Online research in philosophy

The public, mental health consumers, as well as mental health practitioners wonder about what kinds of values mental health professionals hold, and what kinds of values influence psychiatric diagnosis. Are mental disorders socio-political, practical, or scientific concepts? Is psychiatric diagnosis value-neutral? What role does the fundamental philosophical question "How should I live?" play in mental health care? In his carefully nuanced and exhaustively referenced monograph, psychiatrist and philosopher of psychiatry John Z. Sadler describes the manifold kinds (...) of values and value judgements involved in psychiatric diagnosis and classification systems like the DSM. Professor Sadler takes the reader on a fascinating conceptual tour of the inner workings of psychiatric diagnosis, considering the role of science, culture, sexuality, politics, gender, technology, human nature, patienthood, and professions in building his vision of a more humane psychiatric diagnostic process. (shrink)

Flaws, biases, and ethical problems surrounding research and diagnosis may lead to inappropriate or inequitable treatments that exacerbate or fail to improve the misery that some individuals face due to their psychiatric conditions. Possible androcentric biases in the choice and definition of categories for diagnosis available in DSM-III-R may in turn influence the approaches of therapists to clients, particularly male therapists towards female clients. Androcentric bias in diagnosis, which may also be reflected in the values of (...) the psychiatrist, may lead to treatment regimens designed to make clients fit into roles, positions, and norms prescribed by a culture reflecting patriarchal values. Some acceptance of attempts by feminists to correct androcentrism are beginning to emerge in psychiatric diagnosis. Keywords: androcentrism, bias, feminist, psychiatry of biology CiteULike Connotea Del.icio.us What's this? (shrink)

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some (...) manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)

This paper explores the factors that contribute to the degree of a mood disorder patient’s self- insight, defined here as her understanding of the particular contingencies of her life that are responsive to her personal identity, interpersonal relationships, illness symptoms, and the relationship between these three necessary components of her lived experience. I consider three factors: (i) the Diagnostic Statistical Manual of Mental Disorders (DSM), (ii) the DSM culture, and (iii) the cognitive architecture of the self. I argue that the (...) symptom-based descriptions of mood disorders which eliminate the subjective features of the patient’s illness experience, in conjunction with the features of the DSM-culture and the cognitive biases that guide the patient, contribute to the impoverishment of her self-insight. The resulting impoverished self-insight would prevent her from developing resourceful responses to her interpersonal problems. In analyzing how these factors combine to influence the patient’s self-insight, I distinguish the therapeutic impact of receiving a psychiatric diagnosis, which facilitates patient’s clinical treatment, from its reflective impact, how the diagnosis informs the patient’s reflection on who she is, how her mental disorder is expressed, and how her interpersonal relationships proceed. I substantiate my argument by considering a patient’s memoir of psychopathology. (shrink)

Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment. However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a (...) sick role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society. The harmful dysfunction analysis of disorder is used to diagnose the sources of likely false positives, and propose potential remedies to the current weaknesses in the validity of diagnostic criteria. (shrink)

In psychiatry some disorders of cognition are distinguished from instances of normal cognitive functioning and from other disorders in virtue of their surface features rather than in virtue of the underlying mechanisms responsible for their occurrence. Aetiological considerations often cannot play a significant classificatory and diagnostic role, because there is no sufficient knowledge or consensus about the causal history of many psychiatric disorders. Moreover, it is not always possible to uniquely identify a pathological behaviour as the symptom of a (...) certain disorder, as disorders that are likely to differ both in their causal histories and in their overall manifestations may give rise to very similar patterns of behaviour. -/- Consider delusions as an example. It wouldn’t be correct to define delusions as those beliefs people form as a result of a neurobiological deficit and a hypothesis-evaluation deficit (as some versions of the two-factor theory of delusions suggest), because for some delusions no neurobiological deficit may be found, and reasoning biases and motivational factors may be contributors to the formation of the delusion (e.g. McKay et al., 2005). Moreover, it would be a mistake to define delusions as symptoms of schizophrenia alone, because they occur also in other disorders, including dementia, amnesia, and delusional disorders. Thus, aetiological considerations may appear in the description and analysis of delusions, but do not feature prominently in their definition. -/- In this paper I argue that the surface features used as criteria for the classification and diagnosis of disorders of cognition are often epistemic in character. I shall offer two examples: confabulations and delusions are defined as beliefs or narratives that fail to meet standards of accuracy and justification. Although classifications and diagnoses based on features of people’s observable behaviour are necessary at these early stages of neuropsychiatric research, given the variety of conditions in which certain phenomena appear, I shall attempt to show that current epistemic accounts of confabulations and delusions have limitations. Epistemic criteria can guide both research and clinical practice, but fail to provide sufficient conditions for the identification of delusions and confabulations, and fail to demarcate pathological from non-pathological narratives or beliefs. -/- Another limitation of current epistemic accounts – which I shall not address here – is the excessive focus on epistemic faults of confabulations and delusions at the expense of their epistemically neutral or advantageous features (see Bortolotti and Cox, 2009). This may lead to a misconception of delusions and confabulations, and to an oversimplification in the assessment of the needs of people who require clinical treatment for their psychotic symptoms. (shrink)

Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, Borderline, Histrionic, Narcissistic) (...) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the (...) role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the (...) role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the (...) role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the (...) role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

Lennard Davis’s Biocultural Critique of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to patients (...) who suffer from psychological distress. The history of medicine and psychiatry demonstrates that psychiatric diagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains. (shrink)

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the often (...) ambiguous nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria. (shrink)

This paper will consider the right not to know in the context of psychiatric disorders. It will outline the arguments for and against acquiring knowledge about the results of genetic testing for conditions such as breast cancer and Huntington’s disease, and examine whether similar considerations apply to disclosing to clients the results of genetic testing for psychiatric disorders such as depression and Alzheimer’s disease. The right not to know will also be examined in the context of the (...) class='Hi'>diagnosis of psychiatric disorders that are associated with stigma or for which there is no effective treatment. (shrink)

This article argues that traditional models of diagnosis are incomplete in their reliance on a models of certainty that are no longer tenable in a postmodern world. Further, it argues that the current form of diagnosis, as applied to psychiatric and affective disorders, reduces patient agency and reinscribes the effects of biopower.

