E, & Busch SH (2013). Two steps forward, one step back? Implications of the Supreme Court’s health reform ruling for individuals with mental illness. JAMA psychiatry (Chicago, Ill.), 70 (6), 567-8 PMID: 23553230

American Psychology Association, (2013). Current Procedural Terminology (CPT) Code Changes for 2013: The Basics.

Image via A Katz / Shutterstock.

One of the greatest victories for both the insurance industry and health providers has been achieved with the announcement that the Obama administration has moved to increase Medicare Advantage payments to insurers by 3.3 percent for 2014. This falls on the heels of the Administration’s initial endeavor to cut those same reimbursements by 2.2 percent in 2014. Meanwhile, the field of psychiatric medicine remains vulnerable to new changes implemented through the ACA, such as the recently released ICD-10 and CPT code modifications.

The mandated ICD-10 and CPT code changes has only proven to further increase the problematic issues the public faces in finding, receiving, and paying for mental health services. A 2008 survey conducted by the AMA evidenced that of the psychologists consulted, 33% of their clients paid for their services out of pocket, leaving 67% of service payments made through billing insurance companies. It should be noted that most of these were claims filed with programs funded by federal, state, and local governments.

The ACA has taken measures to try and serve the needs of U.S. citizens who require assistance and treatment from mental health professionals. Mandates are now in place requiring insurance carriers to include comprehensive options for mental healthcare within each health insurance plan. This should result in a large reduction in the growing number of individuals who forgo necessary mental health treatment due to financial constraints.

And yet a major issue remains enticing more private practice mental health professionals to accept both public and private health insurance. In an effort to provide mental health professionals with a better understanding of the ICD-10 and CPT code changes, the APA released a series of documents summarizing major CPT code changes that directly affect the field of psychiatric medicine. Here is a brief summary of these documents (important links to these changes can be found in the references):

• Document 90862 has been deleted in one of the biggest CPT code changes. It has been replaced with the appropriate 99xxx series E/M code, which requires more documentation, even up to 11 separate elements. The 90862 code paid lower than a 99214 E/M code for Moderate Complexity.
• Replace 90801 (Initial Psychiatric Evaluation) with:
  • 90791 (and 90785 report with interactive complexity when appropriate): Psychiatric diagnostic evaluation without medical services.
  • 90792 (and 90785 report with interactive complexity when appropriate): Psychiatric diagnostic evaluation with medical services. New patient E/M codes can be used instead of 90792.
• Replace 90802 (interactive diagnostic initial evaluation) with:
  • 90791 and 98785 report with interactive complexity
  • 90792 and 98785 report with interactive complexity
• Replace 90804, 90816, 90806, 90816, 90808, 90821 to be used in all settings (in relationship to time with patient and or family) with:
  • 90832: 30 minutes psychotherapy
  • 90834: 45 minutes psychotherapy
  • 90837: 60 minutes psychotherapy
  • Report with interactive complexity and 90785 when appropriate in all three cases
• Replace 90810, 90823, 90812, 90826, 90814, 90828 to be used in all settings (in relationship to time with patient and or family) with:
  • 90832: 30 minutes psychotherapy
  • 90834: 45 minutes psychotherapy
  • 90837: 60 minutes psychotherapy
  • Report with interactive complexity and 90785
• Replace 90805-90809, 90817-90822 Psychotherapy & Evaluation Management (E/M) with:
  • Proper E/M code (not chosen based on time) and 90833 add-on code for psychotherapy 30 minutes
  • Proper E/M code (not chosen based on time) and 90836 add-on code for psychotherapy 45 minutes
  • Proper E/M code (note chosen based on time) and 90838 add-on code for psychotherapy 60 minutes
  • Report with interactive complexity and 90785 when appropriate and/or required
• New Psychotherapy for crisis 90839 and 90840
• Replace 90857 Interactive group Psychotherapy with:
  • Group psychotherapy 90853 and report with interactive complexity 90785

These CPT code modifications present major changes that will directly affect the fields of psychiatry and psychotherapy. This is the first time in almost two decades that CPT code changes have been directed specifically to psychotherapy services. Although some professionals may find it tedious and difficult to make the change, the overall compatibility of the codes and processes will link to those already used by primary care physicians, as well as other service providers.

References

American Psychiatric Association, Current Procedural Terminology (CPT) Code Changes for 2013: The Basics.

American Psychological Association, Insurance Module, 2008 APA Survey of Health Service Providers, (2009, August).

