Chapter 28 covers the topic of opioid use disorder. Through a case vignette with topical MCQs for consolidation of learning, readers go through the management of a patient with opioid use disorder from from first presentation to subsequent complications of the condition and its treatment. Topics covered include symptoms and diagnosis of acute intoxication and withdrawal symptoms of opioids and management including that of use in pregnant women.

Chapter 27 covers the topic of stimulants use disorder. Through a case vignette with topical MCQs for consolidation of learning, readers are brought through the diagnosis of a patient with stimulants use disorder on first presentation. Topics covered include symptoms and diagnosis of acute intoxication and withdrawal symptoms of stimulants use.

Chapter 26 covers the topic of cannabis use disorder. Through a case vignette with topical MCQs for consolidation of learning, readers are brought through the diagnosis of a patient with cannabis use disorder on first presentation. Topics covered include symptoms and diagnosis of acute intoxication and withdrawal symptoms of cannabis use and amotivational syndrome.

The literature on school maladjustment is too much engaged with its explicit expressions (e.g., school dropout), while only partially discussing its more implicit expressions. It is arguable that school maladjustment can have many faces. A student’s selection of the way to express maladjustment is a derivation of the person’s characteristics, the environmental characteristics, and the broader context within which the person adjusts (e.g., wartime). Thus, the discussion has to address four general aspects of school maladjustment: (a) silent expressions of school maladjustment, the ones that are commonly addressed by researchers and especially by school teams and parents; (b) indicative expressions of school maladjustment, which are the buds of maladjustment and of major importance in the context of students’ educational flourishing; (c) how both the indicative and the silent expressions can be integrated into a flowchart that summarizes the process of sinking into school maladjustment; and (d) vulnerability to school maladjustment as an additional aspect that deserves a different type of preventive intervention: that is, an intervention that addresses the students’ future adjustment to transitions (e.g., from elementary school to middle school)

Chapter 9 summarizes our theoretical expectations and empirical findings about IO exits. It outlines the implications of IO exit for international cooperation, future research, and policymaking. It also provides additional insight into IO exits that have occurred as regional conflicts have engulfed the world in recent years, exemplified by Russia’s invasion of Ukraine in 2022. The chapter analyzes how IO exits might affect international cooperation as multilateralism is being contested on several fronts. It also discusses that patterns of democratic decline and polarized domestic politics may lead the future of IO exits to be different than the past. Even while this contestation is happening, however, we show that IO exits (as well as threats and reentry) extend beyond current affairs; they have been a relatively steady occurrence over time. We conclude by arguing that despite – and sometimes because of – occasional exits, international cooperation continues through IOs and a robust set of other international institutions. We outline several exciting areas for future research that may be inspired by the findings from this book.

Chapter 4 outlines and tests our argument about the consequences of IO withdrawal for exiting states. We argue that there should be negative reputational and cooperative consequences for withdrawing states because IOs operate as hand-tying, credible commitment devices. International actors might regard withdrawal as backing out of a commitment and a signal that decouples the state from a self-chosen “in-group.” Thus, international actors – such as market analysts and other states – may reduce their trust that a withdrawing state will follow through on other commitments. As evidence, we document that withdrawal is associated with worsened perceptions of political risk and investor confidence. We document how the negative reputational consequences vary based on states’ and IOs’ preexisting reputations. We also show that withdrawal reduces the chance of being elected to the UNSC as a non-permanent member and makes states less likely to sign future treaties with the exiting state. We expect the material consequences of withdrawal to be limited due to strategic selection, substitution, and potential gains. We test these arguments on economic IOs because they represent more than half of all IOs and they can be evaluated consistently. We find that withdrawing states on average suffer limited material consequences.

Why do states exit IOs? How often does IO exit happen? And what are the consequences of IO exit for leaving states? Despite recent attention to individual cases and the importance of membership in IOs, little is known about state exit from IOs across states, organizations, and time. Chapter 1 outlines the common logic of IO exit that links withdrawal and suspension: States often use IO exit as a strategy to negotiate institutional change when mechanisms of voice have failed. We summarize our empirical contributions that rely on a new dataset of IO exit across 198 states and 534 IOs from 1913 to 2022. We show that exit is infrequent, intermittent, and often temporary rather than terminal. Factors related to bargaining help predict IO exit, and exit generates negative reputational and cooperative consequences for leaving states. Nonetheless, IO exit is often an imperfect tool in achieving institutional change. Overall, we correct the view of IO exit as recently increasing. We also show that alternative arguments are not correct: IO exit is not widely occurring because of a backlash against globalization, nationalism/populism, IO authority, or legal rules. Moreover, exit is not inconsequential. We end with a roadmap for each chapter.

