Psychiatric Ethics

The distinction between explanation and understanding was foundational to Jaspers’ ‘phenomenological’ approach to psychiatry. It makes sense that those now calling for a phenomenological approach to psychiatry would look to Jaspers for inspiration, and that in doing so, they would take up this distinction. However, I argue that it is and was a mistake to use the distinction in work on psychiatry: adhering to the distinction now would undermine, rather than support, the goals of those advocating a phenomenological approach to (...) psychiatry; furthermore, if the distinction had been adhered to, then contemporary psychiatry and its patients would be worse off. (shrink)

Brief description of Freud's life and work, emphasising the role of fictive belief and experience (phantasy) in his account of mental disorder.

Under the current Mental Health Act of England and Wales, it is lawful to perform deep brain stimulation in the absence of consent and independent approval. We argue against the Care Quality Commission's preferred strategy of addressing this problematic issue, and offer recommendations for deep brain stimulation-specific provisions in a revised Mental Health Act.

Deep Brain Stimulation is currently being investigated as an experimental treatment for patients suffering from treatment-refractory AN, with an increasing number of case reports and small-scale trials published. Although still at an exploratory and experimental stage, initial results have been promising. Despite the risks associated with an invasive neurosurgical procedure and the long-term implantation of a foreign body, DBS has a number of advantageous features for patients with SE-AN. Stimulation can be fine-tuned to the specific needs of the particular patient, (...) is relatively reversible, and the technique also allows for the crucial issue of investigating and comparing the effects of different neural targets. However, at a time when DBS is emerging as a promising investigational treatment modality for AN, lesioning procedures in psychiatry are having a renaissance. Of concern it has been argued that the two kinds of interventions should instead be understood as rivaling, yet “mutually enriching paradigms” despite the fact that lesioning the brain is irreversible and there is no evidence base for an effective target in AN. We argue that lesioning procedures in AN are unethical at this stage of knowledge and seriously problematic for this patient group, for whom self-control is particularly central to wellbeing. They pose a greater risk of major harms that cannot justify ethical equipoise, despite the apparent superiority in reduced short term surgical harms and lower cost. (shrink)

In my presentation I argue for the utility of a philosophical counseling method, called logic-based therapy (LBT), in the treatment of addicted populations. In the context of addiction treatment LBT could be also classified as a philosophical psychotherapy. Philosophical psychotherapy can be understood as an umbrella term for interventions designed to treat mental health disorders, with theoretical foundations that are philosophical. Philosophical psychotherapy would be distinct from philosophical counseling, as the latter does not directly treat mental health disorders. I suggest (...) that LBT has utility beyond philosophical counseling and is a viable intervention in the treatment of certain mental health disorders, like substance use disorders. I provide a brief overview of LBT and then discuss a LBT case study with a client suffering diagnosed with a substance use disorder. In the case study the client was advised to apply the moral philosophy of Friedrich Nietzsche as an uplifting philosophical framework to counteract his unproductive worldview and fallacious thinking. Considering that there is an ostensibly low efficacy rate for the treatment of addiction, articulating the value of philosophical psychotherapies in the context of addiction treatment can assist in the development of novel philosophically-based addiction treatment and recovery-oriented programs––thus expanding the treatment and recovery options available for those seeking recovery from addiction. (shrink)

Abstract:Bipolar or related disorders (BoRD) present unique practical and existential problems for people who live with them. All agents experience changes in the things they care about over time. However people living with BoRD face drastic shifts in what seems valuable to them, which upset their longitudinal values (if, indeed, any stable longitudinal values are available in the first place). Navigating these evaluative high seas presents agents living with BoRD with a distinctive existential question, not shared by those on calmer (...) waters. I draw out two contrasting ways in which someone living with BoRD might seek to support their self-determination in these circumstances, by crafting appropriate self care and support regimes. The first strategy involves managing one’s affective episodes so that they do not interrupt one’s plans and long-term agency over time. The second involves a regimen that allows one the greatest degree of freedom in adapting to changes in one’s experiences of value. What distinguishes these sorts of self-determination is the scope at which they are predicated. Although both sorts of self-determination allow an individual to rule themselves, they alter the overall shape of one’s autonomy in quite different ways. (shrink)