Kaiser Health News, Medicare Boosts Rather Than Cuts Payments To Advantage Plans, (2013, April 2).

Image via Krivosheev Vitaly / Shutterstock.

]]> /2013/06/19/change-on-the-horizon-for-psychiatric-medicine/feed/ 2 /2013/03/17/medicare-reimbursement-whats-the-latest/ /2013/03/17/medicare-reimbursement-whats-the-latest/#comments Sun, 17 Mar 2013 11:00:45 +0000 /?p=14430 Even with the continued political debate over the economics of the Affordable Care Act (ACA), there remains an even more dominating concern. Great concern remains for the actual viability of the overall Act as it applies to providing access to quality care to all US citizens; more specifically, the continued debate over Medicare reimbursement rates.

The mandate to ensure the availability to quality care while also containing and reducing the cost of healthcare in the United States remains an illusion to those entities tasked with this accomplishment. Nevertheless, since the passage of the ACA, there have been both macro and micro level changes within the industry specific to Medicare reimbursements.

Primary macro-level changes that have affected the healthcare delivery system can be noted in cost containment reforms to reduce Medicare and Medicaid spending through restructuring payment reimbursements. This has led to a surge in the implementation of Accountable Care Organizations (ACOs) and the Patient Centered Care Models. It is believed that ACOs are the greatest hope for the much needed and desired delivery system reform.

Operational changes affected by administrative simplification initiatives have taken a critical role in the fiscal solvency, directly affecting the revenue streams for providers and clinicians. Many are facing long and unexplained delays in reimbursements for their clients who are Medicare beneficiaries. The implementation of the HIPAA Version 5010’s deadline initially set for January 1, 2012, has come and gone, leaving practices that were unsuccessful in fully implementing the change faced with extreme delays in reimbursements. The Centers for Medicare and Medicaid Services (CMS) provided a PDF updated document addressing some of the concerns linked to the delayed reimbursements on March 2, 2012. The implementation deadline was then pushed to June of 2012. News on the front indicates that CMS has initiated a program with Emdeon to research the viability of implementing the HIPAA Transaction Version 6020.

Another area of great concern within the healthcare community is the implementation of the ICD-10 codes, along with the consistent HIPAA transactions updates. The push for greater access to information by creating wide-spread HIT systems has created a lack of cohesion within transferring systems. Looming implementation deadlines add to an already stressful environment for practicing clinicians who are struggling financially as a result of the delayed reimbursements from Medicare.

In February 2013, with CMS struggling to overcome a growing level of negative response from practicing clinicians regarding the overall Medicare program, the agency announced continued implementation changes provided through the ACA. These efforts include a proposal to update the 2014 rate-book to mirror the most current Fee-For-Service (FFS) costs, alignment restructuring changes of Medicare Advantage (MA) benchmarks with Medicare FFS costs, and basing some of the MA payment on the quality of the plan. In addition, CMS has proposed a 1.5% increase above the 2013 MA plan payment for 2014, resulting in a 4.91% total adjustment.

Most likely, the continued efforts by health care professionals and organizations to express the ongoing discontent among clinicians regarding the overall state of the Medicare program, served as a catalyst for CMS’ 2013 legislative proposals, which included much needed provider payment incentives. With approximately 92% of Medicare beneficiaries enrolled in the voluntary Medicare Part B program, this should relate to a greater volume of pay-outs for provider incentives in effecting higher levels of quality care. As Medicare Part B assists in covering mental health services primarily provided outside of a hospital setting, this translates into greater opportunity for mental health clinicians who enroll as Medicare providers to offer their services.

As the political debate continues over the ACA, many practicing clinicians remain focused on issues regarding the Medicare program. CMS recognizes the need to ensure cooperation within the health care industry to ensure greater access to quality care for all US citizens as mandated under the ACA. As such, this should continue to effect both macro and micro level changes within the health care industry specific to Medicare reimbursements.

References

Leibenluft RF (2011). ACOs and the enforcement of fraud, abuse, and antitrust laws. The New England journal of medicine, 364 (2), 99-101 PMID: 21175308

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013, February 15). Details for Rate Year: 2014.

U.S. Department of Health and Human Services, Centers for Medicare and
Medicaid Services, (2012, March 4). Medicare Advantage Rates and Statistics.

U.S. Department of Health and Human Services, Centers for Medicare and
Medicaid Services, (2012, June). Medicare and Your Mental Health Benefits.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2012, March 7). Version 5010 and D.0 & 3.0.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013). Fiscal 2013 Budget in Brief: Strengthening Health and Opportunity for All Americans.

