In this unique study Fulford combines the disciplines of rigorous philosophy with an intimate knowledge of psychopathology to overturn traditional hegemonies. The patient replaces the doctor at the heart of medicine. Moral theory and the logic of evaluation replace epistemology as the focus of philosophical enquiry. Ever controversial, mental illness is at the interface of philosophy and medicine. Mad or bad? Dissident or diseased? Dr Fulford shows that it is possible to achieve new insights into these traditional dilemmas, insights at (...) once practically relevant and philosophically significant. (shrink)

Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient–physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust – a crucial matter (...) in healthcare especially because there are numerous ethical implications – has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources. In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework. (shrink)

The human brain is subjective and reflects the life of a being-in-the-world-with-others whose identity reflects that complex engaged reality. Human subjectivity is shaped and in-formed (formed by inner processes) that are adapted to the human life-world and embody meaning and the relatedness of a human being. Questions of identity relate to this complex and dynamic reality to reflect the fact that biology, human ecology, culture, and one's historic-political situation are inscribed in one's neural network and have configured its architecture so (...) that it is a unique and irreplaceable phenomenon. So much is a human individual a relational being whose own understanding and ownership of his or her life is both situated and distinctive that neurophilosophical conceptions of identity and human activity that neglect these features of our being are quite inadequate to ground a robust neuroethics. (shrink)

This study examines the relationship between thought and language by considering the views of Kant and the later Wittgenstein along with many strands of contemporary debate in the area of mental content. Building on an analysis of the nature of concepts and conceptions of objects, Gillett provides an account of psychological explanation and the subject of experience, offers a novel perspective on mental representation and linguistic meaning, looks at the difficult topics of cognitive roles and singular thought, and concludes with (...) an outline of certain considerations relevant to skeptical arguments and the nature of perception. The resulting synthesis demonstrates interesting correlations with current work in cognitive and developmental psychology, and is directly relevant to continuing work in epistemology, philosophy of mind, and philosophical psychology. (shrink)

The concept of futility is sometimes regarded as a cloak for medical paternalism in that it rolls together medical and value judgments. Often, despite attempts to disambiguate the concept, that is true and it can be applied in such a way as to marginalize the real interests of a patient. I suggest we replace it with a conceptual toolkit that includes physiological futility, substantial benefit (SB), and the risk of unacceptable badness (RUB) in that these concepts allow us to articulate (...) what is at stake in ethical judgments where outcomes are crucial in determining what should be done. (shrink)

‘Neuroethics’ is a term which has come into use in the last few years, and which is variously defined. In the Preface to his book, Grant Gillett indicates the sense in which he is using it: the central questions in neuroethics, he says, are those of ‘human identity, consciousness and moral responsibility or the problem of the will’. His aim is to offer an account of human identity which can shed light on issues both in general philosophy and in bioethics.The (...) question which this account seeks to answer is stated in various ways in the book, but perhaps the simplest formulation is this: what is the difference between being somebody and being some body? The Cartesian answer, that the difference lies in the possession of an immaterial thinking substance, is rejected on the grounds that a thinking thing cannot be only a thinking thing: to think is to respond to the world in various ways, which requires bodily means of response. But the same argument also applies to the ‘Cartesian materialism’ which would identify ‘mind’ with ‘brain’. Instead …. (shrink)

The first edition of The Mind and its Discontents was a powerful analysis of how, as a society, we view mental illness. In the ten years since the first edition, there has been growing interest in the philosophy of psychiatry, and a new edition of this text is more timely and important than ever. -/- In The Mind and its Discontents, Grant Gillett argues that an understanding of mental illness requires more than just a study of biological models of mental (...) processes and pathologies. As intensely social animals, he argues, we need to look for the causes of human mental disorders in our interactions with others; in social rule-following and its role in the organization of mental content; in the power relations embedded within social structures and cultural norms; in the way that our mental life is inscribed by a cumulative life of encounters with others. Drawing upon work from within the philosophy of mind, epistemology, post-modern continental philosophy, and philosophy of language, he tries to elucidate the nature of psychiatric phenomena involving disorders of thought, perception, emotion, moral sense, and action. Within this framework, a series of chapters analyse important psychiatric disorders such as depression, attention deficiency, autism, schizophrenia, and anorexia. Along the way, Gillett explores the nature of memory and identity; of hysteria and what constitutes rational behaviour; and of what causes us to label someone a psychopath or deviant. -/- Updated, available in paperback, and more accessible than before, the new edition of this fascinating book will provide readers with important insights into the causes and nature of psychosis. In addition, Gillett's arguments have considerable implications for the way in which we understand and treat people suffering from psychiatric disorders. The Mind and its Discontents will be read by researchers and postgraduate students in a range of academic areas, including psychiatry, bioethics, philosophy of mind, social theory, and clinical psychology. It will also be of considerable interest to practising psychiatrists. (shrink)

