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)

The application of human right frameworks is an increasingly important part of efforts to accelerate progress in global mental health. Much of this has been driven by several influential legal and policy instruments, most notably the United Nations’ Convention on the Rights of Persons with Disabilities, as well as the World Health Organization’s QualityRights Tool Kit and Mental Health Action Plan. Despite these significant developments, however, much more needs to be done to prevent human rights violations. This chapter focuses on (...) a critical component of this broader challenge, which is the question of how best to regulate and reduce the use of coercive measures. The recent literature on coercion in psychiatry – which addresses involuntary commitment, seclusion, restraint, and forced medication – represents a useful resource that can help guide tractable solutions in global mental health. These issues are evaluated from the perspective of global health governance, and several general recommendations are made in order to improve monitoring and enforcement, provide guidance for domestic legislative reform, and strengthen health systems. (shrink)

In this book, T. M. Scanlon offers new answers to these questions, as they apply to the central part of morality that concerns what we owe to each other.

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)

This volume brings together for the first time a significant number of Reid's manuscript papers on natural history, physiology and materialist metaphysics. An important contribution not only to Reid studies but also to our understanding of eighteenth-century science and its context.

Thomas Reid was a philosopher who founded the Scottish school of 'common sense'. Much of Reid's work is a critique of his contemporary, David Hume, whose empiricism he rejects. In this work, written after Reid's appointment to a professorship at the university of Glasgow, and published in 1785, he turns his attention to ideas about perception, memory, conception, abstraction, judgement, reasoning and taste. He examines the work of his predecessors and contemporaries, arguing that 'when we find philosophers maintaining that (...) there is no heat in the fire, nor colour in the rainbow … we may be apt to think the whole to be only a dream of fanciful men, who have entangled themselves in cobwebs spun out of their own brain'. Written by one of the Scottish Enlightenment's most important thinkers, this work brings to life the intellectual debates of the time. (shrink)

In recent years there has been increased recognition of the global burden of mental disorders, which in turn has led to the expansion of preventive initiatives at the community and population levels. The application of such public health approaches to mental health raises a number of important ethical questions. The aim of this collection is to address these newly emerging issues, with special attention to the principle of prevention and the distinctive ethical challenges in mental health. The collection brings together (...) an interdisciplinary group of experts in bioethics, mental health, public health, and global health. (shrink)

Thomas Aquinas produced a voluminous body of work on moral theory, and much of that work is on virtue, particularly the status and value of the virtues as principles of virtuous acts, and the way in which a moral life can be organized around them schematically. Thomas Osborne presents Aquinas's account of virtue in its historical, philosophical and theological contexts, to show the reader what Aquinas himself wished to teach about virtue. His discussion makes the complexities of Aquinas's (...) moral thought accessible to readers despite the differences between Thomas's texts themselves, and the distance between our background assumptions and his. The book will be valuable for scholars and students in ethics, medieval philosophy, and theology. (shrink)

Increased awareness of the importance of mental health for global health has led to a number of new initiatives, including influential policy instruments issued by the World Health Organization (WHO) and the United Nations (UN). This policy brief describes two WHO instruments, the Mental Health Action Plan for 2013–2020 (World Health Organization, 2013) and the Mental Health Atlas (World Health Organization, 2015), and presents a comparative analysis with the Sustainable Development Goals (SDGs) of the UN’s 2030 Agenda for Sustainable Development (...) (United Nations, 2015). The WHO’s Action Plan calls for several specific objectives and targets, with a focus on improving global mental health governance and service coverage. In contrast, the UN’s SDGs include only one goal specific to mental health, with a single indicator tracking suicide mortality rates. The discrepancy between the WHO and UN frameworks suggests a need for increased policy coherence. Improved global health governance can provide the basis for ensuring and accelerating progress in global mental health. (shrink)

Despite widespread recognition that psychiatry would be better served by a classificatory system based on etiology rather than mere description, it goes without saying that much of the necessary work is yet to be done. In this chapter I take up the increasingly important question of how mechanistic explanation fits into the larger effort to build a scientifically sound etiological and nosological framework. I sketch a rough picture of what mechanistic explanation should look like in the context of psychiatric research, (...) with a focus on several potential challenges posed by the special features of many psychiatric conditions. These include the role of social and environmental factors, the relatively transient nature of symptoms, the presumably complex organization of underlying systems, and the likelihood that many disorders are the product of nonstandard development. I suggest that these explanatory challenges can be met with a sufficiently broad notion of mechanism, one that allows for something less than the flawless execution of internal operations, appeals to the influence of contextual factors, and attends to organizational relations both within the mechanism itself and across the wider cognitive system. (shrink)

Nunez's description of the brain as a medium capable of wave propagation has provided some fundamental insights into its dynamics. This approach soon reaches the descriptive limits of the brain as a physical system, however. We point out some biological constraints which differentiate the brain from physical systems and we elaborate on its consequences for future research.

