Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending (...) their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons’ mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge. (shrink)

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging (...) treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

If you developed Alzheimer disease, would you want to go all the way to the end of what might be a decade‐long course? Some would; some wouldn't. Options open to those who choose to die sooner are often inadequate. Do‐not‐resuscitate orders and advance directives depend on others' cooperation. Preemptive suicide may mean giving up years of life one would count as good. Do‐it‐yourself methods can fail. What we now ask of family and clinicians caring for persons with dementia, and of (...) patients given no better option than to go on with lives they may not want, is unacceptable. To explore how one might better control one's own dying and avoid burdening others with overwhelming care and morally painful choices, we propose a thought experiment: an advance directive implant that would enable persons with early dementia, while competent, to arrange their own deaths without the subsequent intervention of anyone else. (shrink)

There is currently much concern over the use of pharmaceuticals and other biomedical techniques to enhance athletic performance—a practice we might refer to as doping. Many justifications of anti-doping efforts claim that doping involves a serious moral transgression. In this article, I review a number of arguments in support of that claim, but show that they are not conclusive, suggesting that we do not have good reasons for thinking that doping is wrong.

In his carefully documented article, “From reciprocity to autonomy in physician-assisted death: an ethical analysis of the Dutch Supreme Court ruling in the Albert Heringa case,” Berand Florijn (20...

Suffering is widely assumed to have particular moral significance, and is of special relevance in medicine. There are, however, many theories about the nature of suffering that seem mutually incompatible. I suggest that there are three overall kinds of view about what suffering is: value‐based theories, including the theory famously expounded by Eric Cassell, which as a group suggest that suffering is something like a state of distress related to threats to things that a person cares about; feeling‐based theories, which (...) equate suffering with aversive feelings or sensations like pain; and objective theories, which suggest that suffering is the absence of objective flourishing. Rather than argue that one or another of these kinds of theory most accurately captures the nature of suffering, I allow that the term is ambiguous and thus that it may have at least three different kinds. I further argue, however, that when we think about suffering as potentially justifying end‐of‐life interventions, especially for cognitively typical adults, we are interested mainly in value‐based suffering. This is because the moral significance of value‐based suffering for persons with decision‐making capacity generally outweighs that of the other types; those other types of suffering achieve overriding moral significance only if they also constitute, or contribute to, value‐based suffering. (shrink)

ABSTRACT:Psychedelic substances have great promise for the treatment of many conditions, and they are the subject of intensive research. As with other medical treatments, both research and clinical use of psychedelics depend on our ability to ensure informed consent by patients and research participants. However, some have argued that informed consent for psychedelic use may be impossible, because psychedelic experiences can be transformative in the sense articulated by L. A. Paul (2014). For Paul, transformative experiences involve either the acquisition of (...) knowledge that cannot be obtained in any other way or changes in the self. Either of these characteristics may appear to undermine informed consent. This article argues, however, that there is limited evidence that psychedelic experiences are transformative in Paul's sense, and that they may not differ in their transformative features from other common medical experiences for which informed consent is clearly possible. Further, even if psychedelic experiences can be transformative, informed consent is still possible. Because psychedelic experiences are importantly different in several respects from other medical experiences, this article closes with recommendations for how these differences should be reflected in informed consent processes. (shrink)

There has been much debate about whether the concept of disease articulated in Boorse’s biostatistical theory is value-neutral or value-laden. Here, I want to examine whether this debate matters. I suggest that there are two basic respects in which value-ladenness might be important: it could threaten either scientific legitimacy or moral permissibility. I argue that value-ladenness does not threaten the scientific legitimacy of our disease-concept because the concept makes little difference to the formulation and testing of scientific hypotheses. Likewise, even (...) if our disease-concept is value-laden, this does not show it is morally impermissible. To determine its permissibility, we must regard it as a tool to structure social institutions. Seen in that way, whether our disease-concept is morally permissible is a consequentialist matter and depends exquisitely on unanswered empirical questions. (shrink)

In ‘Epistemic injustice, children and mental Illness,’1 Edward Harcourt uses Miranda Fricker’s concept of testimonial injustice 2 to make sense of claims, from mental health service users, that clinicians do not listen to them. Being listened to matters. It is a sign of respect as a person and associated with better clinical outcomes. TI involves suffering an unfair credibility deficit because of prejudice, so seems like a promising way of understanding service users’ complaints. Harcourt quickly concludes, however, that it is (...) inadequate. Since many service users are not wholly rational, the credibility deficits they suffer could be fair, and thus cannot constitute TI. Undaunted, Harcourt tries to reimagine TI so it can help. He observes that many children are also unfairly discredited by clinicians. Perhaps they are victims of TI, too, in a way that could help resurrect the concept? It may at first seem not: although providers who work with children often discredit them, this may result from mere ignorance, not prejudice. We should not let clinicians off the hook so easily, however, since they work with children, and should know their real capacities. Since they still discredit children, they must be prejudiced. And even further kinds of TI could be perpetrated by clinicians. Fricker assumes that …. (shrink)

One of the most widely accepted views in bioethics is that paternalistic interference in others’ self-regarding decisions is justified only if those decisions are not autonomous. Typically, a decision is autonomous if and only if it satisfies certain psychological criteria. Namely, it must be competent and also voluntary. This latter criterion means, roughly, that the agent herself decided without being controlled or unduly influenced by other persons or impersonal forces, in light her own values.The modern locus classicus of this idea (...) is undoubtedly Beauchamp and Childress ; they claim we have a duty to respect autonomous agents. (shrink)