Psychiatrists are frequently called upon to make assessments of the rationality or irrationality of persons for a variety of medical-legal purposes. A key category is that of evaluations of a patient's capacity to grant informed consent for a medical procedure. A diagnosis of mental illness is neither a necessary nor a sufficient condition for a finding of incompetence. The notion of competency to grant consent, which is a mixed psychiatric-legal concept, shares some features with philosophical conceptions of rationality, (...) but differs from them in a number of important respects. This article describes the actual practice of psychiatrists when making such judgments, along with the standards of competency they employ. A comparison is made between those notions of competency and predominant philosophical conceptions of rationality. (shrink)

Psychiatric Medicine has been accused justly of making its diagnoses on the patient's report of symptoms and the physician's subjective observations of the patient. The main problem has been the lack of reliable data compounded by the stigma of a mental diagnosis. More recently, third-party pressures have become an added threat to objectivity. New knowledge of brain function, especially neurotransmitters, and more specific and effective medication have made the need for accurate diagnoses more acute. Psychiatry has responded by (...) frequent and often controversial changes in its diagnostic criteria. Much of the controversy stems from a lack of accurate measurements to validate the diagnoses, thereby allowing for differences of opinion of a highly subjective nature. The problem is complicated by the chronic, but irrational, belief that there is a separation between mental and somatic illness. Keywords: calibration, diagnoses, objective vs. subjective, stigma, third-party CiteULike Connotea Del.icio.us What's this? (shrink)

In this article I examine some of the issues involved in taking psychiatric disorders as natural kinds. I begin by introducing a permissive model of natural kind-hood that at least prima facie seems to allow psychiatric disorders to be natural kinds. The model, however, hinges on there in principle being some grounding that is shared by all members of a kind, which explain all or most of the additional shared projectible properties. This leads us to the following question: (...) what grounding do psychiatric disorders qua natural kinds have? My principal method for examining the issue is a case study of a particular psychiatric disorder: the so-called “apathetic children.” I argue that there appear to be at least two competing models that both appeal to non-organic a grounding of the disorder. However, for other psychiatric disorders, such as Alzheimer’s disease, the evidence points toward an organic explanation of the disorder. I contend that what unites psychiatric disorders is not a distinctive type of grounding that all psychiatric disorders share, but the distinctive set of determinable properties that is shared by all psychiatric disorders. (shrink)

Now in its fourth edition, Rational Diagnosis and Treatment: Evidence-Based Clinical Decision-Making is a unique book to look at evidence-based medicine and the difficulty of applying evidence from group studies to individual patients._ The book analyses the successive stages of the decision process and deals with topics such as the examination of the patient,_the reliability of clinical data, the logic of diagnosis, the fallacies of uncontrolled therapeutic experience and the need for randomised clinical trials and meta-analyses. It is (...) the main theme of the book that, whenever possible, clinical decisions must be based on the evidence from clinical research, but the authors also explain the pitfalls of such research and the problems involved in applying evidence from groups of patients to the individual patient._ For this new edition, the sections on placebo and meta-analysis and on alternative medicine have been thoroughly updated, and there is more focus on insufficient reporting of harms of interventions. The sections on different research designs describe advantages and limitations, and the increased medicalisation and the effects of cancer screening on health people are noted. A section on academic freedom when clinicians collaborate with industry and ghost authors is added._ This essential reference work integrates the science and statistical approach of evidence-based medicine with the art and humanism of medical practice; distinguishing between data, sets of data, knowledge and wisdom, and their application. Such an intellectually challenging book is ideal for both medical students and doctors who require theoretical and practical clinical skills to help ensure that they apply theory in practice. (shrink)

In “Mad Narratives: Self-Constitutions Through the Diagnostic Looking Glass,” by using narrative approaches to the self, I explore how the diagnosis of mental disorder shapes personal identities and influences flourishing. My particular focus is the diagnosis grounded on the criteria provided by the Diagnostic Statistical Manual of Mental Disorders (DSM). I develop two connected accounts pertaining to the self and mental disorder. I use the memoirs and personal stories written by the subjects with a DSM diagnosis as (...) illustrations to bolster my claims. First, expanding on the narrative approaches to the self, I explain how narratives about a subject shape her self-constitution. I elucidate how this process is generated by drawing on research in developmental psychology, cognitive science, and social psychology. Next, using this account as a springboard, I argue that the DSM diagnosis of mental disorder serves as a source of narrative, entering into the patients’ autobiographical and social narratives. This plays an important role in the diagnosed subjects’ self-understanding, self-constitution and flourishing. In this vein, how mental disorders are classified is not only a theoretical question about accurately taxonomizing the various experiences related to mental distress but also an ethical question about which ways of talking about mental disorders will allow subjects to respond effectively to their psychological distress, to flourish and to live autonomous and fulfilling lives. Finally, I suggest that the DSM-based narratives wield a double-edged sword when it comes to the subject’s flourishing: On the one hand, there are problems with some DSM-based narratives that stem from the DSM diagnostic schema and the culture of DSM diagnoses. These problems render these DSM-based narratives unbeneficial for flourishing as they constrain the range of adoptive social, cognitive and emotional responses the subjects can give to their mental disorders. On the other hand, there are grounds to believe that some DSM-based narratives help subjects to flourish. For instance, they provide certainty to subjects' otherwise puzzling symptoms and help them reach out to others with similar experiences. Understanding how the DSM-based narratives can both benefit and harm will help us address problems with psychiatric diagnoses and the dissemination of knowledge about mental disorders in popular culture. The project aims to convince both philosophers and psychiatrists that no plausible theory of the self can be developed without attending to the topic of mental disorder and that no theory of mental disorder can be complete without devising the tools provided by the philosophical approaches to the self as well as developmental and social psychology. It also calls for methodological alterations in mental health ethics research, arguing that a careful scrutiny of mental disorder memoirs can advance the ethical underpinnings to the practice of psychiatry. (shrink)

Psychiatric ethics as professional and biomedical ethics -- The distinctiveness of the psychiatric setting -- Psychiatric ethics as virtue ethics -- Elements of a gender-sensitive ethics for psychiatry -- Some virtues for psychiatrists -- Character and social role -- Case studies in psychiatric virtues.

Chronic disorders of consciousness, particularly the vegetative and the minimally conscious states, pose serious diagnostic challenges to neurologists and clinical psychologists. A look at the concept of “diagnosis” in medicine reveals its social construction: While medical categorizations are intended to describe facts in the real world, they are nevertheless dependent on conventions and agreements between experts and practitioners. For chronic disorders of consciousness in particular, the terminology has proven problematic and controversial over the years. Novel research utilizing functional brain (...) imaging has demonstrated that a substantial number of patients retain their capabilities to communicate by brain activity even when they are incapable of classic verbal and nonverbal responses due to the dysfunction of their motor behavior. Moreover, thorough diagnostic assessments constitute the foundations for suitable rehabilitation measures. Thus, ethical arguments support the claim that the potential of emerging methods for communication via brain activity should be evaluated comprehensively in patients with chronic disorders of consciousness, once the technological methodology for this endeavor progresses to a reliable and affordable stage. (shrink)

