Autonomy is a concept that holds much appeal to social and legal philosophers. Within a medical context, it is often argued that it should be afforded supremacy over other concepts and interests. When respect for autonomy merely requires non-intervention, an adult’s right to refuse treatment is held at law to be absolute. This apparently simple statement of principle does not hold true in practice. This is in part because an individual must be found to be competent to make a valid (...) refusal of consent to medical treatment, and capacity to decide is not an absolute concept. But further to this, I argue that there are three relevant understandings of autonomy within our society, and each can demand in differing cases that different courses of action be followed. Judges, perhaps inadvertently, have been able to take advantage of the equivocal nature of the concept to come tacitly to decisions that reflect their own moral judgments of patients or decisions made in particular cases. The result is the inconsistent application of principle. I ask whether this is an unforeseen outcome or if it reflects a wilful disregard for equal treatment in favour of silent moral judgments in legal cases. Whatever the cause, I suggest that once this practice is seen to occur, acceptable justification of it in some cases is difficult to find. (shrink)

Prior to the second world war, most persons confined in insane asylums were regarded as legally incompetent and had guardians appointed for them. Today, most persons confined in mental hospitals are, in law, competent; nevertheless, in fact, they are treated as if they were incompetent. Should the goal of mental health policy be providing better psychiatric services to more and more people, or the reduction and ultimate elimination of the number of persons in the population treated as mentally ill?

Thomas Szasz, the radical critic of state-supported psychiatry, and root and branch sceptic about mental illness, died in September 2012. Based on the obituary1 and editorial comment in The Lancet2 and the response his work commonly elicits, it is evident that there will be mixed reviews of his impact and of the cogency of his position.Certainly, some have seen him as a notable figure from the past. There is a sense in which, as far as Szasz's critique of psychiatry goes, (...) it did not really change at all in its essence from the time it was first explicitly expressed in his writings of the 1960s right up to his last publications and talks in the 2010s. He started his 1960 paper The Myth of Mental Illness3 with the assertion that there is no such thing as mental illness, and this has been an underlying pedal note to all his many pronouncements in this area ever since. Personally, I have always found his written interventions in debates right up to the present to be highly readable and intellectually sharp; he was adept at creating variations on the Szaszian theme. In one of his earlier book length texts, The Manufacture of Madness,4 he likens the contemporary idea that people have mental illness to the historical idea that some people were witches, and he parallels the institutions of modern state-supported psychiatry to those of the Inquisition. In articles he later published in the Journal of Medical Ethics, he likened mental illness to ‘phlogiston’—the non-existent substance that supposedly explained combustion5 and claimed the term ‘mental …. (shrink)

How psychopaths and their capacity for moral action are viewed is not only philosophically interesting but is also important and relevant for policy. The philosophical discussion of psychopathy has focussed upon the psychological faculties that are prerequisites for moral responsibility and empirical findings regarding psychopathy that are relevant to philosophical accounts of moral understanding and motivation. However, there are legitimate worries about whether psychopathy is a robust scientific construct, and there are risks attached to reifying psychopathy or other psychiatric constructs. (...) We defend the concept of psychopathy by pointing out the relevance of empirical studies about it for our ordinary practices of ascribing moral responsibility and folk psychological accounts of moral understanding and motivation. (shrink)

The paper by Szasz is about mental illness and its meaning, and like Procrustes, who altered hapless travellers to fit his bed, Szasz changes the meanings of words and concepts to suit his themes.1 Refuting the existence of “mental illness”, he suggests that the term functions in an apotropaic sense. He submits that in this sense it is used to avert danger, protect society, and hence justify preventive detention of “dangerous” people.But his arguments misrepresent the precise meaning of the term (...) “apotropaic”, which is an adjective, defined in Webster’s, Chambers and the New Shorter Oxford dictionaries as averting or turning aside evil. It is possible that amulets and incantations ward off evil, in the same way as garlic repels vampires, but evil and danger are different concepts. Yet Szasz talks of using phrases like ‘“dangerousness to self and others’ as apotropaics to ward off dangers we fear”, and the word “evil” does not appear in his paper.I will argue that “dangerousness to self and others” and “psychiatric treatment” have a prosaic rather than an apotropaic function.The word “danger” is familiar rather than arcane, and includes many risks. A predatory paedophile is usually both dangerous and evil, but many dangerous people are not evil. For example, a child who plays with a box of matches is dangerous, as is a demented person who drives a car, or a schizophrenic who, acting on delusional beliefs, arms herself with a knife and roams the streets believing she is an avenging angel.Suppose …. (shrink)

Psychopathy, as articulated in Hare’s PCL-R, appears to reliably pick out a forensic category of troubled people. This chapter considers the use and utility of PCL-R by focussing upon two interrelated questions. Does philosophical investigation direct attention toward the issues that should interest us about psychopathy? Is being diagnosed as psychopathic or having ASPD clinically useful, as well as for judicial and sentencing purposes? While the research programmes that developed following the attention paid to psychopathy are warranted, more attention could (...) be directed to the varied nature of psychopathy and the presentations of it that Cleckley described in the Mask of Sanity. It is important to understand psychopathy as it affects lives, as well as a forensic problem. (shrink)

Although many psychiatrists regard psychopathy as a coherent scientific construction, some clinicians and philosophers regard it as irrelevant. According to the latter, psychopathy is nothing more than a means of social control. The present study focuses on the issues of the neurological bases and moral responsibility related to psychopathy. While neuroscience aims to identify dysfunctions in psychopaths, action theory and ethics tend to vindicate the hypothesis of the moral irresponsibility of the psychopath. However, rather than reinforcing the concept of psychopathy, (...) recent results in neuroscience tend to stress its incoherence. Philosophical speculations on psychopaths’ responsibility are not sufficiently empirically informed and seem to announce endless ethical debates. (shrink)