Karl Jaspers: The Icon of Modern Psychiatry.

December 2015 and March 2016 issues of the American Journal of Psychiatry contain a debate focusing on the legacy of Emil Kraepelin, widely considered one of the founders if not the iconic founder of modern scientific psychiatry. The authors, Eric J. Engstrom and Kenneth S. Kendler, challenge the so-called neo-Kraepelinian view of Kraepelin and argue that the true, historical Kraepelin was far more inclined towards scientific psychology, less reductionist and brain-centric, and more skeptical nosologically than his later followers apparently believe. Commenting upon this paper, Rael D. Strous, Annette A. Opler, and Lewis A. Opler do not question these claims per se, but rather recall and emphasize historical facts that the paper regrettably omitted: Kraepelin's avid promotion of degeneration theory, eugenics, racism, and anti-Semitism as well as his mentoring of several of the most prominent Nazi-collaborating psychiatrists. Strous, Opler and Opler go on to suggest that it is now time for psychiatry to unburden itself of any iconic indebtedness to Kraepelin. The authors of the current paper agree, and propose to replace Kraepelin with the psychiatrist Karl Jaspers, MD (1883-1969) as the proper iconic founder of present-day and future psychiatry. Acknowledging our debt to Jaspers can usher in a fully humanistic and scientific psychiatric practice that can flourish as a medical discipline that is respectful of and of service to patients, beneficial for research, multiperspectival and methodologically pluralistic.

Comments on Mohammed Abouelleil Rashed's "A critical perspective on second-order empathy in understanding psychopathology: phenomenology and ethics".

Understanding the mental life of persons with psychosis/schizophrenia has been the crucial challenge of psychiatry since its origins, both for scientific models as well as for every therapeutic encounter between persons with and without psychosis/schizophrenia. Nonetheless, a preliminary understanding is always the first step of phenomenological as well as other qualitative research methods addressing persons with psychotic experiences in their life-world. In contrast to Rashed's assertions, in order to achieve such understanding, phenomenological psychopathologists need not necessarily adopt the transcendental-phenomenological attitude, which, however, is often required if performing phenomenological philosophy. Additionally, in the course of these (non-philosophical) scientific endeavors, differences between persons with psychosis/schizophrenia and so-called normal people seem to have a methodological function and value driving the scientist in her enterprise. Yet, these differences do not extend to ethical dimensions, and therefore, do not by any means touch ethical equality.

Karl Jaspers' multiperspectivalism.

In later editions of his General Psychopathology, Karl Jaspers prescribes many different methods and theoretical points of view for psychopathologists to utilize. Each of these perspectives on the subject matter of psychopathology, however, gives the investigator access to only one dimension of the patient's being. Hence, Jaspers insists that several different perspectives must be employed in order to avoid a one-sided and partial comprehension of the patient and his or her problem. He advocates a multiperspectival approach in psychopathology. Nevertheless, Jaspers remains aware that the patient is a unified whole. This unified whole, however, is not knowable as such, but can rather be approached only under the guidance of an 'idea' of the whole. Jaspers takes the basic notion of 'idea' (Idee) from Kant, but he modifies and uses it for his own purposes. Jaspers' multiperspectivalism may seem to invite charges of relativism because it leaves the psychopathologist to 'pick and choose' any method or theory he or she prefers. This charge is addressed by admitting that there does exist a certain relativism in Jaspers' position in that any one perspective does provide only one approach to the reality of the patient and that other equally useful perspectives could have been chosen. However, each perspective itself can be subjected to test by evidence, and in such tests, claims made from that perspective can be found to be true or false. Helen Longino's theory of scientific knowledge helps support such a thesis.

Psychosomatic medicine and the philosophy of life.