Research on mental health and illness presents a variety of unique ethical challenges. This article argues that institutional review boards (IRBs) can improve their reviews of such research by including the perspectives of individuals with the condition under study either as members of the IRB or as consultants thereto. Several reasons for including the perspectives of these individuals are advanced, with the discussion organized around a hypothetical case study involving the assessment of a novel talk-therapy modality. Having made this case, (...) the article goes on to explain how to implement the idea by building on a recent proposal by Rebecca Dresser, who argues in a number of publications for the inclusion of former research participants in the IRB review process. Finally, concerns about protecting reviewer and consultant confidentiality are addressed. (shrink)

This article describes a case of a teenager with early complex trauma due to chronic domestic violence. Cannabis use triggered auditory hallucinations, after which the teenager was diagnosed with an acute schizophrenia-like psychotic disorder. Antipsychotic medication did not fully resolve symptoms. Eventually the teenager chose to self-medicate with LSD in order to resolve a suicidal condition. The teenager carried out six unsupervised LSD sessions, followed by an extended period of almost daily use of inhaled low-dose DMT. Psychotic symptoms were mostly (...) resolved after approximately one year. Subsequent cannabis use caused a transient relapse. -/- While his psychosis may have been due to cannabis use in the presence of a genetic predisposition, LSD and DMT did not promote psychotic symptoms in this case, and resolved the suicidal condition in one session. Additional high-dose LSD sessions and low-dose DMT sessions appeared to resolve the symptoms related to the early complex trauma. Alternatively, if psychosis is understood as a massive defense system resulting from early complex trauma, and if his psychotic symptoms were partially due to such trauma, psychedelics appeared to transcend this defense system, providing access to traumatic memories in order to allow for an integrative treatment effect. -/- Information was acquired from medical record excerpts provided by the patient, a semi-structured retrospective video interview, and follow-up interviews a year later. The present case suggests a need for further studies on the relationship between psychedelics and psychotic disorders, the feasibility of supervised vs unsupervised settings for various situations, and alternative therapeutic models for utilizing the hyperaware-hypersensitive state induced by psychedelics. With regard to self-treatment, a harm reduction approach should be adopted. Low-risk psycholytic self-treatment protocols could be developed for future use in public health care systems. (shrink)

Given its subject matter, biological psychiatry is uniquely poised to lead STEM DEI initiatives related to disability. Drawing on literatures in science, philosophy, psychiatry, and disability studies, we outline how that leadership might be undertaken. We first review existing opportunities for the advancement of DEI in biological psychiatry around axes of gender and race. We then explore the expansion of biological psychiatry’s DEI efforts to disability, especially along the lines of representation and access, community accountability, first person testimony, and revised (...) theoretical frameworks for pathology. We close with concrete recommendations for scholarship and practice going forward. By tackling head-on the challenge of disability inclusion, biological psychiatry has the opportunity to be a force of transformation in the biological sciences and beyond. (shrink)

As moral injury is a still-emerging concept within the area of military mental health, prevalence estimates for moral injury and its precursor, potentially morally injurious events (PMIEs), remain unknown for many of the world’s militaries. The present study sought to estimate the prevalence of PMIEs in the Canadian Armed Forces (CAF), using data collected from CAF personnel deployed to Afghanistan, via logistic regressions controlling for relevant sociodemographic, military, and deployment characteristics. Analyses revealed that over 65% of CAF members reported exposure (...) to at least one event that would be considered a PMIE. The most commonly PMIEs individuals reported included seeing ill or injured women and children they were unable to help (48.4%), being unable to distinguish between combatants and non-combatants (43.6%), and finding themselves in a threatening situation where they were unable to respond due to the rules of engagement under which they were required to operate (35.4%). These findings provide support for both the presence of exposure to PMIEs in CAF members and the need for formal longitudinal data collection regarding PMIE exposure and moral injury development. (shrink)

Most adult persons with anorexia satisfy the existing criteria widely used to assess decision-making capacity, meaning that incapacity typically cannot be used to justify coercive intervention. After rejecting two other approaches to justification, Professor Radden concludes that it is most likely not possible to justify coercive medical intervention for persons with anorexia in liberal terms, though she leaves it open whether some other framework might succeed. I shall assume here that the standard approach to assessing decisionmaking capacity is adequate.1 The (...) question then is whether we can justify—within a liberal framework—coercive intervention with the decision of a competent... (shrink)