McGregor and MacNamee recently, in this journal, offered several criticisms of an earlier article in which I attempted to refute a number of arguments for the claim that doping in sports is morally wrong. Their criticisms are numerous, but focus on four domains. First, they sketch a view on which the risk profiles of different sports may make doping permissible in some and impermissible in others. Second, they suggest that my criticisms of safety-based arguments assume that doping opponents are bent (...) on harm elimination, rather than harm management. Finally, they offer two methodological criticisms, the first pertaining to my use of analogical arguments, and the second pertaining to the general difficulties of making revisionist arguments in ethics. I defend my criticisms of safety-based arguments by showing that these do not rest on the assumptions McGregor and MacNamee attribute to me and by noting that their own view about the variable relevance of safety considerations is underdeveloped. As for their methodological arguments, I endeavor to show that these are misplaced, in that they either rest on misinterpretations of my earlier article or on an excessively high standard for ethical argumentation. (shrink)

Critics of medical aid in dying (MAID) often argue that it is impermissible because background social conditions are insufficiently good for some persons who would utilize it. I provide a critical evaluation of this view. I suggest that receiving MAID is a sort of “hard choice,” in that death is prima facie bad for the individual and only promotes that person’s interests in special circumstances. Those raising this objection to MAID are, I argue, concerned primarily about the effects of injustice (...) on hard choices. I show, however, that MAID and other hard choices are not always invalidated by injustice and that what matters is whether the injustice can be remediated given certain constraints. Injustice invalidates a hard choice when it can, reasonably, be remedied in a way that makes a person’s life go better. I consider the implications of this view for law and policy regarding MAID. (shrink)

Paternalistic interference in autonomous decisions is typically impermissible. This has several explanations, among which is a view I call theagent-constitution of the good: that the autonomous agent not onlyknowswhat is best for herself, butdetermineswhat is best for herself through her desires, goals and so on (heraims). For instance, it might seem that if an autonomous person does choose not to take insulin for her diabetes, then not only is it inappropriate to force treatment upon her, it is also not in (...) her best interest to take insulin. Here I argue that agent-constitution, though appealing, is false. In fact, autonomous agents can be mistaken about their good, even when it seems to depend only upon their aims. Agent-constitution appears true only because we typically fail to notice constraints on a person's good in private, self-regarding decisions where paternalism might be considered. (shrink)

Background Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with (...) persons with lived experience of mental illness.Methods We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.Results A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.Conclusions Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk. (shrink)

Mandatory vaccination against COVID-19 is a highly controversial issue, and many members of the public oppose it on the grounds that they should be free to determine what happens to their own body. Opinion has generally favored parental authority with respect to vaccination of children, but less attention has been paid to the ethical complexities of how to respond when mature minors refuse vaccination that is requested by their parents. We present a case in which a mature minor, who was (...) psychiatrically hospitalized, refused vaccination that had been requested by her parents, which led to significant moral distress for her caregivers. (shrink)

Volume 19, Issue 10, October 2019, Page W14-W17.

I am grateful for the insightful comments that have been furnished by Drs. Gala, Moseley, and Perring following their reading of my paper. Happily, I find myself in the position of being able to accept many of their criticisms, which identify many of the limitations of my argument as I see them. In only a few cases do I feel that their remarks are misplaced.The first concern raised by Moseley and Gala is that the paper gives the regrettable impression that (...) persons with anorexia nervosa generally have few cognitive deficits and primarily experience problems in valuing. But as is widely known, this is false: many persons with AN reason poorly and suffer perceptual distortions. I did not. (shrink)

Clinical research is difficult. It confronts massive heterogeneity in its participants, who are real people bumping around the world in complex ways. Clinical research in psychology is doubly difficult, since it tries systematically to study conditions that are inherently difficult to systematize. In their thoughtful and closely argued article, Truijens et al. emphasize these difficulties, and describe a novel challenge to psychotherapy research: that the support for many evidence-based therapies is weaker than previously recognized because it relies on patient-reported outcome (...) measures that often yield invalid results. Despite the initial plausibility of their position, however, their... (shrink)

The American Journal of Bioethics, Volume 11, Issue 8, Page 21-22, August 2011.

In a recent article, Tyler Tate argues that the suffering of children — especially children with severe cognitive impairments — should be regarded as the antithesis of flourishing, where flourishing is relative to one’s individual characteristics and essentially involves receiving care from others. Although initially persuasive, Tate’s theory is ambiguous in several ways, leading to significant conceptual problems. By identifying flourishing with receiving care, Tate raises questions about the importance of care that he does not address, giving rise to a (...) bootstrapping problem. By making flourishing relative to an individual’s circumstances, Tate is forced to confront questions about exactly how relative it can be, suggesting the possibility that, on his view, to flourish is simply to be however one is. In an attempt to surmount these problems, I offer a revision and restatement of Tate’s view that defines the relationship between individualized flourishing and the more conventional, species-relative concept, and describe more clearly the role that care should play with respect to flourishing — one that is instrumental and not merely constitutive. Even this restated view, however, fails to answer difficult questions about how one should respond to the medical needs of some children, highlighting the fact that a conceptual analysis of suffering may do little, in the end, to untangle ethical dilemmas in the care of severely ill children. (shrink)