Heroin prescription involves the medical provision of heroin in the treatment of heroin addiction. Rudimentary clinical trials on that treatment modality have been carried out and others are currently underway or in development. However, it is questionable whether subjects considered for such trials are mentally competent to consent to them. The problem has not been sufficiently appreciated in ethical and clinical discussions of the topic. The challenges involved throw new light on the role of value and accountability in contemporary discussions (...) of mental competence. (shrink)

It has been argued recently that some basic emotions should be considered natural kinds. This is different from the question whether as a class emotions form a natural kind; that is, whether emotion is a natural kind. The consensus on that issue appears to be negative. I argue that this pessimism is unwarranted and that there are in fact good reasons for entertaining the hypothesis that emotion is a natural kind. I interpret this to mean that there exists a distinct (...) natural class of organisms whose behavior and development are governed by emotion. These are emoters. Two arguments for the natural kind status of emotion are considered. Both converge on the existence of emotion as a distinct natural domain governed by its own laws and regularities. There are then some reasons for being optimistic about the prospects for consilience in emotion theory. 1 The mantra 2 Griffiths on emotions as natural kinds 3 Panksepp on emotions as natural kinds 4 Emotion as a neurobiological kind 5 Emotion as a psychological kind 6 Response to the mantra 7 Unification or fragmentation? 8 Concluding remarks. (shrink)

Decision-Making Capacity First published Tue Jan 15, 2008; substantive revision Fri Aug 14, 2020 In many Western jurisdictions the law presumes that adult persons, and sometimes children that meet certain criteria, are capable of making their own medical decisions; for example, consenting to a particular medical treatment, or consenting to participate in a research trial. But what exactly does it mean to say that a subject has or lacks the requisite capacity to decide? This question has to do with what (...) is commonly called “decisional capacity”, a central concept in health care law and ethics, and increasingly an independent topic of philosophical inquiry. -/- Decisional capacity can be defined as the ability of subjects to make their own medical decisions. Somewhat similar questions of capacity arise in other contexts, such as capacity to stand trial in a court of law and the ability to make decisions that relate to personal care and finances. However, the history behind the more general legal notions of capacity to stand trial and capacity to manage one’s life is different and operates somewhat differently in law (Roth, Meisel, & Litz 1977; Zapf & Roesch 2005). For the purposes of this discussion the notion of decisional capacity will be limited to medical contexts only; most notably, those where decisions to consent or to refuse treatment or participation in clinical research are concerned. (shrink)

The distinction between cognitive and perceptual theories of emotion is entrenched in the literature on emotion and is openly used by individual emotion theorists when classifying their own theories and those of others. In this paper, I argue that the distinction between cognitive and perceptual theories of emotion is more pernicious than it is helpful, while at the same time insisting that there are nonetheless important perceptual and cognitive factors in emotion that need to be distinguished. A general representational metatheoretical (...) framework for reconciling cognitive and perceptual theories is proposed. This is the Representational Theory of Emotion (RTE). A detailed case study of Antonio Damasio's important new contribution to emotion theory is presented in defense of the RTE. The paper is intended for readers interested in the foundations of emotion theory and cognitive science. (shrink)

In this paper I review some leading developments in the empirical theory of affect. I argue that (1) affect is a distinct perceptual representation governed system, and (2) that there are significant modular factors in affect. The paper concludes with the observation thatfeeler (affective perceptual system) may be a natural kind within cognitive science. The main purpose of the paper is to explore some hitherto unappreciated connections between the theory of affect and the computational theory of mind.

