A signal challenge of twenty-first century psychiatry is the effective treatment of existential/spiritual suffering in palliative care. This chapter will concentrate on research to assess the therapeutic potential of psilocybin to assuage that suffering. If a “psychedelic experience” can facilitate an acceptance of impending death, and reduce the existential suffering of those who endure it, it could prove to be a valuable intervention where one is sorely needed. The therapeutic use of psilocybin with dying patients (hereinafter patients) raises numerous questions (...) about research trial design, the model of psychiatry that might accommodate it, and the kind of experience it induces. Are these the sorts of experience that psychiatric treatment should effect on troubled patients? Is spiritual care within the ambit of psychiatry? There are epistemological questions as to the veridicality of the psychedelic experience. How much credence should we give it? I will argue in cautious support of ongoing research to evaluate the therapeutic use of psilocybin in palliative care. This argument can be extended to research on its therapeutic use in psychotherapy. The chapter will focus on four questions: (1) what is the ethical justification for this research on patients? (2) What types of research trial design are best used to assess the purported benefits of a psychedelic drug experience? (3) What is the epistemic warrant of the “mystical” and “noetic” facets of this experience? (4) What models of (a) psychiatry and (b) drug action could accommodate the therapeutic use of psilocybin in palliative care? (shrink)

This essay argues that the practice ofmedicine is not a phronetic activity in theoriginal Aristotelian sense of that term. Jonsen andToulmin are two philosophers who have conflated thetechne of medicine with phronesis. Thisconflation ignores Aristotle's crucial distinctionbetween techne and phronesis and his useof the medical analogy. It is argued that medicalreasoning is similar to phronesis but does notexemplify it. Phronesis will not save thelife of medical ethics. The concept could be utilized as amoral prosthetic.

The Healing Virtues explores the intersection of psychotherapy and virtue ethics - with an emphasis on the patient's role within a healing process. It considers how the common ground between the therapeutic process and the cultivation of virtues can inform the efforts of both therapist and patient. Within this book, the Duff R. Waring argues that there is a case for patient virtues that are crucially relevant to working through the problems in living that arise in psychotherapy, e.g., honesty, courage, (...) humility, perseverance. The central idea is that treatment may need to build virtues while it ameliorates problems. Hence, the patient's work in psychotherapy can both challenge character strengths and result in their further development. (shrink)

The standard approach to ethics in psychotherapy is to focus on the therapist. Although normative “boundary” ethics revolves around what the therapist ought, or ought not, to do, virtue ethics can revolve around the kind of person the therapist ought to be. One can thus apply virtue ethical theory to clinical practice and argue for therapist virtues that are relevant to meeting professional standards and to working effectively through the problems that arise in psychotherapy. Considerably less attention has been paid (...) to how virtue ethics relates to the patient. The ethics of psychotherapy can also revolve around the sort of person the patient should be. I argue that there are nascent virtues which the patient can bring to psychotherapy that, when cultivated with the therapist, can facilitate a beneficial outcome and virtues that can be seen as psychotherapeutic goals toward which the patient ought to strive. (shrink)

Some authors argue that the ethics of medical care and the ethics of research differ, and that it is a mistake to conflate the two. They propose “that medical research and medical treatment are two distinct forms of activities, governed by different ethical principles.” This raises the question of whether physicians who are also clinical investigators may separate their role as physician from that of researcher when they are involved in clinical trials, thereby avoiding the obligations required in the physician-patient (...) relationship. Miller and Brody suggest that medical training is to blame for what they believe is the physicians’ tendency to confound the obligations of research and practice. “Physician-investigators, after all, went to medical school” they explain. They believe that considering research with patients outside the ethical framework of the physician-patient relationship may be “difficult and threatening” to physicians who have “psychological needs” to consider the ethical obligations flowing from their relationship with their patients. (shrink)

Some authors argue that the ethics of medical care and the ethics of research differ, and that it is a mistake to conflate the two. They propose “that medical research and medical treatment are two distinct forms of activities, governed by different ethical principles.” This raises the question of whether physicians who are also clinical investigators may separate their role as physician from that of researcher when they are involved in clinical trials, thereby avoiding the obligations required in the physician-patient (...) relationship. Miller and Brody suggest that medical training is to blame for what they believe is the physicians’ tendency to confound the obligations of research and practice. “Physician-investigators, after all, went to medical school” they explain. They believe that considering research with patients outside the ethical framework of the physician-patient relationship may be “difficult and threatening” to physicians who have “psychological needs” to consider the ethical obligations flowing from their relationship with their patients. (shrink)

Grunbaum claims that the remedial failure of atreatment's characteristic factors is thegeneric, objective property of a placebo. Hestipulates that a treatment is placebic if thisremedial failure exacerbates the targetdisorder. This stipulation can subsume asplacebic effects that might be solelypharmacological, e.g., paradoxical reactions tocertain psychiatric drugs. If that exacerbationcan be explained pharmacologically, then wemight question whether Grunbaum's definitionalscheme captures the core identity of what weusually intend by the placebo concept. Ipropose that this core identity is bestcaptured by a symbolic meaning hypothesis (...) inwhich psychological factors exert thedeterminative influence. (shrink)

