Philosophy says that life must be understood backwards. But . . . it must be lived forward. . , , It is more and more evident that life can never be really understood in Time. It was a pleasure to read Jason Thompson’s serious and thought-provoking piece, and I am grateful to the editors for giving me a chance to comment. The idea that the self is revealed in narrative is a popular one among different schools of psychotherapy, both in (...) terms of technique and theory; and my response addresses both these issues in turn. As a clinician, I have always liked people’s stories. As a junior psychiatrist, I used to love the moment when I first met someone and could say to them, ‘You were born; and then what .. (shrink)

The Deprivation of Liberty Safeguards (DOLS) were recently introduced into the Mental Capacity Act (MCA) via an amendment to mental health legislation in England and Wales. As Shah (2011) discusses, the rationale behind creating these protocols was to close what is commonly referred to as the ‘Bournewood gap’; a legislative loophole that allowed a severely autistic man (H.L.) who did not initially dissent to admission to be detained in a hospital and deprived of his liberty in his ‘best interests’ as (...) judged by his clinical team. Before the implementation of the DOLS, patients who lacked the capacity to consent to admission or treatment but who were nonetheless compliant could be admitted informally and treated as .. (shrink)

The determinative issue in applying the insanity defense is whether the defendant experienced a legally relevant functional impairment at the time of the offense. Categorical exclusion of personality disorders from the definition of mental disease is clinically and morally arbitrary because it may lead to unfair conviction of a defendant with a personality disorder who actually experienced severe, legally relevant impairments at the time of the crime. There is no need to consider such a drastic approach in most states and (...) in the federal courts, where the sole test of insanity is whether the defendant was “unable to appreciate the wrongfulness of his conduct at the time of the offense.” This is because the only symptoms that are legally relevant in such jurisdictions are those that impair reality-testing and thereby affect the person's capacity to understand the nature and consequences of her actions. However, if the test of insanity includes a “volitional prong” (inability to control one's behavior), some way must be found to limit the scope of the defense to the core cases (involving psychotic conditions) to which it has traditionally been applied, and to prevent a shift toward a deterministic account of criminal conduct — i.e., “people can't help being who they are and doing what they do.” The best way of accomplishing this is to limit the definition of mental disease to severe disorders characterized by gross disturbances of the person's capacity to understand reality. (shrink)

We are very grateful to both Matthew Ratcliffe and Thomas Szasz for taking the time to read and respond to our paper. Ratcliffe is broadly sympathetic to our efforts and provides a very convincing argument against mind–body dualisms by drawing on work from the phenomenological tradition. His comments extend rather than challenge our central thesis. Szasz, however, is dismissive of our position. As a result, most of our response is directed to his commentary. Ratcliffe uses the work of van der (...) Berg to make the case that any easy distinction between bodily and mental illness or suffering is false to our lived reality as human beings. Of course, in the day-to- day world of contemporary medical practice .. (shrink)

In English medical law, it is something of an axiom that adult competent patients have an absolute right to refuse all and any medical treatment, including potentially life-saving and life-sustaining treatment. This legal proposition, which is embedded in the doctrine of consent, has for the last few decades been regarded as the expression of the philosophical principle of personal autonomy and ethical right of self-determination. The Western ethical and legal traditions places heavy emphasis on notions of personal sovereignty reflected in (...) the strong rhetorical entrenchment of patient autonomy in judicial determinations of treatment refusal cases. In a spate of legal cases in the 1980s and 1990s judicial rhetoric .. (shrink)

It is now generally agreed that we have to rely on value judgments to distinguish mental disorders from other conditions, but it is not quite clear how. To clarify this, we need to know more than to what extent attributions of disorder are dependent on values. We also have to know (1) what kind of evaluations we have to rely on to identify the class of mental disorder; (2) whether attributions of disorder contain any implicit reference to some specific evaluative (...) standard; and (3) whether the concept of mental disorder is value laden in the definitional or in the epistemic sense. I will argue that the evaluations we have to rely on are mainly considerations of harm, but that we also need to rely on other evaluations; that there should be no references to specific evaluative standards; and that even though mental disorders are necessarily undesirable, "mental disorder" may well be a descriptive phrase. (shrink)

