While the decision of the House of Lords in Re F in [1990] clarified somewhat the law concerning the treatment of the mentally incapacitated adult, many uncertainties remained. This paper explores proposals discussed in a recent government green paper for reform of the law in an area involving many difficult ethical dilemmas.

The House of Lords in F v West Berkshire Health Authority [1989] considered the lawfulness of providing care and treatment for a mentally incapacitated adult. They did not, however, directly consider the use of restraint to enable the provision of care in the face of resistance from the patient. The law has since had good cause to give consideration to this important issue. This paper establishes the present law in the context of using restraint to deliver care. Although the legal (...) principles established have derived from what might be considered to be “hard cases”, life-and-death cases, they apply to all aspects of routine medical, dental and nursing care. Further, the paper considers the recent government proposals and the effect those proposals may have on the routine care of such patients. (shrink)

Le sentenze che oggi vengono pronunciate contro i criminali psicopatici evitano accuratamente di far leva su considerazioni “morali”. Solitamente l’attribuzione di responsabilità morale ai criminali si basa spesso sul concetto cognitivo di infermità mentale, in maniera tale che il giudizio morale sulla condotta morale dei “criminali psicopatici” in questi casi venga tendenzialmente sterilizzato. La posizione che qui vorrei proporre individua oscurità e limiti epistemici nelle teorie e nei metodi correntemente impiegati nelle società occidentali per alleggerire le responsabilità morali, le quali, (...) pertanto, risultano in parte inaffidabili. Per supportare questa conclusione intendo far leva sui miei più recenti studi di carattere cognitivo, vertenti sulla dimensione plurale dei contesti morali, sulla co-evoluzione geni/nicchia cognitiva e sul concetto di libero arbitrio. (shrink)

What renders some mentally disordered patients incapable of informed consent to medical interventions? It is argued that a patient is incapable of giving informed consent owing to mental disorder, if a mental disorder prevents a patient from understanding what s/he consents to; if a mental disorder prevents a patient from choosing decisively; if a mental disorder prevents a patient from communicating his/her consent; or if a mental disorder prevents a patient from accepting the need for (...) a medical intervention. This paper holds that a patient's capacity to give informed consent should be assessed clinically by using these conditions necessary for informed consent, and should be assessed specifically for each intervention and specifically at the time when the consent has to be given. The paper considers patients' incapacity to give informed consent to treatment, to give informed consent to be examined clinically, and to give informed consent to participate in research. (shrink)

What are the duties of carers and health professionals to people with mental incapacity? How ought we to think about the ethical and legal issues? What can any of us do to improve and safeguard the lives of those cared for? This book seeks to examine in detail and find ethically robust answers to such questions. Among the topics discussed are withholding treatment, tube-feeding patients with dementia, the 'persistent vegetative state', medical research, and sterilisation of intellectually disabled adults. (...) Contributors come from a wide range of disciplines, including psychiatry, nursing, philosophy, theology and law. The book includes an account by Wendy Hiscox of non-voluntary euthanasia in the Netherlands and Belgium, and a chapter by John Finnis exploring some aspects of Britain's Mental Capacity Act 2005. (shrink)

This essay seeks to explain a morally important class of psychological incapacity—the class of what Bernard Williams has called “incapacities of character.” I argue for two main claims: (1) Caring is the underlying psychological disposition that gives rise to incapacities of character. (2) In competent, rational adults, caring is, in part, a cognitive and deliberative disposition. Caring is a mental state which disposes an agent to believe certain considerations to be good reasons for deliberation and action. And caring (...) is a mental state which structures an agent’s practical deliberation, by establishing presumptive boundaries on the landscape of possibilities over which her deliberative imagination ranges. Incapacities of character are a consequence of the structure which these presumptive boundaries give to an agent’s deliberation. (shrink)

Helga Kuhse suggested in 1985 at a session of the World Federation of Right to Die Societies in Nice, that once dehydration to death became legal and routine in hospitals, people would, on seeing the horror of it, seek the lethal injection. The strategy of legalising passive euthanasia is itself flawed. Laing argues that the Mental Capacity Bill threatens the vulnerable by inviting breaches of arts 2,3,5,8, and 14 of the European Convention on Human Rights. Most at risk are (...) the disabled and incapacitated. Sections permitting non-therapeutic research and non consensual sterilisation are at odds with the Nuremberg Code. New third party powers to dehydrate the vulnerable permit new systemic human rights abuse of a clinical though not historically unfamiliar variety. (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)