When emotions are mentioned in the literature on mental competence, it is generally because they are thought to influence competence negatively; that is, they are thought to impede or compromise the cognitive capacities that are taken to underlie competence. The purpose of the present discussion is to explore the possibility that emotions might play a more positive role in the determination of competence. Using the MacArthur Treatment Competence Study as an example, it is argued that appreciation, a central theoretical concept (...) in many contemporary approaches to competence, has important emotive components that are seldom sufficiently recognized or acknowledged. If true, this means that some leading contemporary accounts of competence need to be revised in order to make more adequate provision for the positive contribution of emotion. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that conceptualizing anorexia (...) nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

In this paper I link two hitherto disconnected sets of results in the philosophy of emotions and explore their implications for the computational theory of mind. The argument of the paper is that, for just the same reasons that some computationalists have thought that cognition may be a natural kind, so the same can plausibly be argued of emotion. The core of the argument is that emotions are a representation-governed phenomenon and that the explanation of how they figure in behaviour (...) must as such be undertaken in those terms. I conclude with some interdisciplinary reflections in defence of the hypothesis that emotions might be more fundamental in the organization of behaviour than cognition; that, in effect, we may be emoters before we are cognizers . The aim of the paper is: (1) to introduce a number of promising results in philosophical and empirical emotion theory to a wider audience; and (2) to begin the task of organizing those results into a computational theoretical framework. (shrink)

The Diagnostic Statistical Manual of the American Psychiatric Association defines substance dependence, more commonly known as “drug addiction,” as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior.” If drug addiction is a matter of compulsion, as this definition suggests, then is it correct to say that a drug addict chooses to (...) take their drug of choice? Similarly, does it make sense to say that a person in the grip of fear really chooses to flee from what frightens them? In this book, Jon Elster argues that in general drug addicts and people subject to powerful emotions should be interpreted as making choices. Although there is a compulsion to choose, there is choice nonetheless. This is different from cases where there is a compulsion to act but no choice. But what kind of choice is this? And are such choices rational or not? These are among the central questions addressed in this book. (shrink)

The target of Hanna Pickard's very erudite and thought-provoking article is compulsion. She argues that “addiction is not a form of compulsion” and that “addictive desires are not irresistible” (Pickard 2012, 40). However, I fear that compulsion as she presents it is ultimately a metaphysical straw figure, trapped in a false metaphysical dichotomy. What is lacking is a proper attention to specific individual clinical cases, examined over time. At the same time, Pickard's discussion is extremely important because of the manner (...) in which it highlights both the merits and the perils of philosophical inquiry into the nature of addiction... (shrink)

Following a Canadian Supreme Court ruling invalidating an absolute prohibition on physician assisted dying, two reports and several commentators have recommended that the Canadian criminal law allow medical assistance in dying (MAID) for persons with a diagnosis of mental disorder. A key element in this process is that the person requesting MAID be deemed to have the ‘mental capacity’ or ‘mental competence’ to consent to that option. In this context, mental capacity and mental competence refer to ‘decision-making capacity’, which is (...) a distinct area of clinical study and research in the theory of informed consent. The purpose of this discussion is to bring several controversial but insufficiently acknowledged problems associated with decision-making capacity to the forefront of the proposed extension of MAID to persons diagnosed with mental disorders. Open-ended access to MAID by persons who suffer from mental health conditions already exists in Belgium and the Netherlands, where the issues raised here are equally relevant. In this paper, we highlight the serious limitations of relying on capacity assessments to allow access to MAID/Euthanasia. (shrink)

Purpose of review This review considers the literature on ethical and conceptual issues in eating disorders from the last 18 months. Some reference to earlier work is necessary in order to provide context for the recent findings from research that is ongoing. -/- Recent findings Empirical ethics research on anorexia nervosa includes novel ethical and conceptual findings on the role of authenticity and personal identity in individuals’ reports of their experience, as well as new evidence on the role of affective (...) states and values in decision making at later stages of the illness. Evidence points to the hypothesis that anorexia nervosa may be a distinct affective syndrome that organizes feelings and emotions in accordance with a fixed idea. -/- Summary There has been impressive progress in empirical ethics research on anorexia nervosa, with important implications for ethical and conceptual issues that surround decision-making capacity and our understanding of the illness. (shrink)