INTERDISCIPLINARY WORK OF the sort attempted in my paper is fraught with risks and obstacles. One especially pernicious obstacle is the short-sighted prejudice that insists we should always divide a problem into its various components, allocate different parts to their respective disciplines, publish each separately, and, above all, keep the ethics separate from the rest. Although this may sometimes constitute good tactical advice in the mature stages of inquiry on a complex topic, it begs the question in the early initial (...) stages of discussion on a subject like the present one, which is tangled and complex and not suited to the traditional disciplinary boundaries of professional journals. I am grateful that both my commentators have generously overlooked the many weaknesses in my paper and focused instead on the most pressing issue of substance. This is the thesis that the issues described are important to psychiatry and deserve to be discussed more thoroughly. I therefore feel vindicated in assuming the risks I did, despite knowing there is so much more to be done; notably, moving from anecdotal data to more reliable forms of evidence. The entire episode speaks pointedly to the need for journals like Philosophy, Psychiatry, & Psychology and its innovative mandate. Before I address the remarks of my commentators, some background information on the circumstances that led to the writing of the paper might help readers to understand its wide inter-. (shrink)

In this commentary, I respond to several criticisms of my prior article arguing that, for purposes of assigning moral responsibility, we should understand psychopaths as persons who lack the ability to treat actions as affecting relationships. I discuss the implications of different kinds of psychopaths and the corresponding levels of moral responsibility. I also briefly discuss the legal implications of a psychopath’s diminished moral responsibility.

In this paper, I argue that the responsibility-affecting defect of psychopaths is their incapacity for responding to acts within relationships. I begin with Piers Benn's account of psychopaths as incapable of forming participant reactive attitudes. Benn argues that participant reactive attitudes are essentially communicative and the ability to form and understand participant reactive attitudes is crucial to being a member of the moral community. Against Benn, I argue, though participant reactive attitudes can be communicative, they are not essentially communicative. Instead, (...) they can be simply expressive. Therefore, we must consider psychopaths members of the moral community, in Benn’s sense; however, psychopaths fail to interpret their actions as part of relationships. This inability renders punishment, as an attempt to rectify wrong relationships, inappropriate for psychopaths. Psychopaths have diminished responsibility, insofar as they have forfeited some rights by committing an offense, but are not appropriate candidates for punishment because they cannot understand its significance. (shrink)

The following theses are defended in this paper: (1) The concept of autonomous action is centrally relevant to understanding numerous psychiatric conditions, namely, conditions that subvert autonomy; (2) The details of an analysis of autonomous action matter; a vague or rough characterization is less illuminating; (3) A promising analysis for this purpose (and generally) is a version of the "multi-tier model". After opening with five vignettes, I begin the discussion by highlighting strengths and weaknesses of contributions by other authors who (...) examine the relationship between autonomy and autonomysubverting psychiatric conditions. I then present an analysis of the concept of autonomous action, before employing this analysis in a suggestive exploration of the conditions illustrated in the vignettes. Keywords: autonomy, multi-tier model, psychiatric conditions CiteULike Connotea Del.icio.us What's this? (shrink)

The use of coercive measures in mental health care is an issue of ongoing concern (Cf. Fisher 1994; Janssen et al. 2008; Paterson and Duxbury 2007; Prinsen and Van Delden 2009; Widdershoven and Berghmans 2007; Wynn 2006). On the one hand, coercive interventions seem to infringe the patient’s right to self-determination (principle of autonomy). However, professionals are also committed to providing the care they deem necessary (principle of beneficence). In other words, professionals in mental health care are often caught between (...) the two (opposing) ideals of beneficence and autonomy. In medical practice, the right of self-determination is operationalized in the principle of informed consent. A medical physician is .. (shrink)