Ethical issues are pivotal to the practice of psychiatry. Anyone involved in psychiatric practice and mental healthcare has to be aware of the range of ethical issues relevant to their profession. An increased professional commitment to accountability, in parallel with a growing "consumer" movement has paved the way for a creative engagement with the ethical movement. The bestselling 'Psychiatric Ethics' has carved out a niche for itself as the major comprehensive text and core reference in the field, covering (...) a range of complex ethical dilemmas which face clinicians and researchers in their everyday practice. This new edition takes a fresh look at recent trends and developments at the interface between ethics and psychiatric practice. Coming ten years after the third edition, the editors have observed several emerging aspects of psychiatric practice requiring coverage, as a result, 5 new chapters have been added, including cutting edge topics - such as neuroethics. All other chapters have been fully revised and updated. The book will continue to be essential reading for psychiatrists, psychologists, other mental health professionals, and bioethicists, as well as of interest to policy makers, managers and lawyers. (shrink)

In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and gender (...) issues; rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)

This article aims to clarify the notion of a psychiatric disability. The article uses conceptual analysis, examining and applying established definitions of (general) disability to psychiatric disabilities. This analysis reveals that disability as inability to perform according to expectations or norms is related to impairment as deviation from the (statistical) norm, while disability as inability to achieve (personal) goals is related to impairment as deviation from the (personal) ideal. These two views of impairment and disability are distinct from (...) the self-organization view of impairment as disrupted self-creation or disrupted self-repair and of disability as disrupted whole person self-compensation (in relation to an impairment). All these three views of disability pertain to psychiatric disability. Although there is nothing necessarily psychiatric about psychiatric disability other than the psychiatric impairment related to it, the life course and life circumstances typical of many people with (severe) psychiatric disorders may lead to disability and may thus confer some (psychiatric) specificity on this disability. This analysis may facilitate research on specific psychiatric disabilities and a broader scope for psychiatric rehabilitation. (shrink)

The effects of mental disorder are apparent and pervasive, in suffering, loss of freedom and life opportunities, negative impacts on education, work satisfaction and productivity, complications in law, institutions of healthcare, and more. With a new edition of the 'bible' of psychiatric diagnosis - the DSM - under developmental, it is timely to take a step back and re-evalutate exactly how we diagnose and define mental disorder. This new book by Derek Bolton tackles the problems involved in the (...) definition and boundaries of mental disorder. It addresses two main questions regarding mental illness. Firstly, what is the basis of the standards or norms by which we judge that a person has a mental disorder - that the person's mind is not working as it should, that their mental functioning is abnormal? Controversies about these questions have been dominated by the contrast between norms that are medical, scientific or natural, on the one hand, and social norms on the other. The norms that define mental disorder seem to belong to psychiatry, to be medical and scientific, but are they really social norms, hijacked and disguised by the medical profession? Secondly, what is the validity of the distinction between mental disorder and order, between abnormal and normal mental functioning? To what extent, notwithstanding appearances, does mental disorder involve meaningful reactions and problem-solving? These responses may be to normal problems of living, or to not so normal problems - to severe psycho-social challenges. Is there after all order in mental disorder? With the closing of asylums and the appearance of care in the community, mental disorder is now in our midst. While attempts have been made to define clearly a concept of mental disorder that is truly medical as opposed to social, there is increasing evidence that such a distinction is unviable - there is no clear line between what is normal in the population and what is abnormal. 'What is Mental Disorder?' reviews these various crucial developments and their profound impact for the concept and its boundaries in a provocative and timely book. (shrink)

Psychiatry is a discipline on the border between the biomedical sciences on the one hand and the humanities and social sciences (most notably psychology and anthropology) on the other. This unique position undoubtedly contributes to the attractiveness of psychiatry as a medical specialism for many young doctors, but it also causes significant problems. Unlike other medical disciplines, in which the definitions of diseases are based on objective, measurable pathophysiological underpinnings, psychiatric diagnosis and classification has been based on descriptions (...) of inherently subjective mental and behavioral symptoms that are supposed to be deviant from "normal" psychology or behavior, as reflected in the current .. (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)

IntroductionThose in mental health-related consumer movements have made clear their demands for humane treatment and basic civil rights, an end to stigma and discrimination, and a chance to participate in their own recovery. But theorizing about the politics of recognition, 'recognition rights' and epistemic justice, suggests that they also have a stake in the broad cultural meanings associated with conceptions of mental health and illness.ResultsFirst person accounts of psychiatric diagnosis and mental health care (shown here to represent 'counter (...) stories' to the powerful 'master narrative' of biomedical psychiatry), offer indications about how experiences of mental disorder might be reframed and redefined as part of efforts to acknowledge and honor recognition rights and epistemic justice. However, the task of cultural semantics is one for the entire culture, not merely consumers. These new meanings must be negotiated. When they are not the result of negotiation, group-wrought definitions risk imposing a revision no less constraining than the mis-recognizing one it aims to replace. Contested realities make this a challenging task when it comes to cultural meanings about mental disorder. Examples from mental illness memoirs about two contested realities related to psychosis are examined here: the meaninglessness of symptoms, and the role of insight into illness. They show the magnitude of the challenge involved - for consumers, practitioners, and the general public - in the reconstruction of these new meanings and realities.ConclusionTo honor recognition rights and epistemic justice acknowledgement must be made of the heterogeneity of the effects of, and of responses to, psychiatric diagnosis and care, and the extent of the challenge of the reconstructive cultural semantics involved. (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)

‘Ulysses contracts’ are an instrument through which a psychiatric patient may prearrange involuntary commitments to be put into effect if the patient satisfies certain diagnostic criteria in the future. Proposals for Ulysses contracts typically impose numerous safeguards. This paper argues against the intuitively plausible safeguard which permits only presently remitted patients to contract. Instead of requiring a patient's remission, it is argued that the appropriate safeguard is the patient's ability, whether remitted or not, to offer good reasons for wishing (...) to contract. In short, what matters is not an executive's character, but an executive's reasons, and a bad executive may have good reasons. Attempts to deny the accessibility of good reasons in unremitted patients are rejected on the ground that psychiatric diagnosis requires psychiatrists to be able to distinguish between good and bad reasons in both remitted and unremitted patients. If psychiatrists cannot do that, psychiatric diagnosis is impossible. (shrink)

Linda Morrison brings the voices and issues of a little-known, complex social movement to the attention of sociologists, mental health professionals, and the general public. The members of this social movement work to gain voice for their own experience, to raise consciousness of injustice and inequality, to expose the darker side of psychiatry, and to promote alternatives for people in emotional distress. Talking Back to Psychiatry explores the movement's history, its complex membership, its strategies and goals, and the varied response (...) it has received from psychiatry, policy makers, and the public at large. (shrink)

Labeling theory as ideology and as science: Scheff, T. J. Schizophrenia as ideology. Scheff, T. J. On reason and sanity. Scheff, T. J. The labeling theory of mental illness. Greenley, J. R. Alternate views of the psychiatrist's role. Temerlin, M. K. Suggestion effects in psychiatric diagnosis. Rosenhan, D. L. On being sane in insane places.--Changing the system: Scheff, T. J. Labeling, emotion, and individual change. Schatzman, M. Paranoia or persecution: the case of Schreber. Sidel, R. Mental diseases in (...) China and their treatment. Obeysekere, G. The idiom of demonic possession. (shrink)