Kamm's approach to patient selection qualifies the notion that fairness makes need for scarce, transplantable organs inversely proportional to age. She defines need as how much adequate conscious life a person will have had before death. Length of adequate conscious life correlates highly with age. If so, then younger persons are usually needier than older ones. Since Kamm allows for past periods of non‐adequate conscious life, I argue that this correlation may be neither as close, nor as easy to apply, (...) as she wants it to be. Fairness should require assessment of experiential content in determining how long one's life has been adequately conscious. I argue that such assessments involve some of the goods of experience and quality of life judgements that Kamm thinks a reliance on adequate conscious life will avoid. (shrink)

The central issue of this dissertation is known in bioethics as the problem of fair chances versus best outcomes. The decision-making context is patient selection for scarce, transplantable organs. This problem poses two options for patient selection: either select by a procedure which affords fair chances to all medically suitable transplant candidates or select those whose prognoses indicate the highest levels of prospective medical benefit. The fair chances/best outcomes problem is essentially a problem of choosing between lives. An egalitarian approach (...) to patient selection favours fair chances. A utilitarian approach favours best outcomes. My project is a sustained defence of an egalitarian approach. It targets first a rule utilitarian argument for maximizing medical benefit. It targets second an argument that fairness in patient selection requires a preference for saving younger lives. I argue that patients should have prognoses at or above a threshold level of medical benefit to be medically suitable candidates. I propose random selection by lottery as a means of final selection that equally values lives. I argue that equality of opportunity best reflects an egalitarian commitment to equal concern and respect. (shrink)

The expert clinical community is split about whether the difference between antidepressant treatment and treatment with placebos stems from the efficacy of the drug or from subjects’ heightened expectancy enhanced by side effects—i.e., enhanced placebo effects. Proving whether pharmacological efficacy has been established reliably by randomized controlled trials of antidepressant drugs is difficult, primarily because substituting a placebo for an effective treatment in the control arm of a trial is ethically questionable. I argue that clinical equipoise permits the use of (...) active placebo controls in trials that test antidepressants. Placebo controls for drug trials are ethically defensible and scientifically justified when we have evidence that a standard treatment might only work because of enhanced placebo effects, and when a respectable minority of the expert clinical community endorses these concerns. (shrink)

This article offers a conceptual analysis of self-respect and self-esteem that informs the ethics of psychotherapy in palliative care. It is focused on Chochinov’s Dignity Therapy, an internationally recognized treatment offered to dying patients who express a need to bolster their sense of self-worth. Although Dignity Therapy aims to help such patients affirm their value through summarized life stories that are shared with their survivors, it is not grounded in a robust theory of self-respect. There is reason to be skeptical (...) about deathbed narratives, and Dignity Therapy can unintentionally encourage distorted representations at odds with the self-respect it aims to affirm. Dignity therapy can also encourage distortions of self-esteem that are in conflict with self-respect. Although Chochinov does not address it, the distinction between self-respect and self-esteem is relevant to deathbed accounts. Dillon’s feminist revisioning of self-respect can inform the practice of Dignity Therapy by encouraging honest life stories through a reckoning with one’s moral complexity, especially in moral generativity cases where patients seek forgiveness, relate atonement, or present their lives as examples to be followed. Her concept of self-esteem allows for therapeutic benefits that are less demanding, but no less significant, than those derived from a moral reckoning. Appropriate affirmations of self-esteem can provide much-needed solace when self-respect is damaged beyond adequate repair. Dillon’s account of self-respect and self-esteem enables a richer understanding of the kinds of personal evaluation and disclosure that Dignity Therapy accommodates. As such, their place in Dignity Therapy needs more critical evaluation than it has received. (shrink)

The Malleus Maleficarum was a detailed manual for Dominican witch-hunters. It codified specific criteria for identifying witches and guidelines for their application. It elaborated a system of symptoms that indicated illness caused by witchcraft . These symptoms were seen as the visible projections of a vast and complex organization of behavior. Since the existence of witches was presupposed by those who used the manual, its criteria were confirmed repeatedly during the Inquisition. Once the Malleus was published, its diagnostic system acquired (...) a momentum of its own and generated its own evidence . Its authors saw physicians as experts at distinguishing physical illnesses from those caused by witchcraft. The authors began the manual by asserting that belief in the existence of witches is an essential part of the Catholic faith. Priests and inquisitors were not to doubt the existence of witches . Like the Malleus Maleficarum, the Diagnostic and Statistical Manual is a detailed text which codifies specific criteria for identifying people who are seen as abnormal. It codifies guidelines for applying these criteria and elaborates a system of symptoms that indicates illnesses known as mental disorders. These symptoms are seen as the visible projections of a vast and complex organization of behavior. Since the existence of these disorders is presupposed by many of those who use the manual, its criteria are confirmed repeatedly in the diagnostic process. Once DSM was published , its diagnostic system acquired a momentum of its own and has generated its own evidence. Its authors regard psychiatrists as experts at applying the manualís criteria. They are also seen as experts at distinguishing mental disorders from other illnesses. Belief in the existence of mental disorders is an essential part of the psychiatric faith. (shrink)

By the time of his death in 1989, R.D. Laing was already history. His status as a countercultural legend remained intact, but he had gone from icon to relic. His intellectual and political credibility reached a peak in the late 1960s that he never regained. For many, the publication of The Politics of Experience and The Bird of Paradise in 1967 presaged his critical demise into bad poetry and bellicose shamanism. Laing himself was keenly aware of his fall from popular (...) grace. (shrink)