Given that the concept of coercion remains a central concern for bioethics, Quigley's (Monash Bioethics Rev 32:141–158, 2014) recent article provides a helpful analysis of its frequent misapplication in debates over the use of ‘nudges’. In this commentary I present a generally sympathetic response to Quigley’s argument while also raising several issues that are important for the larger debates about nudges and coercion. I focus on several closely related topics, including the definition of coercion, the role of empirical research, and (...) the normative concerns at the core of these disputes. I suggest that while a degree of precision is certainly required when deploying the relevant concepts, perhaps informed by empirical data, we need to continue to push these debates towards more pressing normative considerations. (shrink)

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific (...) to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy. (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)

This chapter examines the core explanatory strategies of cognitive science and their application to the study of psychopathology. In addition to providing a taxonomy of different strategies, we illustrate their application, with special attention to Autism Spectrum Disorder and Major Depressive Disorder. We conclude by considering two challenges to the prospects of a developed cognitive science of psychopathology.

The topic of coercion has a long and contentious history in both political philosophy and medical ethics. This substantial literature centers on two fundamental questions: What is coercion? And when is it justified? In the context of psychiatry there has been a recent upsurge of interest in coercion, with particular focus on the latter question. For example, a number of research groups have been investigating the relationship between coercion and clinical outcomes. But of course such research relies heavily on assumptions (...) about the former question, that of the concept of coercion. Coercion is often tracked in these studies by various measures of “perceived coercion,” in response to the recognition that involuntary legal status is a poor gauge of the presence of coercion. A result of this approach is that empirical research has started to provide an interesting picture of a variety of coercive pressures and experiences. And these newly emerging findings, in turn, underscore the need for further conceptual analysis. The aim of this paper, then, is to draw out provisional implications for philosophical debates about coercion from recent research in psychiatry. (shrink)

Background: The aim of this study was to investigate associations between demographic and clinical variables and duration of untreated psychosis (DUP) in a sample of cases of psychosis across an adult early intervention in psychosis service and a child and adolescent community team. Method: Cross-sectional baseline data for cases of psychosis across the two teams on the caseload at a given time point were collected, including age of onset, gender, ethnicity, referral route, and DUP. Results: The median DUP across the (...) entire sample was 91 days, while those patients with initial treatment for psychosis from the child and adolescent team had a median DUP of 69 days. Using multiple linear regression, there were two variables that showed a significant association with DUP: referral route (p < .001), and age of onset, with earlier age of onset associated with shorter DUP (p = .015). Conclusion: These findings are discussed in relation to possible explanatory factors, with particular focus on service-level variables and pathways to care. It is suggested that the involvement of child and adolescent teams is vital to the work of early intervention in psychosis services. (shrink)

Recent cognitive models of delusions have attempted to explain why delusions are commonly circumscribed, in that they tend to center on isolated beliefs, and incorrigible, as they often persist in the face of countervailing evidence. In this effort, the suggestion has been made that ‘modularity’ – a concept originating in seminal accounts of the architecture of perceptual and cognitive processes – may help explain delusions. The aim of this paper is to take up this suggestion, critically evaluating the applicability of (...) modularity and its attendant features to the explanation of delusions. The conclusion presented here is that although a modular explanation of delusions may be relatively consistent with models that implicate dysfunctional cognitive components such as motor control and ‘theory of mind’ (ToM) systems, ultimately the application of modularity to delusions conflicts with traditional understandings of cognitive architecture and does not help provide satisfactory or sufficient explanations of delusional symptomatology. (shrink)

Narcissism continues to be an important topic of research, with a great deal of ongoing empirical work in social and personality psychology. But there are theoretical issues that have received less attention recently, including those that relate to the foundational theories of the psychoanalytic tradition. As the first step in a larger project of reevaluation, this article offers a critical review of Freud and Heinz Kohut’s theories of narcissism. Centered on a theoretical reconstruction, it clarifies several significant – and often (...) underspecified – features of each account. I also explore the continuities and discontinuities between these two closely related systems. Most notably, both Freud and Kohut lacked fully developed accounts of primary narcissism and the relevant instinctual drives. At the same time, Kohut’s theory expanded upon Freud’s in innovative ways, particularly with its emphasis on a secondary line of narcissistic development that has positive, transformative features. In the final section, however, I introduce a speculative reading that describes theoretical prefigurations of these features in elements of Freud’s structural theory. (shrink)