Mental competence, or decision‐making capacity, is an important concept in law, psychiatry, and bioethics. A major problem faced in the development and implementation of standards for assessing mental competence is the issue of objectivity. The problem is that objective standards are hard to formulate and apply. The aim here is to review the limited philosophical literature on the place of value in competence in an attempt to introduce the issues to a wider audience. The thesis that the assessment of competence (...) must incorporate elements of value and rationality is defended, and some tentative suggestions offered about how this might be achieved in a clinical setting. (shrink)

Addiction of the variety discussed in this chapter, is a condition that by its very nature compromises decision-making capacity across the decisional spectrum. The impairment is present not only at moments of withdrawal and intoxication, but at all stages of the active addictive cycle, as long as the pathological dispositions to overvalue addictive drugs remain entrenched and operative. In light of this entrenched and pervasive reorientation in pathological values, it seems reasonable to question the unilateral presumption of capacity for cases (...) of this sort. The reason is that there is an important, but restricted, sense in which the addicted individuals in question are not ‘responsible’ for their decisions regarding drug use. The high likelihood of relapse means that, as a clinical matter of fact, they are usually not accountable. At the same time, clinical experience also suggests that we should treat addicted individuals as if they are responsible because that empowerment is crucial to their recovery. In the end, there is probably only one safe course of action to take when faced with such a difficult situation. This is to suspend the unilateral global presumption of capacity and instead assess decision-making capacity on a case-by-case basis, with careful monitoring and encouragement. (shrink)

How does one scientifically verify a psychometric instrument designed to assess the mental competence of medical patients who are asked to consent to medical treatment? Aside from satisfying technical requirements like statistical reliability, results yielded by such a test must conform to at least some accepted pretheoretical desiderata; for example, determinations of competence, as measured by the test, must capture a minimal core of accepted basic intuitions about what competence means and what a theory of competence is supposed to do. (...) The concepts of “face validity” and “content validity” are both important here. Face validity “indicates that an instrument appears to test what it is supposed to and that it is a plausible method for doing so” (Portney and Watkins 2000, 82). Content validity “means that the test contains all the elements that reflect the variable being studied” (Portney and.. (shrink)

There are reasons to believe that decision‐making capacity (mental competence) of women in labor may be compromised in relation to giving informed consent to epidural analgesia. Not only severe labor pain, but also stress, anxiety, and premedication of analgesics such as opioids, may influence women’s decisional capacity. Decision‐making capacity is a complex construct involving cognitive and emotional components which cannot be reduced to ‘understanding’ alone. A systematic literature search identified a total of 20 empirical studies focused on women’s decision‐making about (...) epidural analgesia for labor pain. Our review of these studies suggests that empirical evidence to date is insufficient to determine whether women undergoing labor are capable of consenting to epidural analgesia. Given such uncertainties, sufficient information about pain management should be provided as part of prenatal education and the consent process must be carefully conducted to enhance women’s autonomy. To fill in the significant gap in clinical knowledge about laboring women’s decision‐making capacity, well‐designed prospective and retrospective studies may be required. (shrink)

Medicalization in contemporary psychopharmacology is increasingly dominated by commercial interests that threaten the scientific and ethical integrity of psychiatry. At the same time, the proliferation of new social media has altered the manner in which the social groups and institutions that have stakes in medicalization interact. Consumers are at once more powerful than ever before, but also more vulnerable. The upshot of all these developments is that medicalization is no longer simply the professed enemy of anti-psychiatry and its supporters. It (...) is now also an enemy of psychiatry. Once a welcome ally of psychiatry, medicalization appears to have turned into a fearsome enemy. (shrink)

This chapter argues that the conditions under the umbrella “personality disorders” actually constitute two very different kinds of theoretical entities. In particular, several core personality disorders are actually moral, and not medical, conditions. Thus, the categories that are held to represent them are really moral, and not medical, theoretical kinds. The chapter works back from the possibility of treatment to the nature of the kinds that are allegedly treated, revisiting 18th-century ideas of moral treatment along the way. The discussion closes (...) with a reflection on how the ambiguous medical status of personality disorders and their treatment today is reminiscent of the ideological tug of war that pits alienist “mad doctors” like Pinel against their lay counterparts such as Tuke as they battled over who should be in charge of treating the mad. (shrink)