The Mental Capacity Act, which received Royal Assent in April 2005, will come into force in April 2007. The Act puts into statute the legality of interventions in relation to adults who lack capacity to make decisions on their own behalf. The aim of this paper is to outline the main features of the legislation and its impact on those health care professionals who provide care and treatment for incapacitated adults. The paper sets out the underlying ethical principles that (...) govern interventions under the Act's powers and briefly explores the legal definition of incapacity and the process by which capacity is assessed. It looks at the governing notion of 'best interests' and at the legal indemnity provided by the Act for interventions that are in the best interests of an incapacitated adult. It contains sections on the Act's main innovations, including research involving incapacitated adults, lasting powers of attorney and the new Court of Protection. It also provides information on advance decisions to refuse treatment. (shrink)

In this paper we aim to offer a balanced argument to motivate (re)thinking about the mental illness clause within the insanity defence. This is the clause that states that mental illness should have a relevant causal or explanatory role for the presence of the incapacities or limited capacities that are covered by this defence. We offer three main considerations showing the important legal and epistemological roles that the mental illness clause plays in the evaluation of legal responsibility. (...) Although we acknowledge that these advantages could be preserved without having this clause explicitly stated in the law, we resist proposals that deny the importance of mental illness in exculpation. We argue, thus, that any attempt at removing the mental illness clause from legal formulations of the insanity defence should offer alternative ways of keeping in place these advantages. (shrink)

People with mental illness are treated, in research, as a ‘class’ or category who are vulnerable, without always being clear why they should be treated as such, not why an individual, rather than the class, is vulnerable. The two main reasons given are lack of competence and power imbalance. Competence issues include incapacity and legislation, assessment and the impact of the illness in decisions. Power issues cover the role of mental health legislation, coercion, protectiveness and paternalism, stigma (...) and discrimination and the ‘well’ and ‘ill’ self. These are examined within a framework of risk assessment, both to the patient and to others. Over-concern to protect the vulnerable can lead to gate-keepers preventing their inclusion in studies at various stages of the research. This denies such groups a voice in the research process.It is suggested that ethical scrutiny of research is not only to prevent harm to the vulnerable, but also to provide a framework to empower such people to take part in research. To do otherwise is to further stigmatize and marginalize them. One way forward is to look at the risk presented by different types of research, from clinical intervention trials to non-therapeutic, qualitative studies and to modify capacity and access requirements in the light of the risks presented. (shrink)

The Mental Capacity Act (2005) was designed to protect and empower patients with impaired capacity. Despite an estimated 40% of medical inpatients lacking capacity, it is unclear how many patients undergo capacity assessments and treatment under the Act. We audited the number of capacity assessments on the general medical wards of an English-teaching hospital. A total of 95 sets of case notes were reviewed: the mean age was 78.6 years, 57 were female. The most common presenting complaints were feeling (...) ‘unwell’ (n = 25) and confusion (n = 24). In all, 52 patients had conditions, such as delirium (n = 26) and dementia (n = 15), which often impair capacity. Capacity was assessed in seven (7.4%) patients, all of whom disagreed with the medical team about their treatment. The number of documented assessments fell short of the estimated rate of incapacity, suggesting that some means of improving capacity assessment in busy medical environments is required. (shrink)

The discriminatory effects of categorizing psychiatric patients into competent and incompetent, have urged lawyers, philosophers and health care professionals to seek a functional approach to capacity assessment. Dutch and English law have produced some guidelines concerning this issue. So far, most legal systems under investigation have concentrated on alternatives for informed consent by the patient in case of mental incapacity, notably substitute decision-making, intervention of a judge and advance directives. It is hard to judge the way in which (...) the law may further adapt to a more functional assessment of capacity, because the nature of law shows that legal reforms usually take place only when new methods have been accepted by the field. This is not yet the case today. (shrink)

The concept of vice-wrongful or criminal conduct-poses a metaphysical clash with the non-moral values of impairment, injury, and incapacity that drive illness/disorder concepts. Nevertheless, vice and disorder concepts have interpenetrated psychiatry past and present through practical social-service interactions between the mental health, adult and juvenile criminal justice, and intellectual disability systems. This chapter will unpack and briefly review the philosophical issues, including considerations of moral and legal responsibility, diagnostic constructs, and the medicalization of vice in contemporary psychiatry.