The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or ‘rescue’ procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely (...) disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other ‘rescue situations’, the utility of the procedure cannot be rationalised on a mere cost–benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation. (shrink)

Informed consent is the practical expression of the doctrine of autonomy. But the very idea of autonomy and conscious free choice is undercut by the view that human beings react as their unconscious brain centres dictate, depending on factors that may or may not be under rational control and reflection. This worry is, however, based on a faulty model of human autonomy and consciousness and needs close neurophilosophical scrutiny. A critique of the ethics implied by the model takes us towards (...) a 'care of the self' view of autonomy and the subject's attunement to the truth as the crux of reasoning rather than the inner mental/neural state views of autonomy and human choice on offer at present. (shrink)

Perception is often analysed as a process in which causal events from the environment act on a subject to produce states in the mind or brain. The role of the subject is an increasing feature of neuroscientific and cognitive literature. This feature is linked to the need for an account of the normative aspects of perceptual competence. A holographic model is offered in which objects are presented to the subject classified according to rules governing concepts and encoded in brain function (...) in that form. This implies that the analysis of perception must consider not only the fact that there is an interaction between the perceiving subject and the perceived object but also that the interaction is shaped by a system of concepts which the subject uses in thought and action. (shrink)

Concepts are basic elements of thought. Piaget has a conception of the nature of concepts as informational or computational operations performed in an inner milieu and enabling the child to understand the world in which it lives and acts. Concepts are, however, not merely logico?mathematical but are also conceptually linked to the mastery of language which itself involves the appropriate use of words in social and interpersonal settings. In the light of Vygotsky's work on the social and interactive nature of (...) children's thinking and the nature of language as an essentially public currency of rule?governed signs, we are led to reconstrue conceptual mastery as the acquisition of an interactive and interpersonal repertoire of tools which introduces the child to the world of those who educate it. In this way we come to see the elements of mind as constitutively involving that activity in which the determinants of meaning constrain and direct the child's linguistic development. (shrink)

Neuroscience and technological medicine in general increasingly faces us with the imminent reality of cyborgs—integrated part human and part machine complexes.If my brain functions in a way that is supported by and exploits intelligent technology both external and implantable, then how should I be treated and what is my moral status—am I a machine or am I a person? I explore a number of scenarios where the balance between human and humanoid machine shifts, and ask questions about the moral status (...) of the individuals concerned. The position taken is very much in accordance with the Aristotelian idea that our moral behaviour is of a piece with our social and personal skills and forms a reactive and reflective component of those skills. (shrink)

Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; (...) a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case. (shrink)

?Representation? is a concept which occurs both in cognitive science and philosophy. It has common features in both settings in that it concerns the explanation of behaviour in terms of the way the subject categorizes and systematizes responses to its environment. The prevailing model sees representations as causally structured entities correlated on the one hand with elements in a natural language and on the other with clearly identifiable items in the world. This leads to an analysis of representation and cognition (...) in terms of formal symbols and their relations. But human perception and cognition use multiple informational constraints and deal with unsystematic and messy input in a way best explained by Parallel Distributed Processing models. This undermines the claim that a formal representational theory of mind is ?the only game in town?. In particular it suggests a radically different model of brain function and its relation to epistemology from that found in current representational theories. (shrink)

This book uses a neo-Aristotelian framework to examine human subjectivity as an embodied being. It examines the varieties of reductionism that affect philosophical writing about human origins and identity, and explores the nature of rational subjectivity as emergent from our neurobiological constitution. This allows a consideration of the effect of neurological interventions such as psychosurgery, neuroimplantation, and the promise of cyborgs on the image of the human. It then examines multiple personality disorder and its implications for narrative theories of the (...) self, and explores the idea of human spirituality as an essential aspect of embodied human subjectivity. (shrink)

In all fields of clinical medicine, there is an increasing awareness that outcome must be assessed in terms of quality of life and cost effectiveness, rather than merely length of survival. This is especially the case when considering decompressive craniectomy for severe traumatic brain injury. The procedure itself is technically straightforward and involves temporarily removing a large section of the skull vault in order to provide extra space into which the injured brain can expand. A number of studies have demonstrated (...) many patients going on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation. In an attempt to address these issues, we have used the analytical framework proposed by Jonsen, that requires systematic consideration of medical indications, patient preferences, quality of life and contextual features. (shrink)