This paper examines Ian Hacking's analysis of the looping effects of psychiatric classifications, focusing on his recent account of interactive and indifferent kinds. After explicating Hacking's distinction between 'interactive kinds' (human kinds) and 'indifferent kinds' (natural kinds), I argue that Hacking cannot claim that there are 'interactive and indifferent kinds,' given the way that he introduces the interactive-indifferent distinction. Hacking is also ambiguous on whether his notion of interactive and indifferent kinds is supposed to offer an account of classifications (...) or objects of classification. I argue that these conceptual difficulties show that Hacking's account of interactive and indifferent kinds cannot be based on - and should be clearly separated from - his distinction between interactive kinds and indifferent kinds. In clarifying Hacking's account, I argue that interactive and indifferent kinds should be regarded as objects of classification (i.e., kinds of people) that can be identified with reference to a law-like biological regularity and are aware of how they are classified. Schizophrenia and depression are discussed as examples. I subsequently offer reasons for resisting Hacking's claim that the objects of classification in the human sciences - as a result of looping effects - are 'moving targets'. (shrink)

Hájek has recently presented the following paradox. You are certain that a cable guy will visit you tomorrow between 8 a.m. and 4 p.m. but you have no further information about when. And you agree to a bet on whether he will come in the morning interval (8, 12] or in the afternoon interval (12, 4). At first, you have no reason to prefer one possibility rather than the other. But you soon realise that there will definitely be a future (...) time at which you will (rationally) assign higher probability to an afternoon arrival than a morning one, due to time elapsing. You are also sure there may not be a future time at which you will (rationally) assign a higher probability to a morning arrival than an afternoon one. It would therefore appear that you ought to bet on an afternoon arrival. The paradox is based on the apparent incompatibility of the principle of expected utility and principles of diachronic rationality which are prima facie plausible. Hájek concludes that the latter are false, but doesn't provide a clear diagnosis as to why. We endeavour to further our understanding of the paradox by providing such a diagnosis. (shrink)

Neuroscience and psychiatry -- Psychotherapy and psychiatry -- Diagnosis in psychiatry -- The boundaries of mental disorders -- Mood and mental illness -- Psychiatry's problem children -- Evidence-based psychiatry -- Psychiatric drugs: miracles and limitations -- Talk therapies: the need for a unified method -- Psychiatry in practice -- Training psychiatrists -- Psychiatry and society -- The future of psychiatry.

Abstract Recently, some philosophers of psychiatry (viz., Rachel Cooper and Dominic Murphy) have analyzed the issue of psychiatric classification. This paper expands upon these analyses and seeks to demonstrate that a consideration of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) can provide a rich and informative philosophical perspective for critically examining the issue of psychiatric classification. This case is intended to demonstrate the importance of history for philosophy of psychiatry, and more generally, the (...) potential benefits of historically-informed approaches to philosophy of science. (shrink)

The goal of this article is to put to the fore the importance and the relevance of the “second persons” in the framework of the relational ethics where the person has being related as a primacy over the individual as an isolated subject. While using the psychiatric team of an emergency unit (E.R.I.C.) as a leading thread we seek to show the anthropology of being related, which underlines the practical ethics of such emergency team.

Essential Philosophy of Psychiatry is a concise introduction to the growing field of philosophy of psychiatry. Divided into three main aspects of psychiatric clinical judgement, values, meanings and facts, it examines the key debates about mental health care, and the philosophical ideas and tools needed to assess those debates, in six chapters. In addition to outlining the state of play, Essential Philosophy of Psychiatry presents a coherent and unified approach across the different debates, characterized by a rejection of reductionism (...) and an emphasis on the ineliminability of uncodified skilled judgement. The first part, Values, outlines the debate about whether diagnosis of mental illness is essentially value-laden and argues that the prospects for reducing illness or disease to plainly factual matters are poor. It also explains the important role of skilled contextual judgement, rather than a principles-based deduction, in ethical judgement. The second part, Meanings, examines the central role of understanding and a shared first person perspective, both against attempts to reduce meaning to basic information-processing mechanisms and to explain away the difficulties of understanding psychopathology in recent models of delusion. The third part, Facts, shows the importance of uncodified clinical judgements, both in assessing the validity of psychiatric taxonomy and in the application of Evidence Based Medicine. Despite advances in the codifaction of practice and operationalism of diagnosis, an element of judgement remains in the assessment both of what, at one level, is good evidence for diagnosis and treatment and what, at a higher level, is good evidence for the validity of classification overall. (shrink)

A number of philosophers have argued that psychiatric delusions threaten Donald Davidson's rationalist account of intentional agency. I argue that a careful look at both Davidson's account and psychiatric delusions shows that, in fact, the two are perfectly compatible. Indeed, a Davidsonian perspective on psychiatric delusions proves remarkably illuminating.

According to many researchers, it is inevitable and obvious that psychiatric illnesses are biological in nature, and that this is the rationale behind the numerous neuroimaging studies of individuals diagnosed with mental disorders. Scholars looking at the history of psychiatry have pointed out that in the past, the origins and motivations behind the search for biological causes, correlates, and cures for mental disorders are thoroughly social and historically rooted, particularly when the diagnostic category in question is the subject of (...) controversy within psychiatry. This is obscured by neuroimaging studies that drive researchers to proclaim 'revolutions' in psychiatry, namely in the DSM. Providing neuroimaging evidence to support the contention that a condition is 'real' is likely to be extremely influential, as has been extensively discussed in the neuroethics literature. This type of evidence will also reinforce the pre-existing beliefs of those researchers or clinicians who are already expecting a biological description. The uncritical credence given to neuroimaging research is an ethical issue, not in its potential for contributing to misdiagnosis per se but because of the motivations that often drive this research. My claim is that this research should proceed with an awareness of presumptions and motivations underlying the field as a whole, in addition to an explicit focus on the past and potential future consequences of classification and diagnosis on the groups of individuals under study. (shrink)

A diagnosis of schizophrenia is often taken to denote a state of global irrationality within the psychiatric paradigm, wherein psychotic phenomena are seen to equate with a lack of mental capacity. However, the little research that has been undertaken on mental capacity in psychiatric patients shows that people with schizophrenia are more likely to experience isolated, rather than constitutive, irrationality and are therefore not necessarily globally incapacitated. Rational suicide has not been accepted as a valid choice for (...) people with schizophrenia due in part to a belief that characteristic irrationality prevents autonomous decision-making. Since people with schizophrenia are often seen to lack insight into the nature of their disorder, both psychiatric and ethical perspectives generally presume that suicidal acts result directly from mental illness itself and not from second-order desires. In this article, I challenge notions of global irrationality conferred by a diagnosis of schizophrenia and argue that, where delusional beliefs are unifocal, schizophrenia does not necessarily lead to a state of mental incapacity. I then attempt to show that people with schizophrenia can sometimes be rational with regard to suicide, where this decision stems from a realistic appraisal of psychological suffering. (shrink)

I show how much psychiatric disability is informed by trauma, marginalization, sexist norms, social inequalities, concepts of irrationality and normalcy, oppositional mind-body dualism, and mainstream moral values. Drawing on feminist discussion of physical disability, I present a feminist theory of psychiatric disability that serves to liberate not only those who are psychiatrically disabled but also the mind and moral consciousness restricted in their ranges of rational possibilities.

