Faculty Bibliography

Caplan cites some criticisms of the newly revised Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association--DSM-5. The DSM is often described as the bible of the mental health field--and unfortunate misnomer that leaves it open to attack as a compendium of divinely inspired truths about human behavior. The most common criticism in the reviews and books is that DSM-5 proliferates diseases beyond the boundaries of common sense

Rates of nonmedical exemptions from school immunizations are increasing and have been associated with resurfacing clusters of vaccine-preventable diseases, such as measles. Historically, state-level school immunization policies successfully suppressed such diseases. We examined state immunization exemption regulations across the United States. We assessed procedures for exempting schoolchildren and whether exemption rates were associated with the complexity of the procedures. We also analyzed legal definitions of religious objections and state legislatures' recent modifications to exemption policies. We found that states with simpler immunization exemption procedures had nonmedical exemption rates that were more than twice as high as those in states with more-complex procedures. We also found that the stringency of legal definitions of religious exemptions was not associated with exemption procedure complexity. Finally, we found that although there were more attempts by state legislatures to broaden exemptions than to tighten them in 2011-13, only bills tightening exemptions passed. Policy makers seeking to control exemption rates to achieve public health goals should consider tightening nonmedical exemption procedures and should add vaccine education components to the procedures by either mandating or encouraging yearly educational sessions in schools for parents reluctant to have their children vaccinated.

Comparative effectiveness research has the potential to dramatically improve patient care while reducing costs. In the absence of good evidence about which treatment is best for particular patients, decision making too often hinges on exogenous factors such as advertising and detailing by pharmaceutical companies, what a physician first learned to do, insurance coverage, and local custom. Without good evidence about what is best among competing but generally accepted clinical options, it is often a challenge for physicians to identify the best course of care. A great deal of effort is under way to make it easier and less expensive to . . .

The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment.

Caplan talks about Ariel Sharon's brain activity. Sharon was the eleventh prime minister of Israel, serving from 2001 to 2006. He has been diagnosed as being in a persistent vegetative state since suffering first a minor stroke and then another massive one on Jan 4, 2006. A respirator and a feeding tube have kept him alive for seven years at Sheba Hospital in Tel Hashomer, Israel. Last January, a team of doctors and neuroscientists from Israel's Soroka University Medical Center was hired to subject the now eighty-four-year-old Sharon to a series of sophisticated brain scans. The team showed the former prime minister pictures of random houses, which he would not be expected to be familiar with. Then they flashed a picture of his own house before his eyes. When the images of his own home were shown, areas of his brain "lit up" with activity. Similarly, his brain "fired up" in response to hearing family voices but not when nonsensical gibberish sounds were played for him

Despite novel medications and other therapeutic strategies, addiction to psychotropic substances remains one of the most serious public health problems worldwide. In this review, beginning with an introduction of deep brain stimulation (DBS), we highlight the importance of the nucleus accumbens (NAc) in the context of the reward circuitry and addictive behavior. We will provide a short historic overview of other neurosurgical approaches to treat addiction and describe the experimental and preclinical data on DBS in addiction. Finally, we call attention to key ethical issues related to using DBS to treat addiction that are important for future research and the design of clinical trials.

Experts agree that influenza vaccination of health-care personnel (HCP) is the best method of preventing nosocomial outbreaks. Because voluntary uptake among HCP has not achieved recommended levels, hundreds of health-care facilities and twenty states have implemented mandatory vaccination programs. How- ever, employee unions assert that unilateral changes to working conditions violate established principles of collective bargaining. In this article, we argue that mandatory vaccination in the health-care context is supported by ethics, science, and law. We examine nosocomial influenza outbreaks and how hospitals have attempted to curb infections through mandatory HCP influenza vaccination policies. We also explore employee unions' administrative and legal chal- lenges to the requirements. Finally, we suggest an approach to resolving the dispute between HCP labor representatives and health-care facility management. [PUBLICATION ABSTRACT]