Decision-making depends on bringing evidence together with values: decision theory for example employs probabilities and utilities; health economic decisions employ measures such as quality of life. The hypothesis guiding this chapter is that bringing evidence together with values in clinical decision-making requires an exercise of phronesis. Our aim however is not to justify our guiding hypothesis. It is rather to outline an account of phronesis that is in principle fit for the purposes of clinical decision-making if our guiding hypothesis is (...) correct. The chapter has three sections. Section 1 describes the growing gap between evidence and values in clinical decision-making: the missing link, we suggest, required to bridge this gap, is an appropriate account of phronesis. Section 2 provides an initial characterisation of the required account of phronesis via Michael Polanyi’s twin stipulation on the nature of tacit knowledge. Section 3 then fills out the required account using John McDowell’s characterisation of phronesis as a situation specific but at the same time conceptually structured form of practical discernment. A McDowellian account of phronesis, we argue, in satisfying Polanyi’s twin stipulation, provides an in-principle bridge between evidence and values. We conclude with a note on some of the further requirements if the gap is to be bridged not only in principle but in practice too. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Spiritual Experience and PsychopathologyMike Jackson and K. W. M. Fulford (bio)AbstractA recent study of the relationship between spiritual experience and psychopathology (reported in detail elsewhere) suggested that psychotic phenomena could occur in the context of spiritual experiences rather than mental illness. In the present paper, this finding is illustrated with three detailed case histories. Its implications are then explored for psychopathology, for psychiatric classification, and for our understanding (...) of the concept of mental illness. It is argued that pathological and spiritual psychotic phenomena cannot be distinguished by 1) form and content alone (as in traditional psychopathology), 2) by their relationship either with other symptoms or with pathological causes (as in psychiatric classification), or 3) by reference to the descriptive criteria of mental illness implied by the “medical” model. The distinction is shown to depend, rather, on the way in which psychotic phenomena themselves are embedded in the values and beliefs of the person concerned. This in turn is shown to have implications for diagnosis (it shows the need for clinicians to attend to the values and beliefs of individual patients), for treatment (it points to a cognitive problem-solving model), and for research in psychopathology (especially as related to the emerging sciences of dynamic brain imaging and cognitive neuroscience).Keywordsfirst rank symptoms, schizophrenia, delusion, hallucination, thought disorder, religious experience, mystical experienceIntroductionThis paper explores some of the conceptual and practical implications of the finding that phenomena which in a medical context would probably be diagnosed as psychotic symptoms, may occur in the context of non-pathological, and indeed essentially benign, spiritual experiences.The existence of non-pathological psychotic experiences of this kind (we will call them “psychotic phenomena” as distinct from “psychotic symptoms”—see also Endnote 1, terminology) was a key finding in a study carried out by one of us (MJ) at the Alister Hardy Research Centre (AHRC) in Oxford. Details are given elsewhere both of the overall empirical findings of the study, including the relationship between spiritual experience and personality variables, and of a hypothetical cognitive problem-solving model of these phenomena (Jackson 1991, and forthcoming a and b). In the present paper, 1) the background to the study is described briefly in relation to earlier work on the possible links between spiritual experience and psychopathology; 2) some of the psychotic phenomena identified are illustrated with three detailed case histories; 3) the significance of these phenomena is reviewed for our understanding respectively of psychopathology, of diagnostic syndromes, and of the concept of mental illness; and 4) some of the practical implications of the study for clinical work and research in psychiatry are indicated.BackgroundIt has long been recognized that there are similarities between spiritual and psychotic experiences. [End Page 41] William James (1902), for example, argued that “in delusional insanity, paranoia as they sometimes call it, we may have a kind of diabolical mysticism, a sort of religious mysticism turned upside down” (426). Other commentators have noted a wide variety of phenomena, such as time distortion, synesthesias, loss of self-object boundaries and the transition from a state of conflict and anxiety to one of sudden “understanding,” all of which are reported in both spiritual and psychotic experiences (Buckley 1981; Watson 1982; Wapnick 1969; and Wootton and Allen 1983).Yet the similarities notwithstanding, the distinction between these two kinds of experience can be crucially important. Spiritual experiences, whether welcome or unwelcome, and whether or not they are psychotic in form, have nothing (directly) to do with medicine (Fulford 1996a). It would be quite wrong, then, to “treat” spiritual psychotic experiences with neuroleptic drugs, just as it is quite wrong to “treat” political dissidents as though they were ill (Fulford, Smirnoff and Snow, 1993). Pathological psychotic experiences, on the other hand, or psychotic symptoms, are by definition a proper object of medical treatment, sometimes even against the wishes of the person concerned. Hence it would be both negligent and, as Wing (1978) put it, morally “repellent,” to leave untreated someone who is genuinely ill (244).Given how much turns on the distinction between spiritual experience and psychopathology, it is perhaps not surprising that scholarly discussion of the relationship between them has at times... (shrink)