Kanaan and McGuire elegantly describe three challenges facing the use of fMRI to uncover cognitive mechanisms. They shows how these challenges ramify in the case of identifying the mechanisms responsible for psychiatric disorders. In this commentary, I would like to raise another difficulty for fMRI that also appears to ramify in similar cases. This is that there are good reasons for doubting one of the assumptions on which many fMRI studies are based: that neural mechanisms are always and everywhere (...) sufficient for cognition. I suggest that in the case of the mechanisms underlying psychiatric disorders, this assumption should be doubted. I do not dispute that a malfunctioning neural mechanism is likely to be a necessary component of a psychiatric disorder—as Kanaan and McGuire say, the experimental evidence from cognitive neuropsychiatry gives us excellent reasons to think that this is so. My question is whether a story only in terms of these neural mechanisms is sufficient to explain the mechanism of a psychiatric disorder. Is the reduction, projected by cognitive neuropsychiatry, of psychiatric disorders to disorders in neural functioning even in principle possible? Drawing on recent concerns about the location of mental states, I argue that such a reduction is likely to fail. Even if the considerable problems raised by Kanaan and McGuire for fMRI could be addressed, we have no reason to think that the mechanisms involved in psychiatric disorders are entirely neural, and that fMRI, or even a perfect science-fiction brain-scanner, would be capable of uncovering them. Psychiatric disorders, like numerous other cognitive processes, are liable to cross the brain–world boundary in such a promiscuous way as to be resistant to neural reduction. (shrink)

Radical skepticism about the external implies that no belief about the external is even prima facie justified. A theoretical reply to skepticism has four stages. First, show which theories of epistemic justification support skeptical doubts (show which theories, given other reasonable assumptions, entail skepticism). Second, show which theories undermine skeptical doubts (show which theories, given other reasonable assumptions, do not support the skeptic’s conclusion). Third, show which of the latter theories (which non-skeptical theory) is correct, and in so doing show (...) that all of the rival theories of justification, skeptical and non-skeptical alike, are mistaken. Fourth, explain why skeptical doubts are sometimes (or sometimes merely seem) intuitive, and thereby accommodate skeptical doubts without capitulation. Michael Williams has pioneered the very idea of a theoretical reply. A theoretical diagnosis consists in just the first two stages. An adequate reply, which is correct at each stage, would rebut the skeptic entirely. Williams’ own reply, I argue, is inadequate. I offer in its place an exhaustive and accurate diagnosis of skepticism. I distinguish four kinds of skepticism and five theories of justification. I then show which theories do, and which theories do not, support which kinds of skepticism. (shrink)

Michael Williams believes that scepticism about the externalworld seems compelling only because the considerations that underpin it are thoughtto be ``mere platitudes'''' about e.g., the nature and source of human knowledge, and hence,that if it shown through a ``theoretical diagnosis'''' that it does not rest upon suchplatitudes, but contentious theoretical considerations that we are no means bound toaccept, we can simply dismiss the absurd sceptical conclusion. Williams argues thatscepticism does presuppose two extremely contentious doctrines, however, he admits (...) thatif these doctrines are themselves motivated by ``platitudes'''' then scepticism follows. Iaddress Williams''s arguments for thinking scepticism must presuppose these doctrines,and argue that he overlooks a way that they can be seen as motivated by mere platitudes.Thus, I conclude that William''s novel rejection of scepticism fails. (shrink)

This paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a 'dual role' dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has (...) to be balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register-based epidemiology, lack of consent may be counter-balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders. (shrink)

Extant business research has not addressed the ethical treatment of individuals with psychiatric disabilities. This article will describe previous research on individuals with psychiatric disabilities drawn from rehabilitation, psychological, managerial, legal, as well as related business ethics writings before presenting a framework that illustrates the dynamics of (un)ethical behavior in relation to the employment of such individuals. Individuals with psychiatric disabilities often evoke negative reactions from those in their environment. Lastly, we provide recommendations for how employees and (...) organizations can become more proactive in providing individuals with such disabilities equal employment opportunities for both access and accommodation in the workplace. (shrink)

rarely discussed or defined in psychiatric circles. This paper reviews previous conceptual analyses of the term by philosophers and psychiatrists, and examines its use in ordinary discourse. A series of characteristics which comprise the conceptual core of the term when it is unambiguously applied in interpersonal settings are proposed. Manipulation is contrasted with other behavior control methods such as rational persuasion and coercion, with emphasis on the role played by deception and the communicative context in which the manipulative transaction (...) occurs. It is argued that manipulative behavior is fundamentally intentional, and the usefulness of the concept of ‘unconscious manipulation’ is questioned. Though the proposal that Manipulative Personality Disorder be formally recognized as a new diagnostic category is rejected, it is urged that the concept of manipulation receive wider attention and discussion within the mental health community Keywords: diagnosis, disease, manipulation, philosophy, psychiatry CiteULike Connotea Del.icio.us What's this? (shrink)

The purpose of this paper is to offer a diagnosis and a resolution to generality problem. I state the generality problem and suggest a distinction between criteria of relevance and what I call a theory of determination. The generality problem may concern either of these. While plausible criteria of relevance would be convenient for the externalist, he does not need them. I discuss various theories of determination, and argue that no existing theory of determination is plausible. This provides a (...) case for the no determination view: there are no facts that determine relevant types. This is the diagnosis of the generality problem. The externalist, however, may embrace the no determination view. This is what provides a resolution to the generality problem. (shrink)

: A fascinating criticism of abortion occasioned by prenatal diagnosis of potentially disabling traits is that the complex of test-and-abortion sends a morally disparaging message to people living with disabilities. I have argued that available versions of this "expressivist" argument are inadequate on two grounds. The most fundamental is that, considered as a practice, abortions prompted by prenatal testing are not semantically well-behaved enough to send any particular message; they do not function as signs in a rule-governed symbol system. (...) Further, even granting, for the sake of argument, the expressive power of testing and aborting, it would not be possible, contra the argument's proponents, to distinguish between abortions undertaken because of beliefs about the disabling conditions the fetus might face as a child and abortions undertaken for many other possible reasons--e.g., because of the poverty the fetus would face or the increase in family size that the birth of a new child would occasion. Here, I respond to criticisms of those arguments, and propose and defend another: the expressivist argument cannot, in general, distinguish successfully between abortion and therapy as modalities for responding to disabilities. (shrink)