Basing ourselves on the writings of Hans Jonas, we offer to psychosomatic medicine a philosophy of life that surmounts the mind-body dualism which has plagued Western thought since the origins of modern science in seventeenth century Europe. Any present-day account of reality must draw upon everything we know about the living and the non-living. Since we are living beings ourselves, we know what it means to be alive from our own first-hand experience. Therefore, our philosophy of life, in addition to starting with what empirical science tells us about inorganic and organic reality, must also begin from our own direct experience of life in ourselves and in others; it can then show how the two meet in the living being. Since life is ultimately one reality, our theory must reintegrate psyche with soma such that no component of the whole is short-changed, neither the objective nor the subjective. In this essay, we lay out the foundational components of such a theory by clarifying the defining features of living beings as polarities. We describe three such polarities: 1) Being vs. non-being: Always threatened by non-being, the organism must constantly re-assert its being through its own activity. 2) World-relatedness vs. self-enclosure: Living beings are both enclosed with themselves, defined by the boundaries that separate them from their environment, while they are also ceaselessly reaching out to their environment and engaging in transactions with it. 3) Dependence vs. independence: Living beings are both dependent on the material components that constitute them at any given moment and independent of any particular groupings of these components over time.We then discuss important features of the polarities of life: Metabolism; organic structure; enclosure by a semi-permeable membrane; distinction between "self" and "other"; autonomy; neediness; teleology; sensitivity; values. Moral needs and values already arise at the most basic levels of life, even if only human beings can recognize such values as moral requirements and develop responses to them.

Patient expectations in facial transplantation.

Meeting patients' expectations is essential for successful outcomes in reconstructive surgery. In the case of new procedures like facial transplantation that carry with them many unknowns and real, or potential, risk of toxic side effects this becomes especially important. In this study we assessed patient expectations in facial transplantation by surveying individuals with facial disfigurement (n = 34), reconstructive surgeons (n = 45), and controls from the general population (n = 148). Questions focused on quality of life improvement, esthetic and functional outcomes. Student t test was used to compare means of the 3 study groups. All groups projected low quality of life for nontreated disfigured persons, controls responding the most negatively (M = 1.91), followed by disfigured persons (M = 2.91; t = 2.14, P

Plastic surgeon's risk acceptance in facial transplantation.

BACKGROUND: A great deal of ethical debate has accompanied the introduction of facial tissue allotransplantation into the clinical arena. Critics contend that the risks of lifelong immunosuppression do not justify the benefits of this new non-life-saving reconstructive procedure, whereas proponents argue that they do. Absent from this debate are the opinions of individuals with real-life experiences with the risks and benefits associated with this new treatment. METHODS: In this study, the authors question facially disfigured individuals (n = 33) and the reconstructive surgeons who treat them (n = 45), organ transplant recipients (n = 42) and the professionals who manage their immunosuppression medication (n = 37), and healthy volunteer controls (n = 148) to determine the amount of risk they are willing to accept to receive facial tissue allotransplantation. A survey with psychometrically reliable and validated questions was administered to the above five groups, and appropriate statistical analysis was used to analyze and compare the data within and between groups. RESULTS: Of the five groups studied, reconstructive surgeons would accept the least amount of risk for a facial tissue allotransplant, followed by transplant specialists, then kidney transplant recipients, then facially disfigured individuals, and finally healthy control volunteers, who would accept the most amount of risk. CONCLUSIONS: The authors' data indicate that reconstructive surgeons are the least tolerant of risks compared with the other groups studied concerning facial tissue allotransplantation. This is particularly important because they are the primary caregivers to facially disfigured patients and, as such, will be the ones to lead the effort to move this new reconstructive treatment into the clinical arena.

Ethical considerations in human facial tissue allotransplantation.

BACKGROUND: Human facial tissue allotransplantation is now a clinical reality. Proponents of this new treatment contend that the benefits outweigh the risks, while the critics argue they do not. This debate has been presented in great detail in the bioethics literature but has not been brought to the attention of the plastic surgery community. METHODS: The purpose of this paper is to provide a synopsis of the key issues being debated in facial transplantation by presenting to the plastic surgery community a synopsis of an ethical debate published in the 2004 summer issue of the American Journal of Bioethics. RESULTS: Presented is a set of ethical guidelines for facial transplantation in the form of a "target article." Alongside this are written commentaries from 15 experts in related fields, along with responses to these commentaries. Together, this discussion makes up a landmark exercise in open display and public and professional discussion and evaluation and serves as a comprehensive list of the major ethical issues being debated today in the field of facial tissue allotransplantation. CONCLUSIONS: Plastic surgeons play a central role in the care of facially disfigured patients and will therefore lead the introduction of facial tissue allotransplantation into the clinical arena. Consequently, it is important that they be aware of, and indeed that they play a key role in forming, the debate surrounding this new treatment. It is with this in mind that we present this synopsis to the plastic surgery readership.