Image via S_L / Shutterstock.

]]> /2013/03/17/medicare-reimbursement-whats-the-latest/feed/ 2 /2013/03/05/legislative-changes-in-research/ /2013/03/05/legislative-changes-in-research/#comments Tue, 05 Mar 2013 12:00:59 +0000 /?p=14279 Many changes in the overall scope of research and development have come to pass since the initial implementation of the Patient Protection and Affordable Care Act (ACA). Although the majority of conversation regarding the ACA is centered around the health insurance mandate, for many in the field of medicine, the impact of this act is much more far reaching than has previously been discussed. The ACA has provided a greater platform for funding research and development programs, as well as promoting positive changes in providing greater access to these findings.

The medical community continues to maintain a high profile in discussion that will further impact the roll-out of the ACA. In particular, the American Academy of Neurology (AAN), has created its own resources to assist members in discovering alternative payment methods, as well as engaging in incentive programs that assist in avoiding payment penalties. Through the efforts of the AAN and other health care agencies and professionals, not only can the interests of the general public be preserved, but also the professional and business interests of those medical entities will remain intact.

The issue of access to research and technology has once again reared its inquisitive head in an effort to spark greater continuity within the research community. On February 14, 2013, the Fair Access to Science and Technology Research (FASTR) was introduced to Congress as H.R. 708 and S. 350. Supported by both the American Library Association (ALA) and The Scholarly Publishing and Academic Resources Coalition (SPARC), the bill is designed to provide a platform for greater sharing of publicly funded research articles. It is believed that by opening access to these findings, a higher level of productivity in science and technology research, as well as a higher level of academic achievement can be attained.

Since the passage of the ACA on March 23, 2010, The Agency for Healthcare Research and Quality (AHRQ) continues to remain vigilant in its efforts to clarify challenges faced within the healthcare industry. Most recently, the European Federation of Neurological Societies released new guidelines for the diagnosis and management of Alzheimer’s disease, which has been included in the AHRQ data base. Primary issues addressed include providing an evidenced-based, peer-reviewed statement of guidance for practice to psychiatrists, geriatricians, and clinical neurologists, as well as qualified physician specialists charged with the care of patients with Alzheimer’s Disease.

The ACA also includes several provisions to direct discretionary spending toward specific components that increase the production and productivity of high-risk disease management, such as Alzheimer’s Disease and Parkinson’s Disease. The ACA increased discretionary spending on a number of fronts, opening the door to greater research possibilities. Section 10409 of the ACA allocated approximately $10 million in 2012, with an additional $50 million requested in 2013 for biomedical research. Under Section 10409 these changes reflect the establishment of a Cures Acceleration Network (CAN) program, overseen by the Office of the NIH which will award cooperative agreements, contracts, and/or grants to support the development of treatments for conditions and/or diseases that may be considered uncommon, and where market incentives are deficient. Eligible recipients include both private and public participants, research institutions, biotechnology companies, pharmaceutical companies, research institutions, higher education institutions, medical centers, patient advocacy organizations, academic research institutions, and disease advocacy organizations.

The NIH continues to reach out to the medical community in an effort to provide much needed funding for research and development. Both the government and the private sector recognize the continued need for progressive and consistent tools for advancement in chronic disease management. Although primary focus remains centered on the health insurance mandate, the stage has been set to increase both funding and transparency in biomedical research and development.

References

American Academy of Neurology (2013), The Patient Protection and Affordable Care Act Largely Ruled Constitutional: Now What?.

American Library Association (2013)., The Fair Access to Science and Technology Research (FASTR).

Redhead, C., Colello, K., Heisler, E., Lister, S., Sara, A. (2012, October 1). Discretionary Spending in the Patient Protection and Affordable Care Act (ACA). Congressional Research Services (R41390).

U.S. Department of health and Human Services, Agency for Healthcare Research and Quality (n.d.). National Guidelines Clearing House: EFNS guidelines for the diagnosis and management of Alzheimer’s disease.

Image via Mesut Dogan / Shutterstock.

]]> /2013/03/05/legislative-changes-in-research/feed/ 4 /2011/08/22/politics-of-persuasion-persuasion-in-healing/ /2011/08/22/politics-of-persuasion-persuasion-in-healing/#comments Mon, 22 Aug 2011 12:00:23 +0000 /?p=7024 If there is anything I know a lot about, it’s persuasion. I don’t mean to say that I am a genius sales person or politician, but I had a big lesson about psychotherapy some years ago. I edited a book about persuasion and did a lot of literature research in the process. I realized just how many persuasion techniques I was using as a therapist—in addition to those that I (and many other therapists) were aware of (e.g., Ericksonian hypnotic language and motivational interviewing in particular). Of the previously unconscious (on my part) techniques, one of the most important is priming, which means activating implicit (unconscious, basically) memory, so that the person is more likely to experience a particular state, or evince a particular kind of behavior.