A new diagnostic system for organic psychiatry is presented. We first define "organic psychiatry", and then give the theoretical basis for conceiving organic psychiatric disorders in terms of hypothetical psychopathogenetic processes, HPP:s. Such hypothetical disorders are not strictly identical to the clusters of symptoms in which they typically manifest themselves, since the symptoms may be concealed or modified by intervening factors in non typical circumstances and/or in the simultaneous presence of several disorders. The six basic disorders in our system (...) are Astheno Emotional Disorder (AED), Somnolence Sopor Coma Disorder (SSCD), Hallucination Coenestopathy Depersonalisation Disorder (HCDD), Confusional Disorder (CD), Emotional Motivational Blunting Disorder (EMD) and Korsakoff's Amnestic Disorder (KAD). We describe their usual etiologies, their typical symptoms and course, and some forms of interaction between them. (shrink)

This article explores the possibility that there is a parental duty to use preimplantation genetic diagnosis (PGD) for the medical benefit of future children. Using one genetic disorder as a paradigmatic example, we find that such a duty can be supported in some situations on both ethical and legal grounds. Our analysis shows that an ethical case in favor of this position can be made when potential parents are aware that a possible future child is at substantial risk of (...) inheriting a serious genetic condition. We further argue that a legal case for a duty to use PGD for medical benefit can be made in situations in which potential parents have chosen to conceive through in vitro fertilization and know that any children conceived are at substantial risk of having a serious genetic condition. (shrink)

It is argued that the common definition of diagnosis as the determination of the nature of a disease is misleading. Many diagnoses are not the names of disease entities. This finding reflects the integral relation of the diagnostic task to the rest of clinical reasoning. Diagnosis has no separate goal of its own, in particular it does not have the goal of determining the nature of a disease. Instead, diagnosis contributes to the general goals of clinical medicine. (...) Any attempt to model diagnostic reasoning abstracted from the rest of clinical reasoning will yield an inadequate representation of diagnosis. Such a distortion of medical reasoning will blind us to whatever implications an adequate epistemology of medicine may have for an understanding of the relation between theoretical and practical knowledge in other contexts. (shrink)

Preimplantation genetic diagnosis (PGD) raises serious moral questions concerning the parent-child relationship. Good parents accept their children unconditionally: they do not reject/attack them because they do not have the features they want. There is nothing wrong with treating a child as someone who can help promote some other worthwhile end, providing the child is also respected as an end in him or herself. However, if the child's presence is not valued in itself, regardless of any further benefits it brings, (...) the child is not being treated as an end in the full sense of the term. In this paper, I argue that these principles apply to human embryos, as well as to born human offspring: the human moral subject is a bodily being, whose interests and rights begin with the onset of his or her bodily life. The rights of the living, bodily human individual include a right not to be attacked/abandoned because of his or her genetic profile. PGD is harmful to the parent-child relationship, and we give mixed messages to parents by expecting them to show unconditional commitment to offspring after birth, while inviting them to take a very different approach at the prenatal stage. (shrink)

Differential diagnosis of motor symptoms, for example, akinesia, may be difficult in clinical neuropsychiatry. Symptoms may be either of neurologic origin, for example, Parkinson's disease, or of psychiatric origin, for example, catatonia, leading to a so-called “conflict of paradigms.” Despite their different origins, symptoms may appear more or less clinically similar. Possibility of dissociation between origin and clinical appearance may reflect functional brain organisation in general, and cortical-cortical/subcortical relations in particular. It is therefore hypothesized that similarities and differences (...) between Parkinson's disease and catatonia may be accounted for by distinct kinds of modulation between cortico-cortical and cortico-subcortical relations. Catatonia can be characterized by concurrent motor, emotional, and behavioural symptoms. The different symptoms may be accounted for by dysfunction in orbitofrontal-prefrontal/parietal cortical connectivity reflecting “horizontal modulation” of cortico-cortical relation. Furthermore, alteration in “top-down modulation” reflecting “vertical modulation” of caudate and other basal ganglia by GABA-ergic mediated orbitofrontal cortical deficits may account for motor symptoms in catatonia. Parkinson's disease, in contrast, can be characterized by predominant motor symptoms. Motor symptoms may be accounted for by altered “bottom-up modulation” between dopaminergic mediated deficits in striatum and premotor/motor cortex. Clinical similarities between Parkinson's disease and catatonia with respect to akinesia may be related with involvement of the basal ganglia in both disorders. Clinical differences with respect to emotional and behavioural symptoms may be related with involvement of different cortical areas, that is, orbitofrontal/parietal and premotor/motor cortex implying distinct kinds of modulation – “vertical” and “horizontal” modulation, respectively. Key Words: Bottom-up modulation; catatonia; horizontal modulation; Parkinson's disease; top-down modulation; vertical modulation. (shrink)

An increase in autonomy and freedom is often considered one ofthe main arguments in favour of a broad use of genetic testing.Starting from Gerald Dworkin's reflections on autonomy and choicethis article examines some of the implications which accompanythe increase in choices offered by prenatal genetic diagnosis.Although personal autonomy and individual choice are importantaspects in the legitimation of prenatal genetic diagnosis, itseems clear that an increase in choice offered by prenatalgenetic diagnosis also leads to various implications that maynegatively (...) influence the freedom of the persons involved. (shrink)

Objective : Pre-implantation genetic diagnosis (PGD) has been utilized by assisted reproductive technology (ART) to genetically screen embryos before placement in the uterus. However, many objections have been raised against the genetic screening of embryos, giving the practice an uncertain ethical, legal, and social status. Our aim was, therefore, to survey the possible presence and compliance to any legislation for PGD in the existing 60 in vitro fertilization (IVF) centres in the Gulf Cooperative Council (GCC) countries as well as (...) the availability of such a technological service. Methods : The study was performed in the department of biochemistry at King Faisal University between the periods Mar 2006 to Nov 2007. A questionnaire, in the form of a table, was sent to responsible persons of all 60 IVF centres and health authorities in the GCC countries. The collected data about the regulations and guidelines for the PGD program was analyzed using SPSS software package version 12.0 and the level of significance was set at P Results: 18 respondents, 16 IVF centres and 2 health authorities (26.87% of total) participated in the survey. The PGD techniques, mainly FISH analyses, were practiced in three centres in Saudi Arabia and one centre in the UAE. The major provider of PGD was King Faisal Specialist Hospital and Research Centre in Riyadh where more than 300 PGD tests had been performed. Whilst some regulations and guidelines have been introduced to IVF centres in all GCC countries, their implementations were left to the discretion of the treating centre. Conclusions : PGD services in the GCC countries were under-utilized due to the high cost of tests, the sophisticated technology involved and the poor returns of the investment. As a result of some deficiencies in the legislations which regulated PGD, the medical teams involved often faced difficulties on what rights to exercise in various PGD cases. (shrink)