Cases of severe and enduring Anorexia Nervosa (SEAN) rightly raise a great deal of concern around assessing capacity to refuse treatment (including artificial feeding). Commentators worry that the Court of Protection in England & Wales strays perilously close to a presumption of incapacity in such cases (Cave and Tan 2017, 16), with some especially bold (one might even say reckless) observers suggesting that the ordinary presumption in favor of capacity ought to be reversed in such cases (Ip 2019). -/- (...) Those of us who worry that such trends and proposals amount to (or at least pose a serious threat of) wrongful discrimination on the grounds of disability nevertheless feel the pull of judging many SEAN service users to be incapacitous with respect to decisions regarding (perhaps amongst other things) treatments involving feeding, artificial or otherwise. But it is difficult to get to grips with exactly what their incapacity consists in. Many such service users seem able to understand, retain, use and weigh information, and express a decision (i.e. they seem, prima facie, to satisfy the ‘MacArthur’ criteria). At the very least, they do not, generally. (shrink)

Jimmy Plourde | : Dans cet article, je défends la thèse qu’il ne peut pas y avoir de savoir intuitif sous la forme d’un état purement mental, car, contrairement aux états purement mentaux de connaissance, les intuitions rationnelles n’excluent pas la possibilité de la coexistence de connaissances aux contenus contradictoires. Je soutiens que cela trouve une double justification dans la non-factivité et la non-véridictivité des intuitions, et une explication dans l’idée que les intuitions sont des expériences d’« intellectual seemings (...) ». Enfin, je soutiens que ces caractéristiques des intuitions pourraient constituer une difficulté pour la thèse évidentialiste et, par conséquent, pour la conception du savoir intutitif dans le cadre d’une théorie classique réformée de la connaissance. | : In this paper I argue that there cannot be intuitive knowledge if knowledge is conceived as a purely mental state. States of knowledge may not consist of rational intuitions because these do not, contrarily to purely mental states of knowledge, rule out the possibility of coexisting states of knowledge with contradictory contents. I defend the view that the justification for this incapacity lies in the non-factivity and the non-veridicity of intuitions. It is also argued that this non-factivity and non-veridicity of intuitions has its roots in the fact that intuitions are experiences of “intellectual seemings”. In the end, I consider the possibility that the non-factivity and non-veridicity of intuitions might constitute a problem for the thesis of evidentialism, thereby raising an issue for any conception of intuitive knowledge elaborated within the framework of a modified traditional conception of knowledge. (shrink)

ObjectiveTo examine health and social care professionals’ understanding of the legislation governing research involving adults lacking mental capacity in England and Wales.MethodsA cross-sectional online survey was conducted using a series of vignettes. Participants were asked to select the legally authorised decision-maker in each scenario and provide supporting reasons. Responses were compared with existing legal frameworks and analysed according to their level of concordance.ResultsOne hundred and twenty-seven professionals participated. Levels of discordance between responses and the legal frameworks were high across (...) all five scenarios. Nearly half of the participants provided responses that were discordant in all scenarios. Only two participants provided concordant responses across all five scenarios.DiscussionParticipants demonstrated a lack of knowledge about the legal frameworks, the locus of authority and the legal basis for decision-making. The findings raise concern about the accessibility of research for those who lack capacity, the ability to conduct research involving such groups and the impact on the evidence base for their care.ConclusionThis is the first study to examine health and social care professionals’ knowledge and understanding of the dual legal frameworks in the UK. Health and social care professionals’ understanding and attitudes towards research involving adults with incapacity may warrant further in-depth exploration. The findings from this survey suggest that greater training and education is required. (shrink)