Most contemporary models and tests for mental competence do not make adequate provision for the positive influence of emotion in the determination of competence. This most likely is due to a reliance on an outdated view of emotion according to which these models are essentially noncognitive. Leading developments in modern emotion theory indicate that this noncognitive theory of emotion is no longer tenable. Emotions, in fact, are essentially representational in a manner that makes them “cognitive” in an important sense. This (...) requires a reassessment of the place of emotion in the theory of mental competence. Building on Benjamin Freedman’s “recognizable reasons” account of competence, it will be argued that (1) emotions form a class of recognizable reasons of their own, and (2) that competence to consent is a matter of practical, rather than theoretical, reasoning. Emotions, then, are an essential ingredient in mental competence, and the cognitive bias that permeates the theory of mental competence today must be rejected. (shrink)

The history and philosophy of affective terms and concepts contains important challenges for contemporary scientific accounts of emotion regulation. First, there is the problem of moral undertow. This arises because stipulating the ends of emotion regulation requires normative assumptions that ultimately derive from values and morals. Some historical precedents are considered to help explain and address this problem. Second, there is the problem of organization. This arises because multiple emotions are often organized and oriented in very particular ways over the (...) life of the individual in a manner that cannot be adequately explained using the concept of “emotion.” A modern variant of the traditional concept of passion is invoked to help address this problem. (shrink)

I very much enjoyed reading the interesting and original article by Steel and colleagues (2017). But I found myself strongly disagreeing with its conclusion once the real point of the argument became clear to me. At the same time, I believe that the authors are correct to draw attention to the importance of context and inequities in framing discussions of the ethics of voluntary consent in heroin prescription research. I begin with a brief summary of the authors’ conclusion, quoting directly (...) and adding my own emphases, since there are major philosophical points I wish to make that hinge on nuances in wording... (shrink)

The author comments on the article “The neurobiology of addiction: Implications for voluntary control of behavior,‘ by S. E. Hyman. Hyman suggests that addicted individuals have substantial impairments in cognitive control of behavior. The author states that brain and neurochemical systems are involved in addiction. He also suggests that neuroscience can link the diseased brain processes in addiction to the moral struggles of the addicts.

Building on what he believed was a new ‘medico-philosophical’ method, Philippe Pinel made a bold theoretical attempt to find a place for the passions and other affective posits in psychopathology. However, his courageous attempt to steer affectivity onto the high seas of medical science ran aground on two great reefs that still threaten the scientific status of affectivity today. Epistemologically, there is the elusive nature of the signs and symptoms of affectivity. Ethically, there is the stubborn manner in which fact (...) and value are intermingled in affectivity. Both obstacles posed insuperable difficulties for Pinel, who never really managed to extricate his affective psychopathology from the confines of the Lockean intellectual paradigm. -/- . (shrink)

Psychiatric labeling has been the subject of considerable ethical debate. Much of it has centered on issues associated with the application of psychiatric labels. In comparison, far less attention has been paid to issues associated with the removal of psychiatric labels. Ethical problems of this last sort tend to revolve around identity. Many sufferers are reticent to relinquish their iatrogenic identity in the face of official label change; some actively resist it. New forms of this resistance are taking place in (...) the private chat rooms and virtual communities of the Internet, a domain where consumer autonomy reigns supreme. Medical sociology, psychiatry, and bioethics have paid little attention to these developments. Yet these new consumer-driven initiatives actually pose considerable risks to consumers. They also present complex ethical challenges for researchers. Clinically, there is even sufficient evidence to wonder whether the Internet may be the nesting ground for a new kind of identity disturbance. The purpose of the present discussion is to survey these developments and identify potential issues and problems for future research. Taken as a whole, the entire episode suggests that we may have reached a turning point in the history of psychiatry where consumer autonomy and the Internet are now powerful new forces in the manufacture of madness. (shrink)