Ethical considerations in face transplantation.

Human face transplantation is now a clinical reality. The surgical techniques necessary to perform these procedures have been used routinely in reconstructive microsurgery for many years. From an immunological standpoint since face and hand contain mostly the same tissues it is reasonable to assume that the same immunosuppressive regimen found to be effective in human hand transplants should also work in face transplantation. It is the ethical issues associated with the risks and benefits of performing facial transplantation that have posed the greatest challenges leading up to performing this new procedure. In this editorial, we will review some of the main events that have led to the recently performed human face transplants, specifically focusing on the key ethical issues at the center of this debate. We will discuss how the research and clinical experience in human hand transplantation laid the foundation for performing face transplantation and describe the research and the ethical guidelines upon which a team at the University of Louisville based their position "to move ahead" in spite of much criticism. Finally we will outline some of the key arguments against face transplantation, and conclude with a discussion on what comes next now that the first human face transplants have been performed.

Psychosocial implications of disfigurement and the future of human face transplantation.

Although the first face transplants have been attempted, the social and psychological debates concerning the ethics and desirability of the procedure continue. Critics contend that these issues have not yet been sufficiently addressed. With this in mind, the present article seeks to elaborate on key psychological and social factors that will be central for addressing the ethical and psychosocial challenges necessary to move face transplantation into mainstream medicine. The goals of this article are to (1) discuss the psychosocial sequelae of facial disfiguration and how face transplantation may relieve those problems, and (2) delineate inclusion and exclusion criteria for the selection of research subjects for face transplantation. The article uses concepts from symbolic interaction theory in sociology to articulate a theoretically coherent scheme for comprehending the psychosocial difficulties of facial disfiguration and the advantages offered by facial transplantation. The authors conclude that the psychosocial implications of disfigurement warrant surgical intervention and that research in the area of face transplantation should continue.

Research and events leading to facial transplantation.

Facial transplantation has long captured the interest and imagination of scientists, the media, and the lay public. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation, or congenital birth defects. This article discusses the major technical, immunologic, psychosocial and ethical hurdles that have been overcome to bring facial transplantation from an idea to a clinical reality by providing the reader with a chronologic overview of the research and events that have led this exciting new treatment into the clinical arena.

Composite tissue allotransplantation of the hand and face: a new frontier in transplant and reconstructive surgery.

Each year an estimated 7-million people in the USA need composite tissue reconstruction because of surgical excision of tumors, accidents and congenital malformations. Limb amputees alone comprise over 1.2 million of these. This figure is more than double the number of solid organs needed for transplantation. Composite tissue allotransplantation in the form of hand and facial tissue transplantation are now a clinical reality. The discovery, in the late 1990s, that the same immunotherapy used routinely in kidney transplantation was also effective in preventing skin rejection made this possible. While these new treatments seem like major advancements most of the surgical, immunological and ethical methods used are not new at all and have been around and routinely used in clinical practice for some time. In this review of composite tissue allotransplantation, we: (i) outline the limitations of conventional reconstructive methods for treating severe facial disfigurement, (ii) review the history of composite tissue allotransplantation, (iii) discuss the chronological scientific advances that have made it possible, (iv) focus on the two unique clinical scenarios of hand and face transplantation, and (v) reflect on the critical issues that must be addressed as we move this new frontier toward becoming a treatment in mainstream medicine.

Risk acceptance in laryngeal transplantation.