Elective ventilation (EV) is ventilation—not to save a patient's life, but with the expectation that s/he will die—in the hope that organs can be retrieved in the best possible state. The arguments for doing such a thing rest on the value of the lives being saved by the donated organs, maximally honouring the donor's wishes where the patient can be reasonably thought to wish to donate, and a general principle in favour of organ donation where possible as an expression of (...) human solidarity. Arguments against include difficulties surrounding the patient's consent to donation (including the risk of them surviving in an unacceptably bad state), the possibility of changing our perception of organ donation and care in dying, and the moral distress potentially caused to intensive care unit (ICU) staff involved in EV. EV can occur before or after the patient is declared dead and it is EV before the declaration of death (EVb) that occasions the ethical worries. I argue that when we acknowledge the tragedy involved, attend sensitively to the grief proper to human death, and ensure that we are not working in an ethical and legal climate that increases the likelihood of inadvertent survival in an unacceptably bad state, EVb is ethically defensible. (shrink)

Abstract The phenomenology of Multiple Personality (MP) syndrome is used to derive an Aristotelian explanation of the failure to achieve rational integration of mental content. An MP subject is best understood as having failed to master the techniques of integrating conative and cognitive aspects of her mental life. This suggests that in irrationality the subject may lack similar skills basic to the proper articulation and use of mental content in belief formation and control of action. The view that emerges centres (...) mind on the activity of a subject rather than a structured causal nexus. (shrink)

This collection examines prevalent assumptions in moral reasoning which are often accepted uncritically in medical ethics. It introduces a range of perspectives from philosophy and medicine on the nature of moral reasoning and relates these to illustrative problems, such as New Reproductive Technologies, the treatment of sick children, the assessment of quality of life, genetics, involuntary psychiatric treatment and abortion. In each case, the contributors address the nature and worth of the moral theories involved in discussions of the relevant issues, (...) and focus on the types of reasoning which are employed. 'Medical ethics is in danger of becoming a subject kept afloat by a series of platitudes about respect for persons or the importance of autonomy. This book is a bold and imaginative attempt to break away from such rhetoric into genuine informative dialogue between philosophers and doctors, with no search after consensus.' Mary Warnock. (shrink)

The ability to feel pain is a property of human beings that seems to be based entirely in our biological natures and to place us squarely within the animal kingdom. Yet the experience of pain is often used as an example of a mental attribute with qualitative properties that defeat attempts to identify mental events with physiological mechanisms. I will argue that neurophysiology and psychology help to explain the interwoven biological and subjective features of pain and recommend a view of (...) pain which differs in important respects from the one most commonly accepted. (shrink)

Many senior doctors have had little in the way of formal ethics training, but express considerable interest in extending their education in this area. This paper is the report of an initiative in continuing medical education in which doctors were introduced to narrative ethics. We review the theoretical basis of narrative ethics, and the structure of and response to the two-day workshop.

Abstract The language of consciousness and that of brain function seem vastly different and incommensurable ways of approaching human mental life. If we look at what we mean by consciousness we find that it has a great deal to do with the sensitivity and responsiveness shown by a subject toward things that happen. Philosophically, we can understnd ascriptions of consciousness best by looking at the conditions which make it true for thinkers who share the concept to say that one of (...) them is conscious. This depends on consciousness being manifest. When we also note that manifest, flexible and exploratory responses to one's environment are the basis of concept use, an a priori link between concepts and consciousness is forged. The brain structures subserving such responses are complex but crucially involve the multi?tracked and cross?linked information processing to be found in the neocortex. This function draws on the motivational and orienting activity arising in lower brain systems but orchestrates that into an articulated structure of behaviour control. The conclusion is that human consciousness is an umbrella term for complex and animated mental activity which makes extensive use of many different perceptual systems and also of the social milieu within which human cognition develops. (shrink)

The psychopathic personality disorder historically has been thought to include an insensitivity to morality. Some have thought that the psychopath's insensitivity indicates that he does not understand morality, but the relationship between the psychopath's defects and moral understanding has been unclear. We attempt to clarify this relationship, first by arguing that moral understanding is incomplete without concern for morality, and second, by showing that the psychopath demonstrates defects in frontal lobe activity which indicate impaired attention and adaptation to environmental conditions (...) which are relevant to the formation of complex intentions. We argue that these frontal lobe defects can help to explain both the psychopath's apparent insensitivity to morality and his characteristic imprudence. (shrink)

Grant Gillett argues that it is consciousness which makes a human or other being the 'locus of ethical value'. Since cortical functioning is, in Gillett's view, necessary for conscious activity, an individual whose neocortex is permanently non-functional is no longer a locus of ethical value and cannot be benefited or harmed in a morally relevant sense. This means that there is no obligation to continue treating those who have suffered neocortical death.