This “open letter” to Christopher Boorse is a response to his influential naturalist analysis of disease from the perspective of linguistic-analytic value theory. The key linguistic-analytic point against Boorse is that, although defining disease value free, he continue to use the term with clear evaluative connotations. A descriptivist analysis of disease would allow value-free definition consistently with value-laden use: but descriptivism fails when applied to mental disorder because it depends on shared values whereas the values relevant to mental disorders are (...) highly diverse. A part-function analysis, similarly, although initially persuasive for physical disorders, fails with the psychotic mental disorders because these, characteristically, involve disturbances of the rationality of the person as a whole. The difficulties encountered in applying naturalism to mental disorders point, linguistic-analytically, to the possibility that there is, after all, an evaluative element of meaning, deeply hidden but still logically operative, in the concept of disease. (shrink)

This paper employs the methodological framework of linguistic analytic philosophy to explore the conceptual issues arising from a study of the different models of disorder implicit in five groups of stakeholders concerned in the community care of people with a diagnosis of long-term schizophrenia. Linguistic analysis, gives a precise fix on the nature of the practical difficulties presented by such models, suggests a powerful heuristic for displaying and comparing models, is the basis of a methodology which is neutral as between (...) users and providers of services, provides an intuitively powerful way of understanding the results of work of this kind, and facilitates the translation of research into practice. (shrink)

