Many critics of medicalization express concern that the process privileges individualised, biologically grounded interpretations of medicalized phenomena, inhibiting understanding and communication of aspects of those phenomena that are less relevant to their biomedical modelling. I suggest that this line of critique views medicalization as a hermeneutical injustice—a form of epistemic injustice that prevents people having the hermeneutical resources available to interpret and communicate significant areas of their experience. Interpreting the critiques in this fashion shows they frequently fail because they: neglect (...) the ways in which medicalization may not obscure, but rather illuminate, individuals’ experiences; and neglect the testimony of those experiencing first-hand medicalized problems, thus may be guilty of perpetrating testimonial injustice. However, I suggest that such arguments are valuable insofar as they highlight the unwarranted epistemic privilege frequently afforded to medical institutions and medicalized models of phenomena, and a consequent need for greater epistemic humility on the part of health workers and researchers. (shrink)

Singh's study of 150 UK and US children diagnosed with attention deficit hyperactivity disorder and prescribed psychotropic medication concludes on the basis of interviews with the children that ‘stimulants improve their capacity for moral agency … an ability to meet normative expectations’.1 Reinterpreted in lay language, she finds that, when taking Ritalin, the children conform to the wishes and expectations of their parents and teachers. They get better grades at school and show less ‘oppositional-defiance’. This is not surprising as it (...) is precisely what Ritalin is supposed to do. However, it begs a number of crucial questions. Might it not be that the failure of the child to conform to the expected norms in the non-medicated state is a legitimate expression of the child's own moral agency, rebelling against what he/she experiences as inappropriate …. (shrink)

Psychiatric involvement in patient morality is controversial. If psychiatrists are tasked with shaping patient morality, the coercive potential of psychiatry is increased, treatment may be unfairly administered on the basis of patients’ moral beliefs rather than medical need, moral disputes could damage the therapeutic relationship and, in any case, we are often uncertain or conflicted about what is morally right. Yet, there is also a strong case for the view that psychiatry often works through improving patient morality and, therefore, should (...) aim to do so. Our goal is to offer a practical and ethical path through this conflict. We argue that the default psychiatric approach to patient morality should be procedural, whereby patients are helped to express their own moral beliefs. Such a procedural approach avoids the brunt of objections to psychiatric involvement in patient morality. However, in a small subset of cases where patients’ moral beliefs are sufficiently distorted or underdeveloped, we claim that psychiatrists should move to a substantive approach and shape thecontentof those beliefs when they are relevant to psychiatric outcomes. The substantive approach is prone to the above objections but we argue it is nevertheless justified in this subset of cases. (shrink)

With advances in medical science, the concept of agency has received increasing attention in biomedical ethics. However, most of the ethical discussion around definitions of agency has focused either on patients suffering from mental disorders or on patients receiving cutting-edge medical treatments in developed countries. Very little of the discussion around concepts of agency has focused on the situation of patients suffering from common diseases that affect populations worldwide. Therefore, the most widely-used definitions of agency may be not appropriate to (...) analyse common diseases among large populations. The branch of social sciences known as development studies draw on their own definitions of the term agency that may provide a more applicable and accurate way of referring to common and general cases than the definitions currently used in bioethics. Moreover, the psychological Self-Determination Theory may improve the usefulness of these definitions in common situations. This article explains the characteristics and the shortcomings of current bioethical definitions of agency when they are applied to common medical conditions worldwide. A new, value-based concept of agency, informed by development studies, is proposed as more accurate and useful for biomedical ethics. (shrink)

The profound changes in personality, mood, and other features of the self that neural interventions can induce can be disconcerting to patients, their families, and caregivers. In the neuroethical debate, these concerns are often addressed in the context of possible threats to the narrative self. In this paper, I argue that it is necessary to consider a dimension of impacts on the narrative self which has so far been neglected: neural interventions can lead to a loss of meaning of actions, (...) feelings, beliefs, and other intentional elements of our self-narratives. To uphold the coherence of the self-narrative, the changes induced by neural interventions need to be accounted for through explanations in intentional or biochemical terms. However, only an explanation including intentional states delivers the content to directly ascribe personal meaning, i.e., subjective value to events. Neural interventions can deprive events of meaning because they may favor a predominantly biochemical account. A loss of meaning is not inherently negative but it can be problematic, particularly if events are affected one was not prepared or willing to have stripped of meaning. The paper further examines what it is about neural interventions that impacts meaning by analyzing different methods. To which degree the pull towards a biochemical view occurs depends on the characteristics of the neural intervention. By comparing Deep Brain Stimulation, Prozac, Ritalin, psychedelics, and psychotherapy, the paper identifies some main factors: the rate of change, the transparency of the causal chain, the involvement of the patient, and the presence of an acute phenomenological experience. (shrink)

The potential of memory modification techniques (MMTs) has raised concerns and sparked a debate in neuroethics, particularly in the context of identity and authenticity. This paper addresses the question whether and how MMTs influence authenticity. I proceed by drawing two distinctions within the received views on authenticity. From this, I conclude that an analysis of MMTs based on a dual-basis, process view of authenticity is warranted, which implies that the influence of MMTs on authenticity crucially depends on the specifics of (...) how memory modification would eventually work. Therefore, I continue with a systematic analysis of possible properties of MMTs in which I distinguish between the dimensions of memories and the kinds of experiences that can be modified as well as the properties of the process of memory modification. The impact of MMTs on authenticity is analyzed regarding the possible properties of MMTs and based on a narrative approach to authenticity which fulfills the requirements of a dual-basis, process view of authenticity. Lastly, I explore the potential of MMTs to shift the balance between self-discovery and self-creation within authenticity and thereby alter the concept itself as well as the value of authenticity. (shrink)