In ‘Psychotherapy, Placebos and Informed Consent’, I argued that the minimal standard for informed consent in psychotherapy requires that ‘patients understand that there is currently no consensus about the mechanisms of change in psychotherapy, and that the therapy on offer…is based on disputed theoretical foundations’, and that the dissemination of this information is compatible with the delivery of many theory-specific forms of psychotherapy (including cognitive behavioural therapy [CBT]). I also argued that the minimal requirements for informed consent do not include (...) information about the role of therapeutic common factors in healing (e.g., expectancy effects and therapist effects); practitioners may discuss the common factors with patients, but they are not part of the ‘core set’ of information necessary to obtain informed consent. In a recent reply, Charlotte Blease criticises these two arguments by claiming they are not supported by empirical findings about the therapeutic common factors. Blease’s response is based on serious misunderstandings of both CBT and what the common factor findings actually find. Nevertheless, addressing the reasons for these misunderstandings is instructive and gives us an opportunity to clarify what, exactly, needs to be explained to patients in order to obtain informed consent for psychotherapy. (shrink)

Since its advent in the 20th century, informed consent has become a cornerstone of ethical healthcare, and obtaining it a core obligation in medical contexts. In my dissertation, I aim to examine the theoretical underpinnings of informed consent and identify what values it is taken to protect. I will suggest that the fundamental motivation behind informed consent rests in something I’ll call bodily self-sovereignty, which I argue involves a coupling of two groups of values: autonomy and non-domination on the one (...) hand, and self-ownership and personal integrity on the other. I will then go on to consider two 'case studies' I take to shed light on what is at stake in securing informed consent - consent in psychiatrically ill populations, and consent to interventions that involve the modification of the genetic germline. (shrink)

The biopsychosocial model, which was deeply influential on psychiatry following its introduction by George L. Engel in 1977, has recently made a comeback. Derek Bolton and Grant Gillett have argued that Engel’s original formulation offered a promising general framework for thinking about health and disease, but that this promise requires new empirical and philosophical tools in order to be realized. In particular, Bolton and Gillett offer an original analysis of the ontological relations between Engel’s biological, social, and psychological levels of (...) analysis. I argue that Bolton and Gillett’s updated model, while providing an intriguing new metaphysical framework for medicine, cannot resolve some of the most vexing problems facing psychiatry, which have to do with how to prioritize different sorts of research. These problems are fundamentally ethical, rather than ontological. Without the right prudential motivation, in other words, the unification of psychiatry under a single conceptual framework seems doubtful, no matter how compelling the model. An updated biopsychosocial model should include explicit normative commitments about the aims of medicine that can give guidance about the sorts of causal connections to be prioritized as research and clinical targets. (shrink)

What is it to be mentally healthy? In the ongoing movement to promote mental health, to reduce stigma, and to establish parity between mental and physical health, there is a clear enthusiasm about this concept and a recognition of its value in human life. However, it is often unclear what mental health means in all these efforts and whether there is a single concept underlying them. Sometimes, the initiatives for the sake of mental health are aimed just at reducing mental (...) illness, thus implicitly identifying mental health with the absence of diagnosable psychiatric disease. More ambitiously, there are high-profile proposals to adopt a positive definition, identifying mental health with psychic or even overall well-being. We argue against both: a definition of mental health as mere absence of mental illness is too thin, too undemanding, and too closely linked to psychiatric value judgments, while the definition in terms of well-being is too demanding and potentially oppressive. As a compromise, we sketch out a middle position. On this view, mental health is a primary good, that is, the psychological preconditions of pursuing any conception of the good life, including well-being, without being identical to well-being. (shrink)

Musing for Puncta special issue "Critically Sick: New Phenomenologies Of Illness, Madness, And Disability.".

The professional application of ethics often lacks the necessary conceptual tools to construct adequate theoretical foundations that can be used for practical enterprise. This book focuses on an anthropological approach to mental illness, describing how schizophrenia can distort one's experience of empathy and of the presence in the world through pathological indifference. It describes factual and phenomenological perspectives on a case of schizophrenia, based on the method of Eugène Minkowski.