The law of informed consent to medical treatment has recently been extensively overhauled in England. The 2015 Montgomery judgment has done away with the long-held position that the information to be disclosed by doctors when obtaining valid consent from patients should be determined on the basis of what a reasonable body of medical opinion agree ought to be disclosed in the circumstances. The UK Supreme Court concluded that the information that is material to a patient’s decision should instead be judged (...) by reference to a new two-limbed test founded on the notions of the ‘reasonable person’ and the ‘particular patient’. The rationale outlined in Montgomery for this new test of materiality, and academic comment on the ruling’s significance, has focused on the central ethical importance that the law now accords to respect for patient autonomy in the process of obtaining consent from patients. In this paper, we dispute the claim that the new test of materiality articulated in Montgomery equates with respect for autonomy being given primacy in re-shaping the development of the law in this area. We also defend this position, arguing that our revised interpretation of Montgomery’s significance does not equate with a failure by the courts to give due legal consideration to what is owed to patients as autonomous decision-makers in the consent process. Instead, Montgomery correctly implies that doctors are ethically obliged to attend to a number of relevant ethical considerations in framing decisions about consent to treatment, which include subtle interpretations of the values of autonomy and well-being. Doctors should give appropriate consideration to how these values are fleshed out and balanced in context in order to specify precisely what information ought to be disclosed to a patient as a requirement of obtaining consent, and as a core component of shared decision-making within medical encounters more generally. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 11.2 (2004) 165-173 [Access article in PDF] Professional Judgment, Critical Realism, Real People, and, Yes, Two Wrongs Can Make a Right! K.W.M. Fulford Anthony Colombo Keywords values, values-based practice, models of disorder, concept of mental illness, user-centred practice, patient-centred practice, multidisciplinary teamwork We are grateful to our four commentators for putting much-needed conceptual air and space around the models project. Published originally as an (...) empirical study of the different implicit models of disorder, held by users of services, carers, nurses, psychiatrists, and social workers (Colombo et al. 2003), our paper outlined the philosophical roots of the models project in linguistic analytic philosophy of the "Oxford school" (Fulford and Colombo 2004). Our four commentators provide extra dimensions of understanding, respectively from professional education (Williams 2004), sociology (Bendelow 2004), Heideggerian phenomenology (Heginbotham 2004), and mental health policy and practice (Williamson 2004).Since the original study, the models project has been taken forward as a key contribution to a range of philosophy-into-practice initiatives called, collectively, Values-Based Practice. In this brief response, we outline the key features of Values-Based Practice and indicate how these connect with some of the many thoughtful points about models made by our commentators. Values-Based Practice Values-Based Practice, then, is the theory and skills-base for effective health care decision making where different, and hence potentially conflicting, values are in play (Fulford 2004). Premised on the democratic meta-value of equal respect for all voices, Values-Based Practice relies, much as a political democracy relies, on good process rather than preset outcomes for its practical effectiveness. The ten pointers to good process in Values-Based Practice are summarized in Figure 1. We return to the implications of these for the work on models below.Relying on good process may be thought to be a recipe more for relativism and indecision in clinical decision making than for practical effectiveness. To the contrary, however, the 'values democracy' of Values-Based Practice, again like a political democracy, carries a number of clear and coherent implications for policy and practice in health care. [End Page 165] Click for larger viewFigure 1 10 Pointers to Good Process in VBP [End Page 166]Examples of the implications of Values-Based Practice for policy and practice are given in the Values Framework shown in Figure 2. This is a policy framework for the development of Values-Based Practice in mental health produced by a project group in the National Institute for Mental Health in England (NIMHE), the section of the UK's National Health Service (NHS) responsible for implementing government policy on mental health as embodied in the National Service Framework for Mental Health (Department of Health 1999) and subsequent policies. The framework gives three key principles of Values-Based Practice (the three Rs of recognition, raising awareness, and respect) and then summarizes some of the specific implications of the approach. Racism, for example, is incompatible with Values-Based Practice because racism is by definition intolerant of diversity. Again, we indicate some of the policy implications of Values-Based Practice for the points about models made by our commentators below.Training for mental health practitioners in Values-Based Practice will be rolled out from April 2005, through both voluntary and statutory bodies, in each of the eight regions of the National Health Service of England and Wales. This roll out will be supported by training methods developed and piloted in a unique joint venture between Warwick University's Department of Philosophy and Medical School, and an in-service training provider, the Sainsbury Centre for Mental Health (Fulford, Williamson, and Woodbridge 2002; Woodbridge and Fulford 2003). These training methods are the basis of a detailed workbook for Values-Based Practice (Woodbridge and Fulford 2004). The workbook will be launched in July 2004 at a conference in London by the Minister of State with responsibility for mental health, Rosie Winterton. Professional Training and Professional Judgment The models project has been central to the development of... (shrink)

Mental health research and care in the twenty first century faces a series of conceptual and ethical challenges arising from unprecedented advances in the neurosciences, combined with radical cultural and organisational change. The Oxford Textbook of Philosophy of Psychiatry is aimed at all those responding to these challenges, from professionals in health and social care, managers, lawyers and policy makers; service users, informal carers and others in the voluntary sector; through to philosophers, neuroscientists and clinical researchers. Organised around a series (...) of case studies in five key topic areas - concepts of disorder, the philosophical history of psychopathology, philosophy of science, ethics and philosophical value theory, and philosophy of mind - the book provides a detailed introduction to the field and a framework for study and skill development. Each case study is supported by selected readings from both philosophy and mental health, thinking skills exercises, self-test questions, key learning points and detailed guides to further reading. There is an introduction for philosophers to classification and descriptive psychopathology, and for practitioners to philosophical methods (including logic). The philosophical topics covered include philosophical methods (analytic and Continental); phenomenology, hermeneutics and existentialism, logical empiricism and its successors; idealism and realism; reasons and causes; and modern theories of mind and brain, free will and personal identity. Topics from mental health include psychiatry and 'anti-psychiatry'; Jaspers' psychopathology and the new neurosciences; the future of psychiatric classifications; strengths-based approaches, recovery practice, social inclusion and diversity; and key topics in psychopathology, such as delusion, autism, disorders of volition, thought insertion and other experiences in schizophrenia. The Oxford Textbook of Philosophy of Psychiatry aims to secure the skills-base of the discipline by bringing philosophers closer to the realities of practice in mental health, and mental health practitioners closer to the resources of philosophy as a partner to the sciences in responding to the challenges of twenty-first century mental health and social care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Editors’ IntroductionK. W. M. Fulford and John Z. SadlerThe editors are delighted to present the debut of a new feature in Philosophy, Psychiatry, & Psychology, “Clinical Anecdotes.” Clinical Anecdotes are short narrative essays that present, in concise fashion, several philosophical/conceptual issues concerning the experience of psychiatric practice in a realistic, nitty-gritty story format. A Clinical Anecdote essay serves as a stimulus to selected commentators from diverse fields, who (...) will prepare short responses that address any feature of the anecdote that captures their interest and imagination. Clinical Anecdote authors may then conclude the section with their own brief response, if desired.We encourage anyone (clinicians, patients, philosophers, others) interested in the conceptual aspects of psychiatric practice to submit their own Clinical Anecdotes for publication. Submissions should be formatted as a PPP Main Paper, with no requirement for references or an abstract. Clinical Anecdotes should not exceed a 1,500-word limit, and should have an original title relevant to the narrative content of the piece.How will Clinical Anecdotes submissions be evaluated? They will be sent out for peer review as with any other PPP main article, however, what reviewers will be looking for is:• a vivid, engaging, and compelling writing style,• a story that generates multiple areas of conceptual, philosophical, or ethical interest,• relevance to the editorial focus of PPP, and• novelty of theme (the submission addresses issues that have not previously been considered as a Clinical Anecdote).We hope you will find this inaugural essay from Dr. Christopher Bailey thought provoking. [End Page 221]Copyright © 2009 The Johns Hopkins University Press... (shrink)