Abstract This paper contrasts two views on the ethics of belief, the absolutist position that adopting self?serving epistemic strategies is always morally wrong, and the holist position that non?epistemic factors may legitimately be consulted whenever we adopt epistemic strategies. In the first section, the absolutist view is shown to be untenable because of the holistic nature of moral questions in general. In the second section, the nagging appeal of the absolutist position is explored. An account of our ambivalence regarding the (...) absolutist view is suggested in terms of the conflict between our acceptance of our psychological needs and wants and a wish to overcome them. Five types of considerations that contribute to this conflict are given. (shrink)

This paper discusses the use of deep brain stimulation for the treatment of neurological and psychiatric disorders in children. At present, deep brain stimulation is used to treat movement disorders in children and a few cases of deep brain stimulation for psychiatric disorders in adolescents have been reported. Ethical guidelines on the use of deep brain stimulation in children are therefore urgently needed. This paper focuses on the decision-making process, and provides an ethical framework for (future) treatment decisions in pediatric (...) deep brain stimulation. I defend a shared decision-making model in case of deep brain stimulation for neurological and psychiatric disorders in children. To protect the vulnerable child patient, a dual consent process is needed where parents or parental guardians give their consent, and the child gives his/her assent. (shrink)

This is a reply to Gipps' commentary on my 'The Concept of Mental Disorder'.

A large part of the debate around the right to refuse life-prolonging treatment of anorexia nervosa sufferers centers on the issue of competence. Whether or not the anorexic should be allowed to refuse life-saving treatment does not depend solely or primarily on competence. It also depends on whether the anorexic’s suffering is bearable or tractable, and on the degree of involvement of the family in the therapeutic process. Anorexics could be competent to refuse lifesaving treatment (Giordano 2008). However, the anorexic’s (...) refusal of life-saving treatment should not be respected purely because it is a competent decision. In fact, anorexia has two characteristics that weaken the strength of the principle .. (shrink)

Long before i knew I had a personality disorder, I simply knew that my life felt unbearably difficult to live. For me, life has always been an uphill struggle, and at times I have just let myself tumble down the hill I have strived so hard to climb. Fortunately, I now understand how to keep going, and even to avoid falling down in the first place, but this learning process has taken the entire twenty-eight years of my life, and I (...) still feel I have a long way to go. It feels very difficult to describe the early years of my life. To me, it was like being stuck in a cage, gagged. I can remember feeling a great deal of fear, but being unable to express it. My dad would burst into anger very rapidly, and my .. (shrink)

The Hospital for Rehabilitation, Stavern, in Norway has treated patients with physical symptoms with no organic cause, so called conversion disorder patients, for over a decade. For four years research on the treatment has been carried out. Patients with conversion disorder seem not to fit in traditional somatic hospitals because their patienthood depends upon psychiatric diagnosis. Ironically, they appear not to belong in psychiatric hospitals because of their physical symptoms. The treatment offered these patients at hospitals for rehabilitation is adapted (...) physical activity consisting of behaviour elements such as positive reinforcement of normal function and lack of positive reinforcement at dysfunction. The pedagogical approach is seen as crucial in the successful rehabilitation of the patients. The disorder and treatment can be understood by using theories about the ecstatic body, radical behaviourism and phenomenology. When patients have problems in behaviour concerning both body and mind, it would be natural to employ both in the road to recovery. This article describes the various treatments and discusses them from phenomenological, ethical and philosophical perspectives. (shrink)

Abstract Evidence has long suggested that ‘hardwiring’ is a poor metaphor for brain development. But the metaphor may be an apt one for the dominant paradigm for researching sex differences, which pushes most neuroscience studies of sex/gender inexorably towards the ‘discovery’ of sex/gender differences, and makes contemporary gender structures appear natural and inevitable. The argument we forward in this paper is twofold. In the first part of the paper, we address the dominant ‘hardwiring’ paradigm of sex/gender research in contemporary neuroscience, (...) which is built on broad consensus that there are important ‘original’ sex differences in brain structure and function, organized by sex-differentiating prenatal hormone exposures. We explain why this consensus is both unscientific and unethical. In the second part of the paper, we sketch an alternative research program focused not on the origins of sex/gender differences but on variability and plasticity of brain/behavior. We argue that interventional experiments based on this approach will address more tractable questions, and lead to much more satisfactory results than the brain organization paradigm can provide. Content Type Journal Article Category Original Paper Pages 1-11 DOI 10.1007/s12152-011-9134-4 Authors Rebecca Jordan-Young, Barnard College, Columbia University, New York, NY, USA Raffaella I. Rumiati, SISSA, Trieste, Italy Journal Neuroethics Online ISSN 1874-5504 Print ISSN 1874-5490. (shrink)