I am delighted that Zachar and Potter have chosen to refer to my work on the DSM-IV cluster B personality disorders in their very interesting and ambitious target article. Their suggestion that we turn to virtue ethics rather than traditional moral theory to understand the relation between moral and nonmoral factors in personality disorders is certainly original and worth pursuing. Yet, in the final instance, I am not entirely sure about the exact scope of their proposed analysis. I also worry (...) whether they may have inadvertently presented a slightly inaccurate account of my views on the cluster B personality disorders, as they seek to formulate and defend their own views, which seem to be far wider in scope. I .. (shrink)

Locke is famous for defining madness as an intellectual disorder in the realm of ideas. Numerous commentators take this to be his main and only contribution to the history of psychiatry. However, a detailed exegetical review of all the relevant textual evidence suggests that this intellectualist interpretation of Locke’s account of madness is both misleading and incomplete. Affective states of various sorts play an important role in that account and are in fact primordial in the determination of human conduct generally. (...) Locke’s legacy in this domain must therefore be revised and the intellectualist bias that dominates discussions of his views must be redressed. (shrink)

The question of decision-making capacity for informed consent to experimental brain surgery for severely ill anorectic patients is about as dramatic an ethical issue one can imagine. Sabine Muller and her co-authors (2015) should be commended for this extremely timely and original clinical and ethical discussion of decision-making capacity in relation to the issues raised by informed consent to such therapies. In this commentary, I elaborate on the new account of the nature of anorexia nervosa that the authors allude to (...) in order to frame their discussion. This is the hypothesis that anorexia nervosa is a passion: a view with important implications for how we think about decision-making capacity in anorexia nervosa and elsewhere. (shrink)

The primary aim of this discussion is to present a detailed case study of Descartes’ use of émotion in Les passions de l’ame and in his early writings leading up to that work. A secondary aim is to argue that while Descartes was innovative in suggesting that émotion might be a better keyword for the affective sciences than passion, he did not consistently follow his own advice. His innovation therefore failed in that regard, even though it did inspire later thinkers (...) to explore the distinction between “passion” and “emotion” in their own manner. (shrink)

Hyman (2007) should be commended for bringing up the vexing question of how “loss of control” in addiction relates to issues of moral responsibility. However, his account suffers from a cognitive bias that overlooks the affective and emotional dimensions of addiction. To fully understand these issues, we need to look beyond the confines of cognition and cognitive neuroscience. It is not the case that addiction must be either a brain disease or a moral condition, which is Hyman’s starting point (2007, (...) 8). This dilemma is false. Addiction is both a brain disease and a moral condition and only by admitting the perspective of affective neuroscience can we explain why... (shrink)

Any ethical inquiry into addiction research is faced with the preliminary challenge that the term “addiction” is itself a matter of scientific and ethical controversy. Accordingly, the chapter begins with a brief history of the term “addiction.” The chapter then turns to ethical issues surrounding consent and decision-making capacity viewed from the perspective of the current opioid epidemic. One concern is the neglect of the cyclical nature of addiction and the implications of this for the validity of current psychometric instruments (...) used to evaluate decision-making capacity in addiction. Another is the apparent discrepancy—possibly an ethical double standard—in the manner in which society and addiction researchers view the mental capacity and vulnerability of individuals who suffer from severe addiction. On the whole, the main ethical concern of the chapter is the puzzling lack of clinical research on decision-making capacity in research on addiction. (shrink)

The York Retreat is famous in the histor y of nineteenth-centur y psychiatr y because of its association with moral treatment. Although there exists a substantial historical literature on the evolution of moral treatment at the Retreat, several interpretive problems continue to obscure its unique therapeutic legacy. The nature of moral treatment as practised at the Retreat will be clarified and discussed in a historical perspective. It will be argued that moral treatment at the Retreat was pr imar ily a (...) matter of affective conditioning guided by `benevolent theory'. (shrink)

The chapter traces the history of psychiatric ethics with a focus on the emergence of autonomy and how assumptions and thresholds surrounding informed consent and decision-making capacity have changed over the centuries. Innovators like Philippe PInel and William Tuke are featured in this account of how the 'mad' and the abuses of the 'domestication paradigm' of madness eventually gave way to more humanitarian approaches of treating the 'mad', like moral treatment. The chapter closes with a brief reflection regarding the limits (...) of autonomy and the decline of paternalism in psychiatric ethics. (shrink)