Chapter 5 traces the dynamics of our argument about the causes and consequences of IO withdrawal with three qualitative case studies: the US’ withdrawal from the ILO from 1977–1980, Japan’s withdrawal from the IWC in 2019, and the UK’s withdrawal from the EU in 2020. The cases show how states often think of withdrawal as a negotiation tool and highlight states’ long-term striving for “better” institutional arrangements through other mechanisms of “voice” before exit. In each case, we use archival research and media sources to document that the desire for IO change prompted exit, that states used withdrawal threats for negotiation, and that negotiation prior to withdrawal happened but fell short of the state’s goals, leading to withdrawal. In the cases of the ILO and IWC, negotiation continued while the state was a non-member and led to its return in the case of the ILO. The case studies also underscore the effects of withdrawal: Each of the withdrawing states suffered negative reputational and cooperative consequences and sometimes material consequences from withdrawal. International actors chastised withdrawing states, and the withdrawers then engaged in rhetorical stigma management to try to lessen the impact.

Chapter 2 theorizes the causes and consequences of state exit from IOs. We explain that IOs start as being beneficial to member states but may become dissatisfying to some states as preferences diverge, power shifts, or IOs themselves evolve. Leaning on the “exit, voice, and loyalty” framework by Hirschman (1970), we argue that dissatisfied states can voice their discontent but when this does not generate desired results, states sometimes use the process of IO exit to invoke change. Threatening and enacting exit can accelerate a tipping point by presenting states with a potential future without the exiting state, which could reduce institutional benefits. The ability to use exit as a negotiation strategy shifts with a state’s bargaining power as well as institutional constraints. As part of the negotiating process, many exit threats are not implemented and many exiting states return to IOs. But exit is costly: Given that exiting states may be perceived as reneging on an international commitment, they can incur negative reputational and cooperative consequences from other actors in the international community. Exiting states may therefore engage in stigma management. And while institutional change is often the goal, exit is usually an imperfect tool for achieving it.

Chapter 3 outlines and tests our theory of IO exit by applying it to the predictors of IO withdrawal. We argue that many dissatisfied states use the process of withdrawal to broker deals for institutional change in the IO. Many withdrawals are driven by preference divergence from other member states or declining power. Using our IO Exit dataset, we analyze 387 IO withdrawals from 1913 to 2022 across 534 IOs and 198 states. In categorizing the reasons for state withdrawals, we show that two-thirds of IO withdrawals are motivated by the desire to negotiate change rather than by issues that reflect populism, nationalism, or capitulation toward international cooperation. States also use the threat of withdrawal, which supports the notion that exit is a negotiating process with multiple steps rather than a final or singular act. Withdrawal is usually not permanent; half of the time, states return to the IOs they left. States also likely consider costs a priori and avoid withdrawal if the costs are projected to be too high. This prevents many withdrawals from happening in the first place. We do not find consistent support for alternative arguments that backlash against globalization, encroachment from authoritative IOs, nationalism/populism, or legal rules are robust drivers of withdrawal.

In this chapter of Complex Ethics Consultations: Cases that Haunt is, the author describes the request of a middle-aged patient with COPD for terminal ventilator withdrawal. The consult occurred soon after the author began working at a Catholic hospital. The patient’s husband objected to withdrawal, despite the fact that the patient had reasonable capacity and could mouth or write. The attending physician said he would not withdraw treatment if "there was disagreement" in the family. Upon questioning, the patient reiterated her wishes and said the team should not abide by his wishes and did not want him involved in the decision if he was objecting to her request. A week later, still on the ventilator, she declined SNF placement and her distraught husband wanted transfer. Suspicions about her husband gained traction on the unit. The author offers advice and insights for new ethics consultants. She was haunted by her inexperience, her doubt whether she was assertive enough, the narrative around her husband’s suitability as a surrogate, and some of the staff’s admonition that the consultant did sufficiently advocate for the patient.