There has been an explosion of interest in the metaphysics of fundamentality in recent decades. The consensus view, called metaphysical foundationalism, maintains that there is something absolutely fundamental in reality upon which everything else depends. However, a number of thinkers have chal- lenged the arguments in favor of foundationalism and have proposed competing non-foundationalist ontologies. This paper provides a systematic and critical introduction to metaphysical foundationalism in the current literature and argues that its relation to ontological dependence and substance should (...) be qualified in important ways. (shrink)

In a recent paper Weinberg (2007) claims that there is an essential mark of trustworthiness which typical sources of evidence as perception or memory have, but philosophical intuitions lack, namely that we are able to detect and correct errors produced by these “hopeful” sources. In my paper I will argue that being a hopeful source isn't necessary for providing us with evidence. I then will show that, given some plausible background assumptions, intuitions at least come close to being hopeful, if (...) they are reliable. If this is true, Weinberg's new challenge comes down to the claim that philosophical intuitions are not reliable since they are significantly unstable. In the second part of my paper I will argue that and why the experimentally established instability of folk intuitions about philosophical cases does not show that philosopher's expert intuitions about these cases are instable. (shrink)

Feeling good: four ways -- Finding that feeling -- The place of pleasure -- Knowing what's what -- Making things happen -- Being good -- Love and friendship -- Putting it together.

Recent advances in DNA sequencing have revolutionized the field of genomics, making it possible for even single research groups to generate large amounts of sequence data very rapidly and at a substantially lower cost. These high‐throughput sequencing technologies make deep transcriptome sequencing and transcript quantification, whole genome sequencing and resequencing available to many more researchers and projects. However, while the cost and time have been greatly reduced, the error profiles and limitations of the new platforms differ significantly from those of (...) previous sequencing technologies. The selection of an appropriate sequencing platform for particular types of experiments is an important consideration, and requires a detailed understanding of the technologies available; including sources of error, error rate, as well as the speed and cost of sequencing. We review the relevant concepts and compare the issues raised by the current high‐throughput DNA sequencing technologies. We analyze how future developments may overcome these limitations and what challenges remain. (shrink)

Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula (...) within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education. (shrink)

We believe that the task goal in voluntary movements provides meaning to existing information sources in the environment and determines, in a dynamic way, the use and relative importance of these different sources. This task-centered meaning bridges the apparent controversy between what information is available in principle (i.e., specification), and what information is perceived.

Looking back on it, it seems almost incredible that so many equally educated, equally sincere compatriots and contemporaries, all drawing from the same limited stock of evidence, should have reached so many totally different conclusions---and always with complete certainty.

I critically examine some deflationary theories of properties, according to which properties are ‘shadows of predicates’ and quantification over them serves a mere quasi-logical function. I start by considering Hofweber’s internalist theory, and pose a problem for his account of inexpressible properties. I then introduce a theory of properties that closely resembles Horwich’s minimalist theory of truth. This theory overcomes the problem of inexpressible properties, but its formulation presupposes the existence of various kinds of abstract objects. I discuss some ways (...) to reduce these existence assumptions, but ultimately suggest that deflationists can hardly avoid quantification over abstract objects of one sort or another. I conclude that property deflationism is perhaps not as deflationary as some philosophers want it to be, but that it’s still apt to call the position ‘deflationary’. (shrink)

Issues concerning patients' rights are at the center of bioethics, but the political basis for these rights has rarely been examined. In Bioethics in a Liberal Society: The Political Framework of Bioethics Decision Making , Thomas May offers a compelling analysis of how the political context of liberal constitutional democracy shapes the rights and obligations of both patients and health care professionals. May focuses on how a key feature of liberal society -- namely, an individual's right to make independent (...) decisions -- has an impact on the most important relational facets of health care, such as patients' autonomy and professionals' rights of conscience. Although a liberal political framework protects individual judgments, May asserts that this right is based on the assumption of an individual's competency to make sound decisions. May uses case studies to examine society's approach to medical decision making when, for reasons ranging from age to severe mental disorder, a person lacks sufficient competency to make independent and fully informed choices. To protect the autonomy of these vulnerable patients, May emphasizes the need for health care ethics committees and ethics consultants to help guide the decision-making process in clinical settings. Bioethics in a Liberal Society is essential reading for all those interested in understanding how bioethics is practiced within our society. (shrink)