We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.

Philosophy has much to offer psychiatry, not least regarding ethical issues, but also issues regarding the mind, identity, values, and volition. This has become only more important as we have witnessed the growth and power of the pharmaceutical industry, accompanied by developments in the neurosciences. However, too few practising psychiatrists are familiar with the literature in this area. -/- The Oxford Handbook of Philosophy and Psychiatry offers the most comprehensive reference resource for this area ever published. It assembles challenging and (...) insightful contributions from key philosophers and others to the interactive fields of philosophy and psychiatry. Each contributions is original, stimulating, thorough, and clearly and engagingly written - with no potentially significant philosophical stone left unturned. Broad in scope, the book includes coverage of several areas of philosophy, including philosophy of mind, science, and ethics. For philosophers and psychiatrists, The Oxford Handbook of Philosophy and Psychiatry is a landmark publication in the field - one that will be of value to both students and researchers in this rapidly growing area. (shrink)

This chapter identifies and explores a series of challenges raised by the clinical concept of delusion for theories which conceive autonomy as an agency rather than a status concept. The first challenge is to address the autonomy-impairing nature of delusions consistently with their role as grounds for full legal and ethical excuse, on the one hand, and psychopathological significance as key symptoms of psychoses, on the other. The second challenge is to take into account the full logical range of delusions, (...) which may take the form of true or false factual beliefs, positive or negative evaluations, as well as the paradoxical delusion of mental illness. The third and final challenge is to make room for non-pathological or, autonomy-preserving delusions and to offer a credible way of distinguishing between these and pathological or, autonomy-impairing delusions. By setting out these challenges, we are able to, firstly, distinguish between two separate conceptions of objectivity that may be at work in existing accounts of delusions and, secondly, to put a spotlight on an elusive yet inescapable notion of agential success that underlies our thinking about autonomy as well as mental disorder. (shrink)

Philosophers have hitherto only interpreted the world in various ways; the point is to change it.Karl marx’s distinction between interpreting the world and changing it points by extension to the state of contemporary philosophy and psychiatry. The 1990s resurgence of interdisciplinary work in this area was driven equally by phenomenological scholarship and by initiatives in analytic philosophy. The former reflected the focus in phenomenology on ‘what it is like’ to experience a given mental symptom with the aim of reconstructing the (...) life-worlds of people experiencing mental disorders, while the latter reflected directly or indirectly the influence of J. L. Austin and others from... (shrink)

Analyses of biological concepts of disease and social conceptions of health indicate that they are structurally interdependent. This in turn suggests the need for a bridge theory of illness. The main features of such a theory are an emphasis on the logical properties of value terms, close attention to the features of the experience of illness, and an analysis of this experience as action failure, drawing directly on the internal structure of action. The practical applications of this theory are outlined (...) for a number of problems in each of the three main practical areas, clinical work, teaching and research. In each case the resources of the theory suggest new models and generate new results. The full practical significance of the theory, however, is shown to consist in the way in which it ties together biological and social theories into an integrated picture of the conceptual structure of medicine as a whole. It is argued, finally, that practical efficiency of this kind is a test of theory not only in the philosophy of medicine but also in general philosophy. (shrink)

In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and gender issues; (...) rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)

This volume illustrates the central importance of diversity of human values throughout healthcare. The readings are organized around the main stages of the clinical encounter from the patient's perspective. They run from staying well and 'first contact' through to either recovery or to long-term illness, death and dying.