PURPOSE: Advancements in the fields of head and neck surgery and immunology have paved the way for new quality of life-improving procedures such as larynx transplantation. To quantitatively assess the risks versus benefits in larynx transplantation, we used a questionnaire-based survey (Louisville Instrument For Transplantation [LIFT]) to measure the degree of risk individuals are willing to accept to receive different types of transplantation procedures. METHODS: The LIFT contains 237 standardized questions incorporating standard gamble and time tradeoff outcome measures as well as questions assessing body image perception, depression, self-esteem, optimism, socially desirable responding, and demographics. Respondents were questioned on the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different types of transplant procedures. For this study, we questioned 243 individuals in three study populations with differing life experiences: healthy individuals, organ transplant recipients, and laryngectomees. RESULTS: All populations questioned perceived risks differently based on their varied life experiences and would accept differing degrees of risk for the different transplant procedures. Organ transplant recipients were the most risk-tolerant group, whereas laryngectomees were the least risk-tolerant. CONCLUSIONS: By questioning individuals with life experiences directly relevant to the risks and benefits associated with larynx transplantation, this study provides an empiric basis for assessing risk versus benefit in this new quality of life-improving procedure.

Investigation of risk acceptance in facial transplantation.

BACKGROUND: The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the greatest challenge to performing facial transplantation. At the center of the ethical debate is the question, "Do the risks posed by the life-long immunosuppression that a recipient would have to take justify the benefits of receiving a face transplant?" In this study, the authors answer this question by assessing the degree of risk individuals would be willing to accept to receive a face transplant. METHODS: To quantitatively assess risks versus benefits in facial transplantation, the authors developed the Louisville Instrument for Transplantation, or LIFT, which contains 237 standardized questions. Respondents in three study populations (healthy individuals, n = 150; organ transplant recipients, n = 42; and individuals with facial disfigurement, n = 34) were questioned about the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different transplant procedures. RESULTS: The authors found that the three populations would accept differing degrees of risk for the seven transplant procedures. Organ transplant recipients were the most risk-tolerant group, while facially disfigured individuals were the least risk tolerant. All groups questioned would accept the highest degree of risk to receive a face transplant compared with the six other procedures. CONCLUSIONS: This study presents an empirical basis for assessing risk versus benefit in facial transplantation. In doing so, it provides a more solid foundation upon which to introduce this exciting new reconstructive modality into the clinical arena.

Risk acceptance in composite-tissue allotransplantation reconstructive procedures.

Composite-tissue allotransplantation (CTA) is a new therapeutic modality to reconstruct major tissue defects of the face, larynx, and extremities. Unlike most life-saving organ-transplantation procedures, CTA is considered to improve quality of life. Therefore, the question arises, do the risks posed by the immunosuppression drugs that patients must take to prevent rejection justify the benefits of these procedures? The purpose of this study was to assess the relative risk that individuals are willing to accept in order to receive the benefits of CTA procedures. We used a psychometrically reliable and valid instrument to question two primary populations of individuals: those who live with the risks of immunosuppression, and healthy individuals. The level of risk acceptance for the seven transplant procedures tested (foot, single hand, double hand, larynx, kidney, hemiface, and full face) showed significant differences in research participants' risk acceptance for the different transplant procedures, but no significant differences between groups. Based on these findings, we conclude that certain CTA procedures convey benefits to recipients that are perceived by subjects, including individuals who live with the risks of immunosuppression, to warrant the risks of these procedures.

A window into Richard M. Zaner's clinical ethics.

This essay introduces a thematic issue focused on the contributions to clinical ethics and the philosophy of medicine by Richard M. Zaner. We consider the apparent divorce of Zaner's philosophical roots from his recent narrative immersions into the blooming, buzzing confusions of clinical-moral lifeworlds. Our considerations of the Zanerian context and origins of the clinical encounter introduce the fundamental questions faced by Zaner and his commentators in this issue, questions about the role of ethics consultants, moral authority, and clinical truths.

Richard Zaner's phenomenology of the clinical encounter.