Long-standing psychiatric practice confirms the pervasive use of pharmacological therapies for treating severe mental disorders. In many circumstances, drugs constitute the best allies of psychotherapeutic interventions. A robust scientific literature is oriented on finding the best strategies to improve therapeutic efficacy through different modes and timing of combined interventions. Nevertheless, we are far from triumphal therapeutic success. Despite the advances made by neuropsychiatry, this medical discipline remains lacking in terms of diagnostic and prognostic capabilities when compared to other branches of (...) medicine. An ethical principle remains as the guidance of therapeutic interventions: improving the quality of life for patients. Unfortunately, psychotropic drugs and psychotherapies do not always result in an efficient remission of symptoms. In this paper I corroborate the idea that therapists should provide drug-resistant patients with every effective and available treatment, even if some of such interventions could be invasive, like Electroconvulsive Therapy (ECT). ECT carries upon its shoulders a long and dramatic history that should be better investigated to provide new insights. In fact, ECT has attracted renewed interest in recent years. This is due to the fact that antidepressant drugs in younger patients show often scarce effectiveness and unpleasant side-effects. Moreover, I show that, thanks to modern advances, ECT may work as a successful form of treatment for specific and rare cases, such as severe depression (with suicide attempts) and catatonia. (shrink)

This is the prologue to a collection of essays on eugenics and psychiatry.

I am grateful to the editor for asking me to comment on this interesting article about interdisciplinary work between a philosopher and a psychiatrist, with which I found much to agree. As a medical student, I had no exposure to bioethical reasoning in medicine, and even now, I think it is the case that junior doctors in the UK have variable exposure to good quality ethical reasoning in clinical practice. I also agree that lectures are a poor way to learn (...) about ethical reasoning, especially in psychiatric practice; and I have been part of a special interest group at the Royal College of Psychiatrists that has tried to develop and enhance bioethical awareness in mental health. We do this by a) ensuring that ethical... (shrink)

Just over a decade ago, I began teaching medical students in the required preclinical course ethics and professionalism. The point of the course was to introduce basic ethical and professional norms through a small number of large group sessions, but mostly small group tutorials of 10 or 12 students engaging in weekly sessions combining readings from the literature and case scenarios highlighting real-life ethical tensions they either had, or would most likely, encounter in the future. The students wrote perceptively and (...) thoughtfully each week, and class was topical and lively. Some students went on to complete longer essays for a school-wide ethics competition and even to win. By all accounts a resounding... (shrink)

The essay by Potter and El-Mallakh proposes "on the ground" consultations in psychiatric ethics as a novel style of bioethics deliberation. The continual dialogue between a moral philosopher and clinician creates the opportunity for informal real-time ethical thinking as cases unfold, instead of formal ethics committee reviews and instead of the artificially simple scenarios found in much bioethics literature. The essay has important practical implications for ethics pedagogy during psychiatric training and in mental health settings more generally. It also has (...) important theoretical implications for the cross-talk between... (shrink)

Across the health sector there is increased recognition of the ethical significance of interventions that constrain or coerce. Much of the recent interest stems from debates in public health over the use of quarantines and active monitoring in response to epidemics, as well as the manipulation of information in the service of health promotion (or ‘nudges’). But perhaps the area in which these issues remain most pressing is mental health, where the spectre of involuntary treatment has always loomed large. Indeed, (...) there are good reasons to think of psychiatry as ethically exceptional given its broader role as social and legal arbiter. This is compounded by the fact that mental health treatment has other special features that can serve as potential entry points for more subtle forms of pressure and influence. These include the relative cognitive and emotional vulnerability of patients, the highly confidential information involved, and the importance of the therapeutic relationship. Thus the field of mental health needs to grapple with a range of closely related issues concerning the ethics of influence. In this chapter I explore several, with a primary focus on clinical concerns, although implications for research ethics are also touched on. Discussion of treatment pressure has traditionally focused on ‘coercion,’ or, very roughly, the use of threats or force to get someone to do something they otherwise would not. Here I follow suit, beginning with discussion of its conceptual standing alongside other categories of influence, including manipulation and persuasion. As it stands, there is nothing close to a consensus on these matters. But a relatively broad understanding of coercion is available and can be useful for ethical deliberation. Or so I suggest here. Interestingly enough, there is also a growing body of empirical literature on coercion in psychiatry, including research on the use of coercive measures such as hospitalization, physical restraint, and forced medication, as well as the construct of ‘perceived coercion,’ which tracks patients’ experiences of treatment pressure. I briefly describe several key findings and their relation to recent recommendations to reduce coercion. Building on all of this, I then take up the normative questions directly, by way of evaluating a recently proposed framework for the ethical analysis of influence. (shrink)