Hand-in-hand with other techniques, you can really help lubricate the channel to a new chapter in a person’s life. Or, if you are a sales person, “help” the person buy something they don’t really need. I say this, not as an assault on sales people, but to point out that, if you must use such techniques to sell something, I must raise the ethical questions, “Why is such psychological firepower necessary to sell someone what they need? Are they resisting the truth? If so, who are you to have a higher truth?” Of course, those questions are merely red herrings. The answer is: follow the money.

And it is in this spirit that I raise another question, “Why is so much psychological firepower needed on American political TV?” As a student of persuasion, I am observing very sophisticated techniques used very consistently; so consistently, that I have no doubt that there is training and networking toward perfecting them. I’m also sure that, just as I am finding with psychotherapy, many of these political media types are more intuitive than studied in their skills. But why? Again, follow the money.

Here one of my favorite (in a bad way) skills. Watch for them when you see people debating politics on TV or elsewhere.

Targeted interruption: This is an amazing ability to know exactly when to interrupt the other party so they will not effectively get their points across. After years of watching this, I finally saw someone confronted on this behavior. But Noam Chomsky, a famous intellectual and linguist no less, was effectively undermined at the hands of an expert interrupter, William F. Buckley. Buckley was so talented, he almost made apartheid sound like it was a boon to civilization.

An ethical use of interruption (and priming): A therapist may use forms of interruption to prevent a client from getting into a state of mind that would block them from succeeding at a task in therapy. For example, consider a couple that is on the verge of having a constructive dialog. They begin to fall into their characteristic conflict pattern. The man begins to feel rage. Family therapist Virginia Satir might put her maternal hand on his belly and say that she could feel the hurt in his voice. Not only did this interrupt the rage state, but it also primed the husband for vulnerable feelings. This created an opening for dialog, with constructive results.

Would you like more examples? I could go like this all day! Comment, please.

One of my reasons for wanting people to reflect on these techniques, is that much of the American public appears to be adopting the unethical and illogical methods of debating and presenting that they see on TV. As far as I’m concerned, this is one of the signs of the apocalypse (figuratively speaking, of course). Let’s all work to turn this trend around. Educate! Develop compelling ways to highlight and dispense with unethical moves! If anyone should pick up this mantle, I should think it would by psychologically-minded people, because you can see the meta-level communication such as manipulation of implicit memory.

]]> /2011/08/22/politics-of-persuasion-persuasion-in-healing/feed/ 4 /2011/05/21/healthcare-on-the-hill-or-in-the-home/ /2011/05/21/healthcare-on-the-hill-or-in-the-home/#comments Sat, 21 May 2011 12:00:57 +0000 /?p=6512 Our democracy was designed for the Members of Congress to reflect the will of the people. But who hasn’t complained over the same cup of coffee about both the cost of health insurance and the deficit? And did I hear one more complaint that all they do in Washington is squabble? Maybe Washington is behaving closer to the will of the people than we give them credit for.

It turns out in a poll just released by the Kaiser Family Foundation that Congress is doing what Americans are doing: arguing along Party lines over the projected $500B deficit for 2012 and the future of Medicare, Medicaid, Social Security, and the Patient Protection and Affordable Care Act (PPACA). Those who are self-described Democrats prefer to keep or expand existing programs while self-described Republicans would prefer to see repeal with replacement or repeal outright.

So is it any surprise that the Republican-majority House is passing legislation aimed at reducing or repealing these laws, while the Democratic-majority Senate is letting the legislation die in Committee?

If you read through the tracking poll, at the very end of the write-up, you’ll find the interesting tidbit on PPACA:

Since January, the share wanting to expand or keep the law as is has tricked up from 47 to 52 percent, while the share calling for repeal has declined from 43 to 35 percent.

One has to wonder if the President will emerge the tiebreaker between the two, divided chambers, if he can manage to sway public opinion. The President has not underestimated the conflict — the White House website contains pages devoted to infomercial style videos and the Executive has spent money on advertising campaigns, including $3.1M for three commercials for Medicare staring Andy Griffith.