Psychopathology is the science of what mental illnesses are. Affective psychopathology – or, alternately, the ‘psychopathology of affectivity’ – is the branch of psychopathology devoted to the study of mental disorders that implicate mental states associated with moods and emotions and what used to be called ‘passions’. Some segments of the history of affective psychopathology have been skillfully traced. However, there is one episode in that history that has not received the attention it deserves. It concerns medical writers in France, (...) England, and Scotland, during the latter half of the eighteenth century. The issue at stake is whether affective psychopathology should include or exclude questions of morality. (shrink)

Philippe Pinel (1745–1826) is often said to be the father of modern clinical psychiatry. He is most famous for being a committed pioneer and advocate of humanitarian methods in the treatment of the mentally ill, and for the development of a mode of psychological therapy known as moral treatment. Pinel also made important contributions to nosology and the diagnosis and treatment of mental disorder, especially the psychopathology of affectivity, stressing the role of the passions in mental disorder. Pinel also conducted (...) what may be considered one of the first large‐scale clinical trials in psychiatry and was also arguably the first to introduce the new statistical methods of the time to that domain. (shrink)

La thérapie rationnelle des émotions est basée sur l’hypothèse qu’un trouble de la pensée conduit à des troubles du sentiment qui eux-mêmes conduisent à des troubles de comportement. Du point de vue thérapeutique, la stratégie consiste à corriger les sentiments et le comportement en modifiant le trouble de raisonnement. Cette forme très en vogue de psychothérapie des troubles émotionnels fournit une illustration intéressante des relations nomologiques intriquées qui peuvent exister entre les patrons relativement fixes d’états émotionnels, d’états comportementaux et d’états (...) sensoriels physiologiques. En tant que telle, elle fournit une source d’évidences plausible en faveur de l’hypothèse que les émotions sont une forme spécialisée de système nomologique ou une « espèce ». Le succès de la théorie rationnelle des émotions jette le doute sur le mantra philosophique actuel qui refuse aux émotions le statut d’espèce naturelle, car elle suggère précisément l’inverse, c’est-à-dire que les émotions sont bel et bien une forme d’« espèce naturelle ». Cet appui n’a pas été pris en considération dans le débat en cours au sujet du statut d’espèce naturelle de l’émotion. Il est particulièrement intéressant de noter la façon dont il nous force à repenser la notion d’espèce naturelle telle qu’elle est employée dans les débats philosophiques sur la question. D’autres formulations qui correspondent mieux aux pratiques des sciences concernées pourraient être nécessaires. -/- [English abstrast] Rational Emotive Therapy is based on the hypothesis that disordered thinking leads to disordered feeling, which then leads to disordered behavior. Therapeutically, the strategy it is to correct disordered feeling and behavior by changing the disordered thinking. This immensely popular form of psychotherapy for emotional disorders provides an interesting illustration of the intricate law-like relationships that can exist between relatively fixed patterns of emotional, behavioral, and physiological sensory states. As such, it provides a plausible source of evidence for the hypothesis that emotions form a specialized law-like system or ‘kind’. Evidence of the success of Rational Emotive Therapy casts doubt on the contemporary philosophical mantra that emotions do not form a natural kind. It suggests precisely the opposite, namely, that emotions do form a ‘natural kind’ of some sort. This evidence has not been considered in the ongoing debate over the natural kind status of emotion. Especially interesting is how it forces us to rethink the way in which the notion of a natural kind is usually deployed in philosophical debates in this area. Alternative formulations more in line with the practices of the relevant sciences may be needed. (shrink)