In this chapter we outline ethical issues raised by the application of public health approaches to the field of mental health. We first set out some of the basics of public health ethics that are particularly relevant to mental health, with special attention to the ongoing debate over the traditional presumption of non-infringement, increased recognition of the social determinants of health, and the concept of prevention. Then we turn to the moral particularities of mental health, focusing on questions concerning coercion (...) and treatment pressure, personal identity and sociocultural factors (including stigma), and unresolved conceptual and methodological issues in psychiatry that complicate its extension into the domain of public health. (shrink)

Mental Health as Public Health: Interdisciplinary Perspectives on the Ethics of Prevention, Volume Two in the Developments in Neuroethics and Bioethics series, brings the most recent advances and information on Neuroethics and Bioethics. Chapters in this new release include Machine learning and suicide prevention: Considering context as a guide to ethical design, Identifying adolescents at risk of depression in global health: Benefits and risks, Ethics of early intervention and early detection in psychosis, The prevention of posttraumatic stress and the limits (...) of positive, Parenting research and interventions applied internationally and cross-culturally, and more. (shrink)

We are pleased with the thought-provoking discussion that our article has stimulated. All of the discussants agree that the state of education and infusion of ethical principles and practices into psychiatric decision making is currently suboptimal. The ethical questions raised by the discussants, writ large, have been analyzed, reduced to a seemingly manageable 'core,' or expanded to capture nuance and subtlety, and it is invaluable for clinicians, patients, and others to explore them together.In modern times, where the prevailing Western ethical (...) theories were developed, the aim of ethics was to do the right thing. For example, we ought to aim to maximize overall usefulness based on consequences of actions, or to... (shrink)

It is our privilege to be invited to write a commentary on the "Interface of Ethics and Psychiatry: A Philosophical Case Consultation on Psychiatric Ethics on the Ground." The article presents an innovative collaboration between a philosopher and a psychiatrist reasoning together through the ethical aspects of three clinical cases. The case consultation also offers a unique opportunity to reflect on the teaching of psychiatric ethics in clinical settings. This commentary explores those areas of the article from the perspective of (...) a teacher and trainee whose mentoring relationship is grounded in their shared interest in philosophy and psychiatric ethics.A quick search on PubMed and Google Scholar confirms my own... (shrink)

The principles that usually direct ethical decision making are not easily or straightforwardly applicable to the care and treatment of anorexia nervosa, particularly the care and treatment of severe and enduring anorexia nervosa, where the sufferer seems to be recalcitrant to treatment and where the condition has become life-threatening.There are exceptional circumstances that characterize this puzzling and still scarcely understood condition; I suggest that these exceptional circumstances provide moral reasons for partial derogation from the usual principles of ethical decision making.In (...) what follows I argue... (shrink)

In most areas of medicine, the physician's primary task is to diagnose the patient's presenting problem by correctly identifying the underlying pathology causing that problem. Diagnoses are established through a process of correlating the information obtained from an interview with the patient about his history of illness and circumstances, with additional evidence of the underlying disease derived from physical examination findings and/or the results of laboratory investigations and diagnostic imaging. In contemporary health care, various movements that call for a shift (...) in clinical care away from underlying disease pathology toward understanding people and their experience of disease are receiving growing... (shrink)

The on-the-ground case conference at the interface of philosophical ethics and clinical psychiatry is an innovative idea that advances pedagogy in presenting a creative approach to teaching and practicing psychiatric ethics. In the current exercise of the proposed partnership, there was a generally positive outcome. The philosopher and the psychiatrist learned from each other, were able to find norms that made their collaboration productive, and found that clinical care was enhanced. My commentary aims to help others replicate this model, and (...) preserve its virtues without its vulnerabilities.Would a mathematical logician or philosopher of aesthetics be as good of a collaborator as a moral philosopher? Probably not.... (shrink)

Although clinical understandings of self-injury, the deliberate mutilation of body tissue, have developed significantly since the phenomenon was first studied, the predominant stereotype of who self-injures is still White, teenage girls.1 White girls as well as White women are, indeed, at risk for SI, and sociocultural explanations appealing to oppressive socialization—particularly the influence of Western beauty norms—have been offered to explain their high rates of SI. Yet evidence exists to challenge this conception that SI is exclusively a White, female issue: (...) Black women, South... (shrink)

This case consultation offers three cases that illustrate a collaborative consultation model for psychiatric ethics that we have developed in outpatient clinic and in emergency psychiatry over the last 10 years. After we present these cases, we discuss three points of interest: 1) the characteristics we found to be important to our collaborative project, 2) the benefits of an integrative approach, and 3) ways that our collaborative moral reasoning developed our awareness of and sensitivity to ethical issues. We end by (...) raising some topics on which commentators could engage.Potter began working with El-Mallakh more than 10 years ago. Her impetus was that she was writing a critique of the criteria used in borderline... (shrink)

In this introduction to the edited volume we briefly describe some of the current challenges faced by public mental health initiatives, at both the national and global level. We also include several general remarks on interdisciplinary methodology in public mental health ethics, followed by short descriptions of the chapters included in the volume.