Informed consent is required for any medical procedure although the situations in which it is given are beset by uncertainties and indeterminacies. These make medicolegal scrutiny of such situations very difficult. Although some people find the decision in the Sidaway case incomprehensible because of its continuing regard for a 'professional practice standard' in informed consent, I will argue that an important fact in many cases is the moral integrity of the doctor concerned and the pattern of his practice. This may (...) provide the only morally principled and legally accessible evidence enabling a correct decision to be made in a difficult case. Although the epistemological significance of a professional practice standard is thereby defended the 'prudent patient standard' for what counts as consent is left intact. (shrink)

It has been argued that 'brain bisection' data leads us to abandon our traditional conception of personal identity. Nagel has remarked: The ultimate account of the unity of what we call a single mind consists of an enumeration of the types of functional integration that typify it. We know that these can be eroded in different ways and to different degrees. The belief that even in their complete version they can be explained by the presence of a numerically single subject (...) is an i1lusion.l Parfit has adopted a similar position, contending that patients with 'split brains' become two separate 'streams of consciousness' and thus that our normal sense of personal identity, or at least 'what matters' about personal identity is constituted by psychological relations between connected conscious experiences2 It is claimed that in 'split brain' patients certain of the relations are disrupted and that we thus see clearly that the nature of the unity that is normally present does not reside in a single subject with a given identity, but in the connectedness and continuity that normally obtains. Parfit draws on two sources of support for these contentions: the first is the actual events that transpire after a human being is submitted to the operation of sectioning the corpus callosum (or 'brain bisection'), and the second is the imaginative consideration of various scenarios involving graded mental and physical discontinuity, and the 'fission' and 'fusion' of persons. I shall do little more than argue that the actual data will not sustain the interpretation put on them. (shrink)

Joseph Fins's book Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness is a considerable addition to the literature on disorders of consciousness and the murky area of minimally conscious states. Fins brings to this fraught area of clinical practice and neuroethical analysis a series of stories and reflections resulting in a pressing and sustained ethical challenge both to clinicians and to health care systems. The challenge is multifaceted, with diagnostic and therapeutic demands to be met by (...) clinicians and a mix of moral, scientific-economic, and political resonances for health care analysts. Everything in the book resonates with my own clinical experience and the often messy and emotionally wrenching business of providing ongoing care for patients with severe brain injuries and disorders, people who frequently resist the categorizations that well-organized health care systems prefer and that can dictate terms of patient management. (shrink)

Truth and knowledge are conceptually related and there is a way of construing both that implies that they cannot be solely derived from a description that restricts itself to a set of scientific facts. In the first section of this essay, I analyse truth as a relation between a praxis, ways of knowing, and the world. In the second section, I invoke the third thing—the objective reality on which we triangulate as knowing subjects for the purpose of complex scientific endeavours (...) like medical science and clinical care. Such praxes develop robust methods of “keeping in touch” with disease and illness. An analysis drawing on philosophical semantics motivates the needed account of meaning and truth and underpins the following argument: the formulation and dissemination of knowledge rests on language; language is selective in what it represents in any given situation; the praxes of a given culture are based on this selectivity; but human health and illness involve whole human beings in a human life-world; therefore, medical knowledge should reflectively transcend, where required, biomedical science towards a more inclusive view. Parts three and four argue that a post-structuralist account of the human subject can avoid both scientism and idealism or unconstrained relativism. (shrink)

The embodied human subject is dynamically connected to his or her historico-sociocultural context, the soil from which a person’s psyche is nourished as multiplex meanings are absorbed and enable personal development. In each culture certain towering artistic works embody this perspective. The Dream of the Red Chamber introduces Jia Bao-yu—a scion of the prestigious Jia family—and his relationships with a large cast of characters. Bao-yu is controversial but, at the time of the family’s tragic collapse, he can be seen as (...) embodying a spiritual struggle in which his instinct, nature, sensitivity, and creativity are grounded in his transcendent relationship with a fragment of the world stone, an eternal source of energy and creativity. We are invited to draw on a metaphysical level of thought to consider his struggles with man-made hierarchies and a situated historico-sociocultural order in such a way as to live out his spiritual being. As such, the novel is closely relevant to questions of spirituality in bioethics. Through personal experiences, passions, creativity, and relationships with others, the body is inscribed, forming the soul, which may be misconstrued (for instance, through a medical or Cartesian reformulation of events) but which can be seen as the site of ethical and spiritual thought. (shrink)

Delusions, a key feature of psychosis, are usually thought of as a type of belief, as in the definition of the American Psychiatric Association: A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (e.g. it is not an article of religious (...) faith). This characterization is often criticized, but other definitions typically comprise similar elements. For some, delusions are only loosely considered as beliefs (Jaspers 1963; Moor and Tucker .. (shrink)