OBJECTIVES: To study the resources available and resources needed for ethics teaching to medical students in UK medical schools as required by the new GMC core curriculum. DESIGN: A structured questionnaire was piloted and then circulated to deans of medical schools. SETTING: All UK medical schools. RESULTS: Eighteen out of 28 schools completed the questionnaire, the remainder either indicating that their arrangements were "under review" (4) or not responding (6). Among those responding: 1) library resources, including video and information technology (...) were found to be fairly well developed; 2) many schools had a good supply of handouts and sample cases for teaching; 3) most had a written syllabus, and 4) two-thirds examined in the subject. However, many schools indicated that there was an urgent need for: 1) full-time teachers (most ethics teaching is still by part-time and voluntary staff); funding for books and journals, and 3) additional teaching materials (including further case vignettes, handouts and sample exam questions). CONCLUSIONS: There has been a considerable overall improvement in resources for medical ethics teaching since the time of the last national survey (The Pond Report). However, provision varies widely from medical school to medical school. The particular needs identified were for full-time teachers, library resources and teaching materials. Wider use of existing organisations concerned with medical ethics could help to meet these needs. (shrink)

This collection examines prevalent assumptions in moral reasoning which are often accepted uncritically in medical ethics. It introduces a range of perspectives from philosophy and medicine on the nature of moral reasoning and relates these to illustrative problems, such as New Reproductive Technologies, the treatment of sick children, the assessment of quality of life, genetics, involuntary psychiatric treatment and abortion. In each case, the contributors address the nature and worth of the moral theories involved in discussions of the relevant issues, (...) and focus on the types of reasoning which are employed. 'Medical ethics is in danger of becoming a subject kept afloat by a series of platitudes about respect for persons or the importance of autonomy. This book is a bold and imaginative attempt to break away from such rhetoric into genuine informative dialogue between philosophers and doctors, with no search after consensus.' Mary Warnock. (shrink)

In this paper some of the general issues surrounding recently published guidelines for the practice of research ethics committees are outlined, concentrating in particular on the difficulties raised by research with psychiatric patients. Research is distinguished from ordinary clinical practice by the intention to advance knowledge. So defined, research with psychiatric patients should be governed by the same four principles as research with any other group--knowledge, necessity, benefit and consent. In applying these principles, however, particularly the principle of consent, many (...) acute difficulties are raised by psychiatric patients. A number of proposals for addressing these difficulties are discussed. It is suggested that, notwithstanding the value of published guidelines, and the help that may be available from research ethics committees, the primary responsibility for maintaining high standards of practice in research rests with research workers themselves. (shrink)

Nature and Narrative is the launch volume in a new series of books entitled International Perspectives in Philosophy and Psychiatry. Nature(representing interest in the causes of a problem) and Narrative (for understanding its meanings) will introduce the field and the series, by touching on a range of issue relevant to this interdisciplinary 'border country'.

This article sets out a manifesto for the development of an international values-based practice fully engaged with the diversity of cultural values and implemented through the resources of the international movement in philosophy and psychiatry. Anticipated by mid-twentieth century ordinary language philosophy of the “Oxford School,” the last three decades have witnessed a remarkable flowering of cross-disciplinary work between philosophy and psychiatry. The article indicates the scope and scale of this work and then describes the emergence of contemporary values-based practice (...) as its philosophy-into-practice cutting edge. Values-based practice although originating in philosophy and psychiatry is currently being developed mainly in areas of bodily medicine such as surgery. As such, it has been criticized for focusing, as contemporary health care has largely focused, on the individual at the expense of cultural values. Hence arises the need for extending values-based practice internationally. The resources available from international philosophy and psychiatry for so extending values-based practice are outlined and some of the challenges are indicated. The article concludes with the hope that psychiatry in supporting the development of international values-based practice will by the same token take poll position in the development of contemporary science-led clinical care. (shrink)