Florence Ashley has argued that requiring patients with gender dysphoria to undergo an assessment and referral from a mental health professional before undergoing hormone replacement therapy is unethical and may represent an unconscious hostility towards transgender people. We respond, first, by showing that Ashley has conflated the self-reporting of symptoms with self-diagnosis, and that this is not consistent with the standard model of informed consent to medical treatment. Second, we note that the model of informed consent involved in cosmetic surgery (...) resembles the model Ashley defends, and that psychological assessment and referral is recognised as an important aspect of such a model. Third, we suggest that the increased prevalence of psychiatric morbidity in the transgender population arguably supports the requirement of assessment and referral from a mental health professional prior to undergoing HRT. (shrink)

SELF-INJURY IS A COMPLEX phenomenon that is encountered on a regular basis by health care professionals in mental health care. In this article, I use the concept of epistemic injustice to examine this complex phenomenon and argue that this helps us to understand developments in the way we think about and support people who self-injure. Individuals with lived experience have important knowledge about the nature of self-injury and particularly how it relates to them. If the credibility of this knowledge is (...) denied, for example through accusations of emotional instability, manipulation and attention seeking, then we may cause epistemic and non-epistemic harms. The former by denying the capacity for knowledge, by not... (shrink)

The article by Potter and Rif S. El-Mallakh read empathically, invokes a sense of fulfilment in their experiences, serving as inspiration for others to learn and practice ethics better. It describes their growth that has culminated to this sense of fulfilment and inspirational dignity. Crucial for this desirable growth has been, I want to highlight, their good investment in virtuous relationships and diligent processes. I also highlight from their article a potential conceptual restriction to growing in our learning and practicing (...) of ethics. That is, the restriction that occurs when blinded by too narrow a view on what ethics is about or where its emphasis is supposed to be. (shrink)

The field of mental health continues to struggle with the question of how best to structure its diagnostic systems. This issue is of considerable ethical importance, but the implications for public health approaches to mental health have yet to be explored in any detail. In this article I offer a preliminary treatment, drawing out several core issues while sounding a note of caution. A central strand of the debates over diagnosis has been the contrast between categorical and dimensional models, with (...) renewed attention due to recent publication of the DSM-5, launch of the RDoC, and ongoing work on the ICD-11. This dispute involves an interesting assortment of ethical and empirical considerations, many with direct relevance for public health. It has been proposed, for example, that dimensional diagnosis may be morally preferable because it can help reduce the stigma associated with mental disorder. This is a pressing concern, as preventive strategies are expanded in mental health, often operating under dimensional assumptions that target various risk factors. But this type of proposal relies upon an empirical claim and the scientific status of dimensionality remains unresolved, including its relation to stigma. I suggest, then, that the current state of the evidence does not yet warrant clear adjudication between competing frameworks, and thus any implications for public mental health remain highly provisional. More research is needed to help resolve these issues, including ethical analysis. (shrink)

In a fascinating paper, where the stakes are a good deal higher than the modesty of its tone might suggest, Edward Harcourt requires us to think again about the ethics of psychoanalysis. We should not allow ourselves to be misled by Harcourt's tendency to downplay the ambitious reach of his argument. Indeed, Lacan demonstrated what is at stake here by drawing attention to the "originality of the Freudian position in ethical matters". Lacan may be relied on, more obviously than anyone (...) else I can think of in the Freudian field, as a counterweight to the assimilation of psychoanalysis to moral philosophy. A stenographer began to transcribe Lacan's seminars starting in 1952 and, reflecting on matters... (shrink)