Schizophrenia affects more than 1% of the world's population, causing great personal suffering and socioeconomic burden. These costs associated with schizophrenia necessitate inquiry into the causes and treatment of the illness but generate ethical challenges related to the specific nature and deficits of the illness itself. In this article, we present a systematic analysis of narrative data from 63 people living with the illness of schizophrenia collected through semistructured interviews about their attitudes, beliefs, and experiences related to psychiatric research. In (...) the comments of these individuals, half of whom had had prior personal experience in research protocols, we identified factors influencing openness toward research involvement as well as deterrents that appear to lessen interest in participation. Clear response pattern differences emerged between those with prior research experience and those without such experience. In the discussion, we explore these key findings and outline the implications for safeguards in mental illness research. (shrink)

This article will examine how the notion of emotional authenticity is intertwined with the notions of naturalness and artificiality in the context of the recent debates about ‘neuro-enhancement’ and ‘neuro-psychopharmacology.’ In the philosophy of mind, the concept of authenticity plays a key role in the discussion of the emotions. There is a widely held intuition that an artificial means will always lead to an inauthentic result. This article, however, proposes that artificial substances do not necessarily result in inauthentic emotions. The (...) literature provided by the philosophy of mind on this subject usually resorts to thought experiments. On the other hand, the recent literature in applied ethics on ‘enhancement’ provides good reasons to include real world examples. Such case studies reveal that some psychotropic drugs such as antidepressants actually cause people to undergo experiences of authenticity, making them feel ‘like themselves’ for the first time in their lives. Beginning with these accounts, this article suggests three non-naturalist standards for emotions: the authenticity standard, the rationality standard, and the coherence standard. It argues that the authenticity standard is not always the only valid one, but that the other two ways of assessing emotions are also valid, and that they can even have repercussions on the felt authenticity of emotions. In conclusion, it sketches some of the normative implications if not ethical intricacies that accompany the enhancement of emotions. (shrink)

The NeuroGenderings project is reminiscent of an interdisciplinary program called Critical Neuroscience. But the steps towards a feminist/queer Critical Neuroscience are complicated by the problematic ways in which critical neuroscientists conceive of their critical practices. They suggest that we work and talk across disciplines as if neuroscientists were from Mars and social scientists from Venus, assigning the latter to the traditional feminine role of assuaging conflict. This article argues that brain science studies scholars need to clarify how we want to (...) frame our critical practices—a critique of what and for whom?—and promote interdisciplinarity. The challenge is to articulate a critical stance that could not be collapsed into the all-encompassing claims of neuroscience, Critical Neuroscience included. I suggest we shift focus: from enhanced communication to the study of controversies (but also non-controversies, failed controversies, etc.) and conflicts. I explore the productiveness of this shift through two examples: the non-controversial notion of brain plasticity, and the controversial question of whether gender identity formation in intersex people is a function of their brain or their genitals. Socializing neuroscience with insights from gender and science studies is good; highlighting the conflicting dimensions of social life in the same gesture is even better. (shrink)

The question of the psychopath's responsibility for his or her wrongdoing has received considerable attention. Much of this attention has been directed toward whether psychopaths are a counterexample to motivational internalism (MI): Do they possess normal moral beliefs, which fail to motivate them? In this paper, I argue that this is a question that remains conceptually and empirically intractable, and that we ought to settle the psychopath's responsibility in some other way. I argue that recent empirical work on the moral (...) judgments of psychopaths provides us with good reason to think that they are not fully responsible agents, because their actions cannot express the kinds of ill-will toward others that grounds attributions of distinctively moral responsibility. I defend this view against objections, especially those due to an influential account of moral responsibility that holds that moral knowledge is not necessary for responsibility. (shrink)