This article sets out key contributions to the long-running debate about mental disorder from the ordinary language philosophy of the ‘Oxford School’. The distinction between definition and use of concepts underpinning ordinary language philosophy reframes the debate as a debate not just about mental disorder but about disorder in general, bodily as well as mental. The field work of ordinary language philosophy (focusing on the use of concepts as a guide to their meanings) shows that, attempts at elimination notwithstanding, there (...) is an essential evaluative element in the meaning of disorder, bodily as well as mental. The concept of disorder in the debate thus reframed presents a double challenge for analysis: to explain why disorder has evaluative connotations used of mental conditions but descriptive connotations used of bodily conditions. Philosophical value theory, derived by applying ordinary language philosophy to the language of values, provides a rich resource of ideas for meeting this double challenge. It meets the double challenge at the level of theory by allowing both aspects of the double challenge of disorder to be derived from a logical property that disorder shares with all other value terms. It meets the double challenge at the level of practice by supporting the development of a new approach to working with values alongside evidence in healthcare called values-based practice. Ordinary language philosophy, notwithstanding these several contributions, is no panacea. It helps us to make a start, no more and no less, in understanding mental disorder. (shrink)

In the current climate of dramatic advances in the neurosciences, it has been widely assumed that the diagnosis of mental disorder is a matter exclusively for value-free science. Starting from a detailed case history, this paper describes how, to the contrary, values come into the diagnosis of mental disorders, directly through the criteria at the heart of psychiatry's most scientifically grounded classification, the American Psychiatric Association's DSM (Diagnostic and Statistical Manual). Various possible interpretations of the prominence of values in psychiatric (...) diagnosis are outlined. Drawing on work in the Oxford analytic tradition of philosophy, it is shown that, properly understood, the prominence of psychiatric diagnostic values reflects the necessary engagement of psychiatry with the diversity of individual human values. This interpretation opens up psychiatric diagnostic assessment to the resources of a new skills-based approach to working with complex and conflicting values (also derived from analytic philosophy) called 'values-based practice.' Developments in values-based practice in training, policy and research in mental health are briefly outlined. The paper concludes with an indication of how the integration of values-based with evidence-based approaches provides the basis for psychiatric practice in the twenty-first century that is both science-based and person-centred. (shrink)

We describe the teaching programme in ethics, law and communication skills for clinical medical students which is being developed as part of the Oxford Practice Skills Project. These three elements of practice are approached in an integrated teaching programme which aims to address everyday clinical practice. The role of a central value of patient-centred health care in guiding the teaching is described. Although the final aim of the teaching is to improve actual practice, we have found three 'sub-aims' helpful in (...) the development of the programme. These sub-aims are: increasing students' awareness of ethical issues; enhancing their analytical thinking skills, and teaching specific knowledge. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Past, Present—and Future Perfect?Taking Psychiatry Beyond Its Single Message MythologiesK. W. M. Fulford (bio)I am grateful to John Sadler and his colleagues for their generous invitation to contribute to this collection marking Philosophy, Psychiatry, & Psychology (PPP)'s thirtieth birthday. True to our editorial tradition of "no nonsense" publishing, the "ask" was a reflection on PPP's past, present and future, limited to 500 words. In fact, one word does (...) it for me—collegiality.Collegiality was our watch word from the start. I still treasure a group photo taken at an early pre-meeting of the Association for the Advancement of Philosophy and Psychiatry (AAPP) convened by Michael Schwartz at his home in 1992, when, among other initiatives, PPP was conceived through transferring our then-nascent journal proposal from a small British publishing house to its current international publisher, the Johns Hopkins University Press. Michael and I had met earlier by phone when he had called the Royal College of Psychiatrists in London to enquire about its recently launched Philosophy Group and (by mere chance) I happened to be standing next to the person who took the call! PPP, with John and myself its founder editors, was subsequently born as, and has remained, a joint venture between our two groups: and Peter Zachar's recent initiative in building closer links with the International Network for Philosophy and Psychiatry (INPP) has taken us an important step towards the vision shared by Michael, John and myself that PPP should grow to reflect and represent a global open society of philosophy and mental health.As a pointer to the future, this global open society was no mere utopian vision but a joint commitment to what we conceived as a necessary ambition. Contemporary disenchantment with the repeated failures of translation of current narrowly empirical models of psychiatry, points to the truth of our German colleague, Paul Hoff's, characterization of the history of psychiatry as a history of serial collapses into single message mythologies. This disenchantment might seem to offer an opportunity for colonial expansion of philosophy into psychiatry (a re-assertion, perhaps, of phenomenology?). But PPP was born out of the "decade of the brain" and has remained throughout an ally of, not competitor to, the neurosciences. [End Page 3] So, while it is true that, with Peter's initiative, and with editorial and other innovations introduced by John, PPP is actively extending its reach (to new areas of philosophy, and to new voices, informed notably by experience as well as by training), this expansion remains a collegial not colonial enlargement of the field. I need hardly point to the challenges presented by the inclusive ambitions of such enlargement (not least to maintaining the highest standards of editorial and peer review). But PPP's collegiality provides the foundation for the work needed to deliver on these challenges. Even if imperfectly realized, this collegiality will help to take us beyond the single message mythologies by which our discipline has too long been hobbled. [End Page 4]K. W. M. Fulford K.W.M. (Bill) Fulford is a Fellow of St Catherine's College and Member of the Philosophy Faculty, University of Oxford; Emeritus Professor of Philosophy and Mental Health, University of Warwick Medical School; and Founder Director of the Collaborating Centre for Values-based Practice, St Catherine's College, Oxford (valuesbasedpractice.org).Copyright © 2023 Johns Hopkins University Press... (shrink)