What is the relationship between negative experience, artistic production, and prudential value? If it were true that (for some people) artistic creativity must be purchased at the price of negative experience (to be clear: currently no one knows whether this is true), what should we conclude about the value of such experiences? Are they worth it for the sake of art? The first part of this essay considers general questions about how to establish the positive extrinsic value of something intrinsically (...) negative. The second part emphasizes the importance of various distinctions within the realm of the negative. We must distinguish between adversity (which is non-mental) and negative mental states, and between negative thoughts (or attitudes) and negative affect. Within the realm of negative affect, we must distinguish between negative emotions and moods, on the one hand, and negative affective perspectives on the other, and then between mildly negative affective perspectives and severely negative ones (for which I reserve the term ‘suffering’). These distinctions matter greatly, since different types of negative experience have very different degrees of prudential disvalue. Although many types of negative experience may be “worth it”—because their positive extrinsic value outweighs their negative value—this is rarely true of severe suffering. (shrink)

Gilbert et al. have raised important questions about the empirical grounding of neuroethical analyses of the apparent phenomenon of Deep Brain Stimulation ‘causing’ personality changes. In this paper, we consider how to make neuroethical claims appropriately calibrated to existing evidence, and the role that philosophical neuroethics has to play in this enterprise of ‘evidence-based neuroethics’. In the first half of the paper, we begin by highlighting the challenges we face in investigating changes to PIAAAS following DBS, explaining how different trial (...) designs may be of different degrees of utility, depending on how changes to PIAAAS following DBS are manifested. In particular, we suggest that the trial designs Gilbert et al. call for may not be able to tell us whether or not DBS directly causes changes to personality. However, we suggest that this is not the most significant question about this phenomenon; the most significant question is whether these changes should matter morally, however they are caused. We go on to suggest that neuroethical analyses of novel neuro-interventions should be carried out in accordance with the levels of evidence hierarchy outlined by the Centre for Evidence-Based Medicine, and explain different ways in which neuroethical analyses of changes to PIAAAS can be evidence-based on this framework. In the second half of the paper, we explain how philosophical neuroethics can play an important role in contributing to mechanism-based reasoning about potential effects on PIAAAS following DBS, a form of evidence that is also incorporated into the CEBM levels of evidence hierarchy. (shrink)

Mindfulness exercises are presented as being compatible with almost any spiritual, religious or philosophical beliefs. In this paper, we argue that they in fact involve imagining and conceptualising rather striking and controversial claims about the self, and the self’s relationship to thoughts and feelings. For this reason, practising mindfulness exercises is likely to be in tension with many people’s core beliefs and values, a tension that should be treated as a downside of therapeutic interventions involving mindfulness exercises, not unlike a (...) side effect. Clients ought to be informed of these metaphysical aspects of the exercises, and mental health providers ought to take them into account in assessing which course of treatment to recommend. Given these concerns, the casual way in which mindfulness exercises are presently distributed by mental health providers to the general public is inappropriate. (shrink)

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of (...) Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. (shrink)

Those whom the gods wish to destroy, they first make mad, says a Nigerian proverb. These words of wisdom re-echo in traditional approaches to mental health ethics in sub-Saharan Africa. Among many cultures in Nigeria, it is customary to subject persons with mental health illness, especially those who present with violent behavior, to physical restraint and beatings. The belief is that such subjugation could restore mental health in the early stages of madness. Physical restraint and beatings only form a part (...) of the healing process, as it also has communitarian cum spiritual aspects. The healing process is carried out by family members or community, who share in the life of the mentally ill person. Their... (shrink)

In this article we address the social value of bioethics research and show how a participatory approach can achieve social impact for a wide audience of stakeholders, involving them in a process of joint moral learning. Participatory bioethics recognizes that research co-produced with stakeholders is more likely to have impact on healthcare practice. These approaches aim to engage multiple stakeholders and interested partners throughout the whole research process, including the framing of ideas and research questions, so that outcomes are tailored (...) to the interests and context, and the type of impact stakeholders envisage. There is an emphasis on realizing social change through the conduct of the research, and it is believed that the engagement of stakeholders in the research process will promote their intrinsic motivation to change their practice. Another distinctive feature of participatory bioethics research is that its central normative commitment is to reflection and dialogue, not to a particular substantive ethical approach. In reflection and dialogue there is an emphasis on inclusion and the co-production of knowledge. Furthermore, empirical and normative research are combined, and there is a deliberate attempt to give voice to otherwise marginalized positions. This provides a model of social impact which is relevant not only for bioethics research, but also for other areas of health care research. We will show the merits of a participatory approach to bioethics research with a case example. It concerns the reduction of coercion and in particular seclusion in Dutch mental healthcare. (shrink)