This essay investigates the influences that led J.B. Watson to change from being a student in an introspectionist laboratory at Chicago to being the founder of systematic (or radical) behaviourism. Our focus is the crucial period, 1913-1914, when Watson struggled to give a convincing behaviourist account of mental imaging, which he considered to be the greatest obstacle to his behaviourist programme. We discuss in detail the evidence for and against the view that, at least eventually, Watson rejected outright the (...) very existence of mental images. We also discuss in detail whether or not Knight Dunlap was the crucial influence on his eventual rejection of mental images. Finally we consider whether Watson's rejection of mental images was bolstered by some personal incapacity as regards imaging or whether his rejection was more like a form of 'ideological blindness'. (shrink)

The Mental Incapacity Bill not only paves the way for euthanasia, but invites wholesale abuse and homicide, writes Jacqueline Laing. On 19 October 2004, when the Mental Capacity Bill was at its crucial committee stage, the Law Society issued a statement of ‘strong support’, claiming that it empowers patients and in no way introduces euthanasia. Laing argues that the Bill threatens the incapacitated by granting a raft of new third parties power to require that health professionals withhold (...) ‘treatment’, which, after the controversial decision in Airedale NHS Trust v Bland [1993] AC 789, includes food and fluids delivered both by tube and, in certain cases, by spoon. The Bill further endangers the vulnerable, first, by allowing non-therapeutic research on the non-consenting mentally incapacitated, in breach of the Nuremberg Code and First Declaration of Helsinki, and secondly, by permitting new agents power to undertake on people with learning disabilities certain questionable procedures currently authorised by the High Court, such as non-voluntary sterilisation. (shrink)

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an alternative (...) justification. However, this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis. (shrink)

Advance care planning (ACP) is promoted as beneficial practice internationally. This article critically examines different ways of understanding and measuring success in ACP. It has been 50 years since Luis Kutner first published his original idea of the Living Will, which was thought to be a contract between health carers and patients to provide for instructions about treatment choices in cases of mental incapacity. Its purpose was to extend a patient's right to autonomy and protect health carers from (...) charges of wrong-doing. Yet, it can be doubtful whether different types of ACP achieve these goals rather than aiming at secondary gains. My discussion suggests that the current promotion of ACP is not always engaging critically with the original ACP intentions and may even pursue notions of success that may run contrary to respecting autonomy. The risk of this may especially be the case when high participation rates are taken as indicators of success for institutional ACP programs. I further suggest that Kutner's two original aims of protecting patient autonomy and preventing charges of wrong-doing are near impossible to achieve in conjunction, because their simultaneous pursuit fails to acknowledge that patients and carers have opposing needs for reassurance about possible judgment errors. I conclude that the most realistic idea of success of modern ACP is an acknowledgement of the importance of ongoing dialogue about what constitutes appropriate care and a diversity of aims rather than any kind of advance, contractual insurance in the face of controversy. (shrink)

The practice of coercive measures in psychiatry is controversial. Although some have suggested that it may be acceptable if patients are a danger to others or to themselves, others committed themselves to eliminate it. Ethical, legal and clinical considerations become more complex when the mental incapacity is temporary and when the coercive measures serve to restore autonomy. We discuss these issues, addressing the conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the effects of coercive (...) measures. We argue that an appeal to respect autonomy and/or human dignity cannot be a sufficient reason to reject coercive measures. All together, these ethical aspects can be used both to support and to reject a non-seclusion approach. The total lack of controlled trials about the beneficial effects of coercive measures in different populations however, argues against the use of coercive measures. (shrink)

The “Adam Smith problem” has traditionally been concerned with the issue of authorial integrity: the issue of how a single author, Adam Smith, could have written two such apparently dissimilar, even contradictory, works as The Theory of Moral Sentiments and The Wealth of Nations. As the problem to be resolved was the single authorial origin of two such works, the perceived incompatibilities between them were explained in terms of Smith's intellectual biography – for example, Smith's travels to France, Smith's meetings (...) with the physiocrats, or the mental incapacities of an aging man. The current consensus is that the Adam Smith problem is a “pseudo problem” and that Smith's works represent a unified project, but the same reference to authorial origins now provides thr opposite claim that “the same man” wrote both books. Here the postulate of authorial integrity, “of stable integrated character, not subject to deep intellectual doubts or fissures” provides an assurance that such a man is unlikely to have written two entirely different books, an assurance underwritten by a coherent authorial intentionality that guarantees the consistency of the two works. (shrink)