Debates concerning whether Attention Deficit/Hyperactivity Disorder mitigates responsibility often involve recourse to its genetic and neurodevelopmental etiology. For such arguments, individuals with ADHD have diminished self-control, and hence do not fully satisfy the control condition for responsibility, when there is a genetic or neurodevelopmental etiology for this diminished capacity. In this article, I argue that the role of genetic and neurobiological explanations has been overstated in evaluations of responsibility. While ADHD has genetic and neurobiological causes, rather than embrace the essentialistic (...) notion that it directly diminishes self-control and, therefore, responsibility, we ought to think of ADHD as constraining only some self-control practices. In particular, situational self-control strategies remain feasible for people with ADHD. However, not all individuals have access to these strategies. I suggest a way to evaluate responsibility in terms of situational rather than agential pleas, which tracks whether the individual had access to self-control behaviors. While I restrict my discussion to ADHD, the access-based approach is also relevant for assessments of responsibility for other cases where self-control failures are at stake. (shrink)

Stimulants have been shown to be safe and effective for reduction of the symptoms of attention deficit hyperactivity disorder. Despite much debate, however, there has been little empirical evidence as to whether stimulants affect authenticity and moral agency in children. Singh presents evidence that stimulants do not undercut children's' sense of self and increase their experience of agency. These findings are consistent with laboratory evidence that stimulant drugs in therapeutic doses improve cognitive control over thought and behavior.

Minors with attention-deficit-hyperactivity disorders are liable to use pharmacological treatment against their will and may find their authentic “I” modified. Thus, their use is widely criticized. In this study, the effect of ADHD drugs on adolescents’ personal experience is examined. The goal is to understand how psychological changes that young people experience when they take these medications interrelate with their attitude toward being medicated. Methylphenidate is the most common pharmacological treatment for ADHD. We look into the change that Israeli adolescents (...) undergo when they use it; their experience in controlling the change, and their assessment of the meaning of the change for their lives. Thirty-eight adolescents participated in semi-structured interviews. The findings, analyzed using grounded theory, show that methylphenidate affects the participants’ demeanor, mood, and even preferences. The participants, aware of these effects, apply discretion in taking methylphenidate and thus influence their traits and their willingness to engage in various activities. When needing to prepare for a matriculation exam, for example, they take methylphenidate; when they need to be creative or sociable, they avoid it and enjoy what they consider the advantages of ADHD, such as creativity and spontaneity. As discretionary users, they shape their life stories in a way that makes them more meaningful and diverse, better tailored to their social surroundings, and more useful in maintaining personal autonomy in the course of pharmacological treatment of ADHD. (shrink)

New neural models for anorexia nervosa are emerging as a result of increased research on the neurobiology of AN, and these offer a rationale for the development of new treatment technologies such as neuromodulation. The emergence of such treatment technologies raises new ethical questions; however these have been little discussed for AN. In this article, I take an empirical approach and explore how young women who suffer from AN perceive treatment technologies in light of the concept of authenticity. Interview data (...) showed that participants in this study did not seem to unconditionally adhere to treatment modalities that only imply laborious self-work, such as therapy. The data also showed that they were willing to accept new treatment possibilities such as pharmacological or brain-directed treatment strategies, which they view as having potential instrumental value in coping with certain symptoms of the illness. However, such modalities can pose threats to patients’ authenticity, especially with regard to self-discovery. I argue that, in a context where there is an increased interest in brain-directed treatment strategies for AN, studies should continue to explore the ethical and psychological impact of such treatment technologies on individuals. (shrink)

The underappreciated moral theorist Benjamin Franklin in his youth made up a list of virtues he felt ought to be followed as sound guides for living one's life. Some of the virtues he prescribed relate to personal behaviour: temperance, order, resolution, frugality, moderation, industry, cleanliness and tranquillity. The rest are social character traits: sincerity, justice, silence, chastity and humility. He never abandoned his faith in those values, teaching them to his son and anyone who cared to read his Poor Richard's (...) Almanack. In his autobiography, Franklin tells us that he kept a diary in which he evaluated, on a daily basis, his success in living up to each virtue.1That Franklin enjoyed a life in which the virtues he extolled were not omnipresent is well known. He would be the first to confess that there were more than a few occasions when he failed to live up to his own moral teaching.1 What is interesting about his virtue ethic is not his personal struggle to conform to it but his belief that moral character is made …. (shrink)

Background: Psychiatric interventions are a contested area in medicine, not only because of their history of abuses, but also because their therapeutic goal is to affect emotions, thoughts, beliefs...

This article explores some of the normative commitments which persist in the literature on behavioural interventions for disorders of inattention and hyperactivity. These programmatic texts grapple with a contradiction: on one hand, they posit individuals who cannot be held responsible for their behaviour on the grounds that it is pathological, rather than wilful; on the other hand, these texts are written for individuals diagnosed with these disorders and for related authorities, obliged to mitigate said behaviour on the grounds that it (...) is disvalued and impairing. Facing the practical problem of alleviating impairing and disruptive behaviours, this literature has also consistently expressed a goal of producing individuals who demonstrate self-control. Self-control, in this context, however, is not simply the manifestation of wilful autonomy over one’s body, but the capacity to be ascribed responsibility for one’s actions. In the move from bodily control to self-control, institutions responsible for treating those diagnosed with these disorders produce what Foucault has called a ‘political economy of illegality’, where the management of disvalued behaviour is not the eradication of said behaviour, but a redistribution of the right to reward and punish based on the individualization of action. (shrink)