Recent work in neuroimaging suggests that some patients diagnosed as being in the persistent vegetative state are actually conscious. In this paper, we critically examine this new evidence. We argue that though it remains open to alternative interpretations, it strongly suggests the presence of consciousness in some patients. However, we argue that its ethical significance is less than many people seem to think. There are several different kinds of consciousness, and though all kinds of consciousness have some ethical significance, different (...) kinds underwrite different kinds of moral value. Demonstrating that patients have phenomenal consciousness — conscious states with some kind of qualitative feel to them — shows that they are moral patients, whose welfare must be taken into consideration. But only if they are subjects of a sophisticated kind of access consciousness — where access consciousness entails global availability of information to cognitive systems — are they persons, in the technical sense of the word employed by philosophers. In this sense, being a person is having the full moral status of ordinary human beings. We call for further research which might settle whether patients who manifest signs of consciousness possess the sophisticated kind of access consciousness required for personhood. (shrink)

Psychopaths are renowned for their immoral behavior. They are ideal candidates for testing the empirical plausibility of moral theories. Many think the source of their immorality is their emotional deficits. Psychopaths experience no guilt or remorse, feel no empathy, and appear to be perfectly rational. If this is true, sentimentalism is supported over rationalism. Here, I examine the nature of psychopathic practical reason and argue that it is impaired. The relevance to morality is discussed. I conclude that rationalists can explain (...) the moral deficits of psychopaths as well as sentimentalists. In the process, I identify psychological structures that underpin practical rationality. (shrink)

In considering the argument that Thomas Szasz advances on behalf of his claim that there is no mental illness, it becomes evident that despite his stated assumptions, moral valuations are necessarily tied up with assessment of disease. By following his remarks about differential diagnosis, it becomes evident that behavior is the occasion for differential diagnosis, that behavior determines which anatomical deviations are counted as diseases, and that Szasz's insistence on autonomy introduces his own moral assumptions into the concept of disease. (...) Consequently, although none of these considerations disproves Szasz's conclusions about the existence of mental illness, neither can his argument support the weight of that conclusion. CiteULike Connotea Del.icio.us What's this? (shrink)

The answer, if you look at this paper, is that writing is not good for your mental health, but I think that anything done excessively is not good for your mental health. This paper is about excessive reactions, which given the childhood he gives us a glimpse of he has a tendency toward. I, like him, am a mental health service user. However, all experiences of mental ill health are unique to the person concerned. We all have a tendency to (...) blame others for what has happened to us, for what has triggered our mental distress. For Jason, it is his mother who was triggered in to mental illness. For me it was an alcoholic husband, who was triggered in to alcoholism/mental illness by childhood events. This is a .. (shrink)

Norval Morris, Madness and the Criminal Law Chicago: The University of Chicago Press, 1982, 235 pp.

The ethics of medically-authorized limb amputation in individuals with Body integrity identity disorder (BIID) remains extremely controversial. One factor to consider is the putative locus of a disease process, and whether the proposed treatment--in this case, limb amputation—reasonably addresses the issue of what organ is mediating the patient’s complaint.

The making and taking of psychotropic drugs, whether on medical prescription or as self-medication, whether marketed by pharmaceutical companies or clamoured for by an anxious population, has been an integral part of the twentieth century. In this modern era of speed, uncertainty, pleasure and anguish the boundaries between healing and enhancing the mind by chemical means have been redefined. Long before Prozac would become a household name for an ‘emotional aspirin’ did consumers embrace the idea and practice of taking psychotropics (...) not only to treat mental illness but also to make them feel better about living in a modern world. The Freudian promise that each individual can remake him- or herself in the pursuit of health and happiness was helpful in promoting and legitimizing the idea and practice of seeking wellness on prescription. We will argue that the modern consumer-driven political culture of medicine will continue to transverse the boundaries of therapy and enhancement of the mind into the largely unexplored territories of human cognition and behaviour. However exciting, this endeavour will come at the cost of further widening the problem of iatrogenic addiction in the age of happiness pills as ‘botox’ for the mind. (shrink)