With full implementation of PPACA not due until January 1, 2015, America may see changes yet. There are presidential and congressional elections in 2012, and congressional elections, again, in 2014. Neither the Republican majority in the House, nor the Democratic majority in the Senate should be considered safe.

And about all that is clear at the moment, is that in spite of annual deficits and mounting long-term debt, American health care programs and entitlement benefits are here to stay — at least until the public changes the channel.

References

Kaiser Health Tracking Poll — April 2011. Public Opinion and Survey Research Program

Personal Correspondence between Pamela Gentry and Tegan Millspaw. Department of Health and Human Services. 10/28/2010.

]]> /2011/05/21/healthcare-on-the-hill-or-in-the-home/feed/ 4 /2010/10/10/translational-neuroscience-%e2%80%93-untapped-potential-for-education-and-policy/ /2010/10/10/translational-neuroscience-%e2%80%93-untapped-potential-for-education-and-policy/#comments Sun, 10 Oct 2010 12:00:45 +0000 /?p=5529 Recent decades have seen extraordinary advances in the fields of neuroscience, molecular biology, genetics, psychology, and cognitive science. In particular, the National Institutes of Health called the last 10 years of the 20th century the “Decade of the Brain.” Aside from the scientific advances made during that time, government agencies, foundations, and professional organizations put forth substantial efforts to increase public awareness about brain development and diseases. A growing number of neuroscientists indicate that these efforts need to be elevated in order for neuroscience findings to be translated into principles that can facilitate sound policymaking relevant to early childhood education.

Ten years ago, the Institute of Medicine and National Research Council published a report entitled From Neurons to Neighborhoods: The Science of Early Childhood Development, in which great emphasis was placed on the need to utilize knowledge about early childhood development to ensure the health and well-being of young children. Many are now taking this further and emphasize what they call “Neuro-Education” – the utilization of scientific findings about learning and environments to create more effective teaching methods and curricula, as well as to influence educational policy.

The lofty goals of Neuro-Education are deeply rooted in the knowledge that genes interact with both early experiences and environments to shape the structure and function of the developing brain. On this topic, neuroscience has been more informative regarding the negative consequences of these interactions in cases where, for example, early experiences and/or environments are less than ideal. For this reason, scientific contributions to policymaking have been focused on interventions in the lives of children facing considerable adversity. However, given the plethora of evidence suggesting that enriching early experiences have beneficial outcomes in terms of cognitive abilities, placing greater emphasis on this facet of policymaking holds considerable promise. In order for neuroscience to influence early childhood education and policy effectively, there must now be a focus on what can be done to increase the impacts of current educational interventions, as well as on how they can best be implemented. To this end, the power of critical periods in brain development, during which time experience has a particularly powerful influence, must be recognized and utilized as part of organized efforts to positively influence the cognitive, emotional, and social development of young children.

It is time for neuroscience to begin to realize its full translational potential in the world of educational policy. Children in the U.S. and beyond are not doing well academically. Arne Duncan, the U.S. Secretary of Education, called the state of education in America a national public health crisis. Importantly, some Neuro-Education initiatives have recently been established in order to begin to address these issues. In 2009, Dr. Thomas J. Carew, Professor of Neurobiology and Behavior at the University of California at Irvine, and then President of the Society for Neuroscience, created the Neuroscience Research in Education Summit, which gave rise to the creation of the Neuro-Education Leadership Coalition that is working to further the goals of Neuro-Education. Also, the Johns Hopkins University School of Education has established a Neuro-Education Initiative, which promotes the applicability of findings from neuroscience to inform and enrich educational practices. In addition, the Harvard Graduate School of Education offers master’s and doctoral degrees in Mind, Brain, and Education, which emphasize the applicability of the biological and cognitive sciences to pedagogy and public policy. Such efforts, however, are only a beginning.

Neuro-Education provides a framework within which science can inform education and public policy through the application of knowledge gained across multiple disciplines that have not traditionally worked in collaboration. If efforts in Neuro-Education are implemented on a large scale, they may help produce children that are better learners who can rise to the challenges required for leadership in the 21st century. Some have even argued that Neuro-Education may be financially and socially rewarding because, if successful, it may result in reduced costs associated with remedial education, clinical treatment, public assistance, and even incarceration. The existence of so many potentially favorable outcomes of Neuro-Education suggests that we, as a society, cannot afford to continue to do without it.