The practice of covertly administering medication is controversial. Although condemned by some as overly paternalistic, others have suggested that it may be acceptable if patients have permanent mental incapacity and refuse needed treatment. Ethical, legal, and clinical considerations become more complex when the mental incapacity is temporary and when the medication actually serves to restore autonomy. We discuss these issues in the context of a young man with schizophrenia. His mother had been giving him antipsychotic medication (...) covertly in his soup. Should the doctor continue to provide a prescription, thus allowing this to continue? We discuss this case based on the “four principles” ethical framework, addressing the conflict between autonomy and beneficence/non-maleficence, the role of antipsychotics as an autonomy restoring agent, truth telling and the balance between individual versus family autonomy. (shrink)

It has been argued that the inherent risks of advance directives made by healthy people are disproportionate to the potential benefits, particularly if the directive is implementable in cases of reversible mental incapacity. This paper maintains that the evidence for such a position is lacking. Furthermore, respect for the principle of autonomy requires that individuals be permitted to make risky choices about their own lives as long as these do not impinge on others. Even though health professionals have (...) an obligation to try and ensure that patients have appropriate information about possible future treatment options, they cannot predict and describe every eventuality but nor can they disregard firm decisions knowingly made on the basis of incomplete information by competent adults. To attempt to do so would be to reinstate notions of medical paternalism which are contrary to current public expectations. (shrink)