This edited volume illustrates the central importance of diversity of human values throughout healthcare. The readings are organised around the main stages of the clinical encounter from the patient's perspective. This introductory chapter opens up crucial issues of methodology and of practical application in this highly innovative approach to the role of ethics in healthcare.

This paper explores the relationship between mania, or pathologically elevated mood, and philosophical theories of well-being. A patient, Mr. M., is described who oscillated between periods when he refused medication and periods when he was willing to accept it, and whose desires and life objectives were radically different in his medicated and unmedicated states. The practical dilemmas this raised are explored in terms of the three principal philosophical theories of well-being: hedonism, the desire fulfillment theory, and objectivism. None of these (...) adequately accounted for Mr. M.'s case: hedonism, because pleasure is increased in mildly manic states; desire fulfillment theories, because these suggest that an unending cycle of treatment and nontreatment would be in Mr. M.'s best interests; and objectivism, because, in a form that would be applicable to Mr. M., that theory brings with it substantial risks of paternalism. Four further philosophical approaches are explored briefly—approaches focusing on autonomy, rationality, personal identity, and illness, respectively—but these also provide no straightforward resolution of the clinical dilemmas. It is concluded that philosophical analysis, even if it does not resolve cases like Mr. M.'s, can deepen our understanding of the issues involved in clinical decision making in psychiatry, especially the importance of sensitivity to the patient's wishes and values; and conversely, that mild mania is an important "real life" case against which philosophical theories of well-being can be tested. (shrink)

Marie Stenlund’s careful reading of values-based practice and her demonstration of its links with Martha Nussbaum’s Capabilities Framework are innovative theoretically and have potentially important implications for policy and practice in mental health. As she indicates the two approaches converge in a number of key respects. Notably, both recognise the diversity of individual human values. This diversity crucially underpins contemporary person-centred conceptions of recovery in mental health based on quality of life as defined by reference to the values of the (...) person concerned rather than that of a generic professional ‘needs assessment’.1 2 Where the two theories diverge, too, Stenlund finds practically important consequences. Thus Nussbaum’s Capabilities Framework, as Stenlund indicates, is outcomes-oriented, while values-based practice focuses on process. The two approaches are not however thereby necessarily inconsistent. Drawing on early accounts of values-based practice, Stenlund suggests a degree of implicit blurring between it and Nussbaum’s capabilities. Here we need to be careful: values-based practice does not regard recovery as an outcome; it …. (shrink)

From the perspective of values-based practice, there is much of interest in Lorenzo Gilardi and Giovanni Stanghellini's "I am a Schizophrenic." Their dialogue exhibits many of the key elements of VBP, it exemplifies the particular challenges presented by VBP in mental health, it illustrates the power of phenomenology in meeting these challenges, and it points by extension to an insight into contemporary psychiatry's professional identity as a medical profession.VBP is a resource for working with values—with what matters or is important (...) to those concerned—in healthcare. Avoiding preset answers, it offers instead a process that supports those concerned in a given situation... (shrink)