References

Carew TJ, & Magsamen SH (2010). Neuroscience and education: an ideal partnership for producing evidence-based solutions to Guide 21(st) Century Learning. Neuron, 67 (5), 685-8 PMID: 20826300

Shonkoff JP, & Levitt P (2010). Neuroscience and the future of early childhood policy: moving from why to what and how. Neuron, 67 (5), 689-91 PMID: 20826301

Shonkoff JP, & Phillips DA, eds. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development (Washington, DC: National Academy Press).

Society for Neuroscience (2009). Neuroscience Research in Education Summit: The Promise of Interdisciplinary Partnerships Between Brain Sciences and Education [PDF]

]]> /2010/10/10/translational-neuroscience-%e2%80%93-untapped-potential-for-education-and-policy/feed/ 15 /2010/02/19/you-have-a-right-to-choose-if-we-agree/ /2010/02/19/you-have-a-right-to-choose-if-we-agree/#comments Fri, 19 Feb 2010 12:00:47 +0000 /?p=3804 My first encounter with informed medical consent came as a young law student. I was assigned to assist a lawyer in the defense of an older man who had refused treatment for leukemia. His daughter objected, and asked the court to appoint her to be his conservator so she could compel him to undergo treatment.

When the father spoke to my supervisor, his position became clear. His atypical choice was informed by his cultural background and personal character. An immigrant from Eastern Europe, he was adamantly against yielding control of his life to his daughter. He had tried the medicines, and found they sapped his strength and made him weak. He would rather go on strong for as long as possible and remain his own master.

At the hearing, the lawyer told the judge that his client understood his illness and the prospect of oncoming death, and still chose for his own reasons to turn down further treatment. After confirming this with the man himself, the judge denied the daughter’s request, leaving him to live or die on his own terms.

In the aftermath, it occurred to me that there had been no true issue concerning the man’s ability to comprehend the situation or express his feelings. Yet, he was still forced into a court fight because he decided to turn down treatment. Shouldn’t his clearly stated opinions be enough?

Dr. Alec Buchanan of the Yale Department of Psychiatry evaluated the existing state of law and practice concerning informed consent and reported his findings in a paper in the Journal of the Royal Society of Medicine. Examining medical and legal approaches to the issue of capacity in such matters, he found that “mental capacity is not the sole determinant of what will happen when a patient chooses a course of treatment that doctors consider against the patient’s best interests.” Other factors included the views of relatives, “previous expressed views of the patient,” the opinions of medical staff, and the values of society as a whole.

Buchanan pointed out that acceptance of a patient’s medical decision by professionals and family depends in part on the complexity and gravity of the issue. The harder the choice, or the more grave the potential outcome, the higher the level of scrutiny to which any choice will be subjected. Legal opinions have also followed this logic, holding that “the more serious the decision, the greater the capacity required.”

Such scrutiny is in conflict with the value of autonomy, the ability of the individual to act freely in accordance with their own perceptions and belief. Buchanan says that in the context of medical consent, the importance of autonomy increases with the level of a person’s capacity.

While it is clear that these observations correctly describe how the real world works, it is disturbing that they reflect true disrespect of individual autonomy. If it is acceptable to drag clearly lucid people into court to measure their mental capacity for medical consent, why not question capacity for other decisions? The potential outcome of a poorly chosen marriage might be a devastating divorce, with tragic paths for children of the union. A business contract might eventually lead to unforeseen results which could end in someone’s lifetime ruin. Yet we do not find clearly lucid individuals brought into court in advance so they may be judged as to their ability to make those decisions. At most, poor outcomes in domestic or business pursuits might result in a later determination of incompetence.

Of course, in the area of medical treatment, a poor choice may result in permanent injury or death. For this reason, the law permits family, medical staff, and “other interested parties” the option of advance intervention in health care decisions. Such action is a direct negation of the individual’s right to choose in the most crucial and intimate of matters.

How to both assure competence and maintain autonomy?

From the standpoint of the medical profession, the appropriate emphasis should be on ethical and legal education for professionals to assure that the rights of individuals are not violated.

From the standpoint of the patient, there is no substitute for a properly drafted advanced medical directive or power of attorney which clearly sets forth his or her specific desires and which names an individual who can honestly, quickly, and accurately discern a patient’s wishes in the context of medical treatment. Such an individual can sustain the decision of a patient if a question of capacity arises.

The ability of a physician or of the state to override the wishes of a patient and to violate their body should be closely and exhaustively controlled. It should not depend on the subjective assessment of capacity made by someone else, regardless of their qualifications.

Reference

Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment Journal of the Royal Society of Medicine, 97 (9), 415-420 DOI: 10.1258/jrsm.97.9.415

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