Alexander Crichton (1763—1856) made significant contributions to the medical theory of the passions, yet there exists no systematic exegesis of this particular aspect of his work. The present article explores four themes in Crichton's work on the passions: (1) the role of irritability in the physiology of the passions; (2) the manner in which irritability and sensibility contribute to the valence, or polarity, of the passions; (3) the elaboration of a psychopathology of the passions that emphasizes their physiological form rather (...) than meaningful content or connections; and (4) the insistence that medical science ought to ignore ethical and other `moral' psychological and social aspects of the passions. (shrink)

Clinton is certainly correct that there can be serious ethical problems with mental health professionals referring clients with substance dependence and other addictionrelated problems to 12-step programs. But the philosophical doctrine of representationalism he proposes is not a helpful way to address those issues. It seems more like red herring that only serves to detract attention from the real problem. This is the coercive nature of referrals to 12-step programs in many treatment and rehabilitation centres. Clinton’s discussion is helpful because (...) it invites us to consider this important ethical issue. But unfortunately his analysis fails to address the issue satisfactorily. At the same time, it seriously misconstrues the nature of 12- step programs, obscuring their own ethical stance on consent, eligibility and membership... (shrink)

We are grateful for these two insightful commentaries, which both see novelty and value in the manner in which we invoke the hypothesis that anorexia nervosa is a passion, to help explain data from the Anorexia Experiences Study, which provides the basis of our inquiry. In this response, we wish to clarify and elaborate on our hypothesis; in particular, the difference between passions and moods, the manner in which our hypothesis touches on issues of authenticity and identity, and the compelling (...) parallel with addiction. We also wish to emphasize that, in proposing the hypothesis that anorexia nervosa is a passion, our primary aim is not so much to exclude or replace alternative theoretical approaches. Our focus, really, is to argue that the hypothesis that anorexia nervosa is a passion adds something rich and unique to our current understanding of that condition, which is not fully or adequately captured by alternative accounts... (shrink)

This case study in the history of “passion” and “emotion” is based on the writings of William James. James is famous for his (1884) theory of emotion. However, like his illustrious colleague, Théodule Ribot, he also recognized the importance of “passion” in psychology. That aspect of James’s work is underappreciated. Ribot explicitly defends the necessity of including “passion” in psychology. James does not go that far. But he does utilize a very similar concept in connection with the term “passion” and (...) there can be little doubt he considered it scientifically legitimate. Consequently, like Ribot, James must be considered an exception to historical accounts of this period which describe a transition from “passion” to “emotion” in which “passion” plays no part. (shrink)

Following a Canadian Supreme Court ruling invalidating an absolute prohibition on physician assisted dying, two reports and several commentators have recommended that the Canadian criminal law allow medical assistance in dying (MAID) for persons with a diagnosis of mental disorder. A key element in this process is that the person requesting MAID be deemed to have the ‘mental capacity’ or ‘mental competence’ to consent to that option. In this context, mental capacity and mental competence refer to ‘decision-making capacity’, which is (...) a distinct area of clinical study and research in the theory of informed consent. The purpose of this discussion is to bring several controversial but insufficiently acknowledged problems associated with decision-making capacity to the forefront of the proposed extension of MAID to persons diagnosed with mental disorders. Open-ended access to MAID by persons who suffer from mental health conditions already exists in Belgium and the Netherlands, where the issues raised here are equally relevant. In this paper, we highlight the serious limitations of relying on capacity assessments to allow access to MAID/Euthanasia. (shrink)

THE TARGET OF ERICA LILLELEHT'S interesting comparison between 19th-century moral treatment and 20th-century psychiatric rehabilitation is contemporary psychiatric rehabilitation. Using Foucault's (1979) Discipline and Punish as her critical foil, she argues that psychiatric rehabilitation is "an approach to madness fraught with paradox." The paradox lies in the fact that the techniques of psychiatric rehabilitation can be practiced in a manner that contradicts its professed humanitarian intentions; notably, liberating the mad from "resource dependency and segregated living." The lesson to be drawn (...) from this paradox is that "our practices, may be shaped and reformulated to serve goals of which we are only dimly aware." The resulting "mindfulness" is supposed to make us more careful and critical of what to count as success and progress in psychiatric treatment... (shrink)