This article explores the role of an international open society of mental health stakeholders in raising awareness of values and thereby reducing the vulnerability of psychiatry to abuse. There is evidence that hidden values play a key role in rendering psychiatry vulnerable to being used abusively for purposes of social or political control. Recent work in values-based practice aimed at raising awareness of values between people of different ethnic origins has shown the importance of what we call “values auto-blindness” – (...) a lack of awareness of one’s own values as a key part of our background “life-world” – in driving differential rates of involuntary psychiatric treatment between ethnic groups. It is argued that the vulnerability of psychiatry to abuse stems from values auto-blindness operating on the judgments of rationality implicit in psychiatric diagnostic concepts. Acting like a “hall of mirrors,” an international open society of mental health stakeholders would counter the effects of values auto-blindness through enhanced mutual understanding of the values embedded in our respective life-worlds across and between the diverse perspectives of its constituents. The article concludes by noting that a model for the required open society is available in the contemporary interdisciplinary field of philosophy and psychiatry. (shrink)

This volume of articles, literature and case studies illustrates the central importance of human values throughout healthcare. The readings are structured around the main stages of the clinical encounter from the patient's perspective.

Ten years ago the Royal Institute of Philosophy marked the establishment of the Society for Applied Philosophy with a series of public lectures, published in an earlier book in this series, under the title Philosophy and Practice. Looking back it i s hard to believe this was only ten years ago. Applied philosophy still has its critics. But it is now so pervasive, so much the norm, that it seems to have been with us always. Law, medicine, education, nursing, the (...) environment, politics, economics … almost it seems, no subject is quite respectable nowadays without its philosophy and its philosophical exponents. (shrink)

The links between Descartes logito and the schizophrenic symptom of "inserted thoughts" are used to illustrate the potential for two- way exchange between philosophy and psychiatry. Patients suffering thought insertion have thoughts in their heads, which "they" are thinking, but which they experience as the thoughts "of someone else": "I think therefore someone else is". Philosophical work on personal identity helps to clarify the remarkable phenomenological features of thought insertion: conversely, thought insertion challenges philosophical theories of personal identity. More generally, (...) future cross- disciplinary work will require a strong academic infrastructure, including training and research. (shrink)

These are exciting times for philosophy and psychiatry. After drifting apart for most of this century, the two disciplines, if not yet fully reconciled, are suddenly at least on speaking terms. With hindsight we may wonder why they should have ignored each other for so long. As Anthony Quinton pointed out in a lecture to the Royal Institute of Philosophy a few years ago, it is remarkable that philosophers, in a sense the experts on rationality, should have had so little (...) to say about the phenomena of irrationality. There have been partial exceptions, of course. Descartes and Kant both touched on madness; and there were, notably, important philosophical influences on the development of modern psychiatry in the late nineteenth and early twentieth centuries. Yet even John Locke, who was a doctor as well as philosopher, confined himself to a fair-l y superficial distinction between what we should now call mental illness and mental defect—those with, in Locke's view, respectively too many ideas and too few. (shrink)

Until recently there has been little contact between the mind-brain debate in philosophy and the debate in psychiatry about the nature of mental illness. In this paper some of the analogies and disanalogies between the two debates are explored. It is noted in particular that the emphasis in modern philosophy of mind on the importance of the concept of action has been matched by a recent shift in the debate about mental illness from analyses of disease in terms of failure (...) of functioning to analyses of illness in terms of failure of action. The concept of action thus provides a natural conduit for two-way exchanges of ideas between philosophy and psychiatry. The potential fruitfulness of such exchanges is illustrated with an outline of the mutual heuristic significance of psychiatric work on delusions and philosophical accounts of Intentionality. (shrink)

In addition to the neglect of philosophy by medicine, emphasized in a recent editorial in this journal, there has been an equally important neglect of medicine by philosophy. Philosophy stands to gain from medicine in three respects: in materials, the conceptual difficulties arising in the practice of medicine being key data for philosophical enquiry; in methods, these data, through their problematic character, being ideally suited to the technique of linguistic analysis; and in results, the practical requirements of medicine placing a (...) direct demand for progress on philosophical theory. The future of the relationship between philosophy and medicine depends on the development of a positive two-way trade between them. (shrink)