Executive function has become an important concept in explanations of psychiatric disorders, but we currently lack comprehensive models of normal executive function and of its malfunctions. Here we illustrate how defeasible logical analysis can aid progress in this area. We illustrate using autism and attention deficit hyperactivity disorder (ADHD) as example disorders, and show how logical analysis reveals commonalities between linguistic and non-linguistic behaviours within each disorder, and how contrasting sub-components of executive function are involved across disorders. This analysis (...) reveals how logical analysis is as applicable to fast, automatic and unconscious reasoning as it is to slow deliberate cogitation. (shrink)

Psychiatric research is advancing rapidly, with studies revealing new investigative tools and technologies that are aimed at improving the treatment and care of patients with psychiatric disorders. However, the ethical framework in which such research is conducted is not as well developed as we might expect. In this paper we argue that more thought needs to be given to the principles that underpin research in psychiatry and to the problems associated with putting those principles into practice. In particular, (...) we comment on some of the difficulties posed by the twin imperatives of ensuring that we respect the autonomy and interests of the research subject and, at the same time, enable potentially beneficial psychiatric research to flourish. We do not purport to offer a blueprint for the future; we do, however, seek to advance the debate by identifying some of the key questions to which better answers are required. (shrink)

Classification shapes medicine and guides its practice. As clinicians classify symptoms and illnesses, they trigger a range of actions and consequences. The assignment of particular disease labels is linked to both therapeutic and social responses. However, the classifications of medicine, natural though they may seem, contain significant social content, and are arrived at via a number of cultural framing devices (Aronowitz 2008). This article will explore the social intent and construction of classification and their embodiment in medical diagnosis.Effective classification (...) recognizes difference as well as similarity. By classifying, we are putting items together that have more in common with one another than they .. (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)

I was delighted to be asked to comment on Peter Zachar’s paper, partly because he presents an elegant proposal for how personality disorders (PD) might be considered to fit into a broadly medical conception of disorder, but also because the overlap between moral and clinical elements of disorder, and more broadly moral and clinical psychiatric kinds, seems to me to be a question central to the theory and practice of psychiatry. The moral context of diagnosis and treatment is (...) a question not just in the PD field (Pearce and Pickard 2009, 2010). The fact that over half of prisoners in the United Kingdom have a PD and a similar number can be diagnosed with a neurotic disorder (Singleton, Meltzer, and Gatward 1998) .. (shrink)

Clinical decisionmaking includes reasoning from prescientific or scientific theories, reasoning from uncontrolled or controlled experience, and reasoning based on empathic understanding and moral beliefe. The development of contemporary clinical thinking is discussed, and it is found that successive generations of medical practitioners have had different views of the rationality and relative importance of these modes of reasoning: that which is considered rational by one generation of doctors is sometimes denounced by the next. The author's book, Rational Diagnosis and Treatment (...) , which is an example of clinical thinking in the 1960s and early 70s, is used to illustrate one particular view of clinical decisionmaking. Keywords: rational, clinical decisionmaking, biological theory, controlled clinical studies, empathic understanding, ethical reasoning CiteULike Connotea Del.icio.us What's this? (shrink)

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has for decades been a locus of dispute between ardent defenders of its scientific validity and vociferous critics who charge that it covertly cloaks disputed moral and political judgments in scientific language. This essay explores Alasdair MacIntyre's tripartite typology of moral reasoning—"encyclopedia," "genealogy," and "tradition"—as an analytic lens for appreciation and critique of these debates. The DSM opens itself to corrosive neo-Nietzschean "genealogical" critique, such an analysis holds, (...) only insofar as it is interpreted as a presumptively objective and context-independent encyclopedia free of the contingencies of its originating communities. A MacIntyrean tradition-constituted understanding of the DSM, on the other hand, helpfully allows psychiatric nosology to be understood both as "scientific" and, simultaneously, as inextricable from the political and moral interests—and therefore the moral successes and moral failures—of the psychiatric guild from which it arises. (shrink)

At this point in time, it is hard to say which consequences for the concept of mental illness result from modern genetics. Current research projects are trying to find significant statistical correlations between the diagnosis of a disease and a gene locus or an endophenotype. Up until now, there has not been any identification of alleles or mutations causing mental illness. In the meantime, the relations between the genetic basis and the disease are given the term genetic vulnerability as (...) a placeholder; this concept simplifies the complex relations between the DNA and even the simplest cell functions observed in modern genetics. According to complex gene models like the systemic theory of DNA, it will not be possible to identify the genetic factors without a precise knowledge of the factors which modulate the gene expression. The significance of genetics as part of the concept of mental illness will not be able to be defined without further progress in developmental biology and psychology. Currently, psychological theory fails to acknowledge the complexity of the relationship between the DNA and the environment. Some starting points from which to develop such an understanding can be received from developmental studies and studies of the psychophylogenesis . An interdisciplinary concept of the biological basis of the psyche is needed. (shrink)

This paper provides an interpretation, based on the social systems theory of German sociologist Niklas Luhmann, of the recent paradigmatic shift of mental health care from an asylum-based model to a community-oriented network of services. The observed shift is described as the development of psychiatry as a function system of modern society and whose operative goal has moved from the medical and social management of a lower and marginalized group to the specialized medical and psychological care of the whole population. (...) From this theoretical viewpoint, the wider deployment of the modern social order as a functionally differentiated system may be considered to be a consistent driving force for this process; it has made asylum psychiatry overly incompatible with prevailing social values (particularly with the normative and regulative principle of inclusion of all individuals in the different functional spheres of society and with the common patterns of participation in modern function systems) and has, in turn, required the availability of psychiatric care for a growing number of individuals. After presenting this account, some major challenges for the future of mental health care provision, such as the overburdening of services or the overt exclusion of a significant group of potential users, are identified and briefly discussed. (shrink)

A recent literature review of commentaries and ‘state of the art’ articles from researchers in psychiatric genetics (PMG) offers a consensus about progress in the science of genetics, disappointments in the discovery of new and effective treatments, and a general optimism about the future of the field. I argue that optimism for the field of psychiatric molecular genetics (PMG) is overwrought, and consider progress in the field in reference to a sample estimate of US National Institute of Mental (...) Health funding for this paradigm for the years 2008 and 2009. I conclude that the amounts of financial investment in PMG is questionable from an ethical perspective, given other research and clinical needs in the USA. (shrink)