This chapter of Complex Ethics Consultations: Cases that Haunt Us recounts the case of a previously healthy 7-year-old whom the author saw in the emergency department. In the PICU, she was diagnosed with meningococcemia and purpura fulminas. She required ventilation, dialysis, and vasopressors. If she did not recover, she faced double upper extremity amputation, multiple reconstructive surgeries, and uncertain neurological function. Her parents requested withdrawal of life-sustaining treatment, but PICU staff thought this was too soon and inappropriate. They wanted more time, which her parents declined. Her parents relied on a faith tradition that matched the author’s. He reflects on an ethics consultation in which he recommended respecting the parents’ wishes for terminal withdrawal. The author reflects on the child’s frightened face as he reassured her in the ED that she would be fine. She wasn’t. These thoughtful parents, who allowed another day for evaluation, asked what he would do if faced with the same situation and he replied. The child died.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author describes a 24-year-old woman who was comatose with a devastating neurological injury after suffering a cardiac arrest soon after receiving chemotherapy for acute myelogenous leukemia. The treating team recommended discontinuing ICU level care and shifting to comfort care. The patient’s mother declined, saying this course of action did not align with the patient’s and her Islamic faith and requesting transfer, which was impossible due to the patient’s medical instability. The author reflects on the culture of adult medicine, in contrast to her pediatric practice. She is haunted because she worries she did a good job as an ethics consultant but was lacking as a physician. This case raises the complexities of the dual role some consultants play as clinicians and ethics consultants.

The addiction syndrome is quite similar across different addictive drug types, reflecting a shared pathway of pathological changes within motivational circuits that increasingly prioritize drug acquisition and use. This neurobiology, and drug addiction symptomatology, overlaps considerably with behavioral addictions (e.g., gambling disorder). However, addiction is distinct from symptoms and mechanisms underpinning intoxication and withdrawal, which are diverse and unique to each drug class. The intoxication phase is followed by some degree of withdrawal, manifesting clinically as opposite to intoxication, reflecting a homeostatic response to it. Withdrawal has a quality, duration, and dangerousness that depends on the individual, the drug type, and drug use history. Heavy/chronic patterns of use in addiction can produce longer, more severe withdrawal phases, but addiction and withdrawal can exist separately. How a drug acts upon different receptors and other downstream brain systems (pharmacodynamics) impacts the strength of its psychoactive (intoxicating) and motivational (addictive effects). Meanwhile, the route and rate of drug intake and its breakdown and elimination (pharmacokinetics) can also impact intoxication, withdrawal, and addiction risk. With addiction, the patient becomes tolerant (insensitive) to the intoxicating profiles of drugs they like, whereas their motivation, craving, and wanting to use the drug sensitizes (grows pathologically).

From a strategic standpoint, the final years of the American war in Vietnam highlighted a persistent uncertainty over how the conflict would end. Both civil and military leaders wrestled with confusing estimates on the war’s progress. These uncertainties mattered because they influenced the timing of and ways in which US forces withdrew from a war that would not end once the Americans had departed. Despite arguments that General Creighton Abrams had fought a “better war” in Vietnam leading to a military victory, a sense of strategic stalemate hung over these final years. Problems remained in assessing the political aspects of pacification, the staying power of the South Vietnamese armed forces once American troops departed, and the longterm viability of the Saigon regime. By early 1969, Abrams also had to confront political decisions leading to the first withdrawal of US troops, decisions that would pit him against the Nixon administration and bring to the surface grave civil–military tensions. Despite years of effort, a key question remained unanswered as these withdrawals began – how stable would South Vietnam be once Americans departed? Ultimately, these final years left the Americans no closer to answering the question of whether they would achieve “victory” in Vietnam.

Substance use disorders commonly co-occur with mood disorders (major depression, bipolar disorder) and may be due to the direct effects of illicit substances, such as intoxication and withdrawal, or due to effects stemming from chronic use, including substance-induced mood disorders. Self-medication of mood disorders with legal or illicit substances is highly prevalent. Careful assessment of patients is necessary to determine whether a co-occurring disorder is due to substance use or a separate diagnosis that requires independent treatment. Many depressive symptoms may resolve with treatment of the substance use disorder. Independent mood disorders can be treated with behavioral therapy and standard pharmacological therapy. Some mood disorder medications are also effective for substance use disorders. Some substances that have historically been used recreationally are being studied as possible treatments for mood disorders.

This chapter considers ascetic experience. It provides historical background for the ascetic movement in the early centuries of Christianity and highlights the texts that can serve as sources for the examination of this type of experience. It shows that ascetic experience is characterized by processes of withdrawal and repentance, both physical and emotional, which try to eliminate temptation, combat passions, and purify the heart. This is achieved through practices of vigilance and discernment that involve a close monitoring of emotions and patterns of thought and action. Such practices result in a purification and reorientation of the self that move through self-denial and self-control to transformation. Ascetic experience thus emerges as a way of grappling with the deeply experienced shortcomings of the human condition through processes of abnegation and a radical break with “ordinary” life.