The "clinical ethics" propounded by Richard Zaner is unique. Partly because of his phenomenological orientation and partly because of his own daily practice as a clinical ethicist in a large university hospital, Zaner focuses on the particular concrete situations in which patients and their families confront illness and injury and struggle toward workable ways for dealing with them. He locates ethical reality in the "clinical encounter." This encounter encompasses not only patient and physician but also the patient's family and friends and indeed the entire "lifeworld" in which the patient is still striving to live. In order to illuminate the central moral constituents of such human predicaments, Zaner discusses the often-overlooked features of disruption and crisis, the changed self, the patient's dependence and the physician's power, the violation of personal boundaries and their necessary reconfiguring, and the art of listening.

On the ethics of facial transplantation research.

Transplantation continues to push the frontiers of medicine into domains that summon forth troublesome ethical questions. Looming on the frontier today is human facial transplantation. We develop criteria that, we maintain, must be satisfied in order to ethically undertake this as-yet-untried transplant procedure. We draw on the criteria advanced by Dr. Francis Moore in the late 1980s for introducing innovative procedures in transplant surgery. In addition to these we also insist that human face transplantation must meet all the ethical requirements usually applied to health care research. We summarize the achievements of transplant surgery to date, focusing in particular on the safety and efficacy of immunosuppressive medications. We also emphasize the importance of risk/benefit assessments that take into account the physical, aesthetic, psychological, and social dimensions of facial disfiguration, reconstruction, and transplantation. Finally, we maintain that the time has come to move facial transplantation research into the clinical phase.

Schizophrenia as a temporal mode of being: an existential "ante-festum" impatience.

We suggest in a phenomenological perspective to consider schizophrenia as a special form of human temporality. From this perspective, we view the symptoms of schizophrenia as actions undertaken by subjects to stabilize themselves in existence. From this vantage, we describe the clinical expression of the disorder as a type of "existential impatience", characterized by a painful and elusive "now". This present time posits the prime moment of the constitution of the person. Existential impatience reflects from our patients the persistence of excessive efforts towards individuation. Schizophrenia. In human life in general, individuation consists in an unceasing dynamic process of building up of the self. This process starts with the non-self and particularly with the other. Therefore, the emergence of any relation within the self is grounded in the relation with the other and is based on the relation the other establishes with himself. Schizophrenia distinctly displays the two constitutive moments of "being oneself." These moments are generally linked for all of us: an "unending coming to oneself" (difference of identity), and a "continuous maintenance of being a self" (identity of difference). Existential impatience is not only an irritability of a formal order. Existence itself is impatient in the schizophrenic experience as it hastens to reach human goals while trampling on an "ante-festum" temporal mode. This "before-the-feast" temporal structure is dominated by the shiver before an unknown future, a sign of a basic quest for a task. Schizophrenic "ante-festum" is both a constant fear of being unable to come to oneself and a desperate effort to reach this unknown future. If psychopathology claims to settle [establish] that "order" and "measure" would constitute the two fundamental anthropological bases of human being, impatience of existence draws the emblematic figure of the disorder of measure as a referential motion of the birth of any temporalisation. Such considerations suggest the value, in treatment and rehabilitation, of praising patience and focusing on building, or re-building, the past. The main objective is to reach a maieutics of the self based on relationships in the community and with care-givers, all within an accompanying structured, daily framework.

Rebuilding reality: a phenomenology of aspects of chronic schizophrenia.

Schizophrenia, like other "pathological" conditions, has not been systematically included in the general study of consciousness. By focusing on aspects of chronic schizophrenia, we attempt to survey one way of remedying this omission. Some basic components of Edmund Husserl's phenomenology of human experience (intentionality, constitution, and unbuilding) are explicated in detail, and these components are then employed in an account of exemplary aspects of chronic schizophrenia. We maintain that in schizophrenic experience some very basic constituents of reality--constituents so basic we call them "ontological"--are lost so that the patient must try to explicitly re-constitute those ontological features of the world. Using Husserl's concepts such experiences are described as a weakening of "automatic mental life" so that much of the world that is normally taken-for-granted cannot continue to be so. This requires the patient to actively busy him or herself with re-laying the ontological foundations of reality.