The author examines the existential, historical, and political roots of psychiatric power, locating them, respectively, in the universality of guilt feelings and the desire to escape them, in psychiatry (replacing religion) as an institution offering surcease from such (and similar disturbing) feelings, and in the alliance, in modern societies, between psychiatry and the state. Clinical psychiatry and psychoanalysis, each in its own distinctive way, have served to legitimize the uses of psychiatric power. Liberty from coercive psychiatry requires destroying (...) the legitimacy, and hence power, of coercive psychiatric principles and practices. (shrink)

Is it justified to detect minor genetic aberrations before birth and terminate pregnancies based upon such information? We present the case of a woman who wanted Prenatal Diagnosis (PND) to detect whether her female fetus was a Haemophilia mutation carrier. Such carriers are usually healthy.She wished to eradicate the Haemophilia mutation from her family to avoid future generations being affected and to protect her children from having to go through PND themselves. We explore existing practice guidelines, public attitudes and (...) possible objections to providing PND for minor abnormalities. We argue that in a society where couples have considerable autonomy relating to decisions about the fetus at least until viability, the routine restriction of PND for minor genetic abnormalities would be an unjust infringement of individual liberty. (shrink)

In the care of patients with disorders of consciousness (DOC), some ethical difficulties stem from the challenges of accurate diagnosis and the uncertainty of prognosis. Current neuroimaging research on these disorders could eventually improve the accuracy of diagnoses and prognoses and therefore change the context of end-of-life decision making. However, the perspective of healthcare professionals on these disorders remains poorly understood and may constitute an obstacle to the integration of research. We conducted a qualitative study involving healthcare professionals from (...) an acute care university medical center. A short questionnaire captured demographic data as well as the experience of participants with DOC patients. A semi-structured interview was used to explore attitudes toward ethical issues identified in a previous literature review. Qualitative content analysis of interviews was conducted with the NVivo software. Accurate diagnosis among DOC is often regarded as a challenge, but this was generally not the case for our participants because most reported high confidence in DOC diagnoses. However, participants reported struggling with prognosis, especially because of its essential role for end-of-life decision making and communication with families. Variability of opinion between healthcare professionals was reported and identified by some as a minor issue while others stressed how families struggle with different medical opinions. End-of-life decision making encompassed a large proportion of ethical challenges in these patients, and the removal of artificial nutrition and hydration created significant discomfort in a minority of participants. The concept of futility was subject to wide-ranging understandings with both favorable and unfavorable opinions. Our data suggest that to ensure the incorporation of new evidence-based advances, attention should be directed to the real-world practices and challenges of accurate diagnosis and prognosis. Given pervasive challenges in end-of-life care, we recommend improved training of healthcare professionals in the care of patients with DOC, particularly in end-of life care, understanding the context of decision making, and determining how to optimally integrate new neuroscience research on the care of patients with DOC. (shrink)

The question of the extent to which one can rationally reconstruct the process of medical diagnosis and reduce it to an algorithm is explored. The act of diagnostic insight is such that a computational program cannot ‘catch on’ in the way that a competent diagnostician can. Clinical diagnostic reasoning in a particular case requires as a necessary condition an extraordinarily complex and rich structure of background knowledge as well as an intuitive element, such as is manifest when one ‘catches (...) on’ to a joke. Computers cannot ‘catch on’ due to their limitations in the computational mode. As a consequence, there can be no computer simulation of an essential element in diagnostic procedures. Keywords: clinical judgment, computer diagnosis, intuition, medical decision-making CiteULike Connotea Del.icio.us What's this? (shrink)

Giam, Patrick This article seeks to explore some further ethical and legal issues surrounding the practice of preimplantation genetic diagnosis (PGD) which was the subject of a 2009 article for BRN. After briefly reviewing the state of regulation of PGD in Australia, focusing mainly on the national Guidelines developed by the National Health and Medical Research Council (NHMRC), I proceed to consider the ethical problems with PGD from the Catholic and natural law position that the embryo is a human (...) person with inherent dignity and the right to life, which forms the basis for revisiting the conclusions reached in my previous article on the proper response to the regulation of such technology. (shrink)

This article gives an overview about the ethical dispute on preimplantation genetic diagnosis (PGD), its legal status and its practical usage in Europe. We provide a detailed description of the situation in Germany wherein prenatal diagnosis is routinely applied, but PGD is prohibited on the basis of the internationally unique embryo protection act (EPA) that was put into force in 1991. Both PGD and stem cell research were vigorously debated in Germany during the last four years. As regards (...) the PGD debate specifically, the voices of the ones directly affected were not adequately taken into consideration. We describe the predominant lines of argumentation in this debate and some essential results of our "bioethical field study" of opinions on and usage of PGD in Germany and their implications for the German legislation and ethical theory. (shrink)

This essay argues that making a diagnosis in medicine is essentially a hermeneutic enterprise, one in which interpretation skills play a major part in understanding a disease. The clinical encounter is an event comprised of two voices; one is the voice of science which is grounded in empiricism, the other is that of human experience, which is grounded in story-telling and the interpretation of those stories.Using two voices, one from the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, which describes (...) alcohol abuse and alcohol dependence, and the other, that of Claire, a character in Edward Albee's play, A Delicate Balance, who is conversing with her brother-in-law, Tobias, I apply principles from Hans-Georg Gadamer's hermeneutics to the clinical diagnostic process. The essay will demonstrate that we overlook an enormous amount of information about alcoholism by an overreliance on objective data and that our hope for understanding alcoholics is in listening to their voices, and sharing the interpretation of their experiences with them. (shrink)

Diagnosis of dementia in primary care is both difficult and important. The recommendations by several authors to improve the diagnosis of dementia by general practitioners are important, but insufficient. It is argued that perhaps the disease concept in itself is a cause of confusion for clinicians. Primary care physicians need an adapted procedure, gradually leading to the final diagnosis of dementia. It has to be a stepwise labelling strategy, using global descriptions and non-disease specific labels in the (...) beginning, ending up with well-defined disease criteria. In this process, there is circularity: previous diagnoses have to be kept in mind because symptoms and signs may gradually change during the progression of the disease, leading to reconsideration of previous deleted options. To frame this properly, the primary care physician needs to adopt a broad frail elderly geriatric concept. Implementation of this concept not only helps the diagnostic process, but also stimulates the care for dementing patients and their caregivers. Relevant arguments for early diagnostic involvement of primary care physicians can be put forward on condition that a new concept, adapted procedures and adapted instruments are used. (shrink)

To what extent does payment method (managed care vs. out of pocket) influence the likelihood that an independent practitioner will assign a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis to a client? When a practitioner does diagnose, how does payment method influence the specific choice of a diagnostic category? Independent practitioners responded to a vignette describing a fictitious client with symptoms of depression or anxiety. In half of the vignettes, the fictitious client intended (...) to pay via managed care; in the other half, the fictitious client intended to pay out of pocket. Payment method had a very significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to receive diagnoses and more likely to receive adjustment disorder diagnoses in particular. We discuss implications involving informed consent and other ethical issues. (shrink)