This paper puts the famous story of Jekyll and Hyde to work for a specific analytic purpose. The question of responsibility for crime, complicated by the divided subjectivity implicit in Mr. Hyde’s appearance, and illuminated by Robert Louis Stevenson’s grasp of contemporary psychiatric, evolutionary and medical thought as promising new technologies for effecting a distinction between criminality and innocence, is key to the interest of the story. I argue that Jekyll and Hyde serves as a powerful metaphor both for specifically (...) late Victorian perplexities about criminality and criminal responsibility, and for more persistently troubling questions about the legitimacy of and practical basis for criminalization. A close reading of the story illustrates the complex mix of elements bearing on criminal responsibility-attribution, and—incidentally—helps to explain what is wrong with the influential argument that, by the end of the nineteenth Century, attributions of responsibility in English criminal law already rested primarily and unambiguously on factual findings about the defendant’s state of mind. Far from representing the triumph of a practice of responsibility-attribution grounded in the assessment of whether the defendant’s capacities were fully engaged, I argue that the terrain of mental derangement defences in late nineteenth Century England helps us to understand that longer-standing patterns of moral evaluation of character remained central to the criminal process. And precisely because ‘character’ remained key to the institutional effort to distinguish criminality and innocence, the ‘terror’ of Stevenson’s story resides in its questioning of whether either scientific knowledge or moral evaluation of character can provide a stable basis for attributions of responsibility. In conclusion, I will also suggest that Stevenson’s tale can help us to make sense of the resurgence of overtly ‘character-based’ practices of responsibility attribution in contemporary Britain and the United States, which themselves reflect a renewed crisis of confidence in our ability to effect a ‘dissociation’ between criminality and innocence. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Recent and Classic References at the Interface of Philosophy, Psychiatry, and Abnormal PsychologyArticlesAggernaes, A. 1972. The expanded reality of hallucinations and other psychological phenomena. Acta Psychiatrica Scandinavica 48: 220–238.Anonymous. 1991. Child sexual abuse and the limits of responsibility. Lancet 337: 890.Anonymous. 1993. Mental incapacity and medical treatment. Lancet 341: 1123–1124.Appelbaum, M. D., and A. Creer. 1993. Confidentiality in group therapy. Hospital and Community Psychiatry 44: 311–312.Beatson, J. (...) A. 1993. The psychiatrist and peer review—a psychodynamic review of the literature. Australia and New Zealand Journal of Psychiatry 27: 311–318.Berrios, G. E. 1987. Dementia during the seventeenth and eighteenth centuries: a conceptual history. Psychological Medicine 17: 829–837.Blackburn, R. 1988. On moral judgments and personality disorders: the myth of psychopathic personality revisited. British Journal of Psychiatry 153: 505–512.Blackmon, W. D. 1993. Are psychoanalytic billing practices ethical? American Journal of Psychotherapy 47: 613–620.Blashfield, R. K., and J. G. Draguns. 1976. Evaluative criteria for psychiatric classification. Journal of Abnormal Psychology 85, no. 2: 140–150.Blashfield, R. K., J. Sprock, and A. K. Fuller. 1990. Suggested guidelines for including or excluding categories in the DSM-IV. Comprehensive Psychiatry 31, no. 1: 15–19.Blashfield, R. K., J. Sprock, D. Haymaker et al. 1989. The family resemblance hypothesis applied to psychiatric classification. Journal of Nervous and Mental Disease 177: 492–497.Borys, D. S. 1994. Maintaining therapeutic boundaries: the motive is therapeutic effectiveness not defensive practice. Ethics and Behavior 4, no. 3: 267–273.Brown, W. M. 1985. On defining disease. Journal of Medicine and Philosophy 10: 311–328.Bub, J. 1994a. Is cognitive neuropsychology possible? Proceedings of the Biennial Meetings of the Philosophy of Science Association 1: 417–427.Bub, J. 1994b. Testing models of cognition through the analysis of brain-damaged performance. British Journal of Philosophy of Science 45, no. 3: 837–855.Buck, C. 1989. Problems with the Popperian approach: A response to Pearce and Crawford-Brown. Journal of Clinical Epidemiology 42: 185–187.Buck, R. 1994. The neuropsychology of communication: spontaneous and symbolic aspects. Journal of Pragmatics 22, no. 3-4: 265–278.Camp, N. M. 1993. The Vietnam war and the ethics of combat psychiatry. American Journal of Psychiatry 150: 1000–1009.Crockett, C. 1961. Ethics, metaphysics, and psychoanalysis. Inquiry 4: 37–52.Dalton, E., K. Hopper, and S. Reiner. 1976. Ethical issues in behavior control. Values and Ethics in Health Care 2: 1–40.Faust, D. 1993a. Use and then prove, or prove and then use? Some thoughts on the ethics of mental health professionals’ courtroom involvement. Ethics and Behavior 3, no. 3-4: 359–380.Fodor, J., and E. Lepore. 1994. What is the connection principle? Philosophy and Phenomenological Research 54: 4.Foss, L. 1994. Putting the mind back into the body: a successor scientific medical model. Theoretical Medicine 15, no. 3: 291–313.Galletly, C. A. 1993. Psychiatrist-patient sexual relationships: the ethical dilemmas. Australia and New Zealand Journal of Psychiatry 27: 133–139.Glymour, C. 1994. On the methods of cognitive neuropsychology. British Journal of Philosophy of Science 45, no. 3: 815–835.Gottlieb, M. C. 1994. Ethical decision making, boundaries, and treatment effectiveness: a reprise. Ethics and Behavior 4, no. 3: 287–293.Gutheil, T. G. 1994. Discussion of Lazarus’s “How certain boundaries and ethics diminish therapeutic effectiveness”. Ethics and Behavior 4, no. 3: 295–298.Helme, T. 1993. A special defence—a psychiatric approach to formalising euthanasia. British Journal of Psychiatry 163: 456–466.Kovel, J. 1976–77. Therapy in late capitalism. Telos 30: 73–92.Lazarus, A. A. 1994a. How certain boundaries and ethics diminish therapeutic effectiveness. Ethics and Behavior 4, no. 3: 255–261.Lazarus, A. A. 1994b. The illusion of the therapist’s power and the patient’s fragility: my rejoinder. Ethics and Behavior 4, no. 3: 299–306.Lehrman, N. S. 1980. Psychiatric power and responsibility: Abuse and abdication, a proposed corrective conference. The Humanist 40: 9–13.Lockhart, T. 1992. Professions, confidentiality, and moral uncertainty. Professional Ethics: A Multidisciplinary Journal 1, no. 3-4: 33–52.Margolin, S. G. 1964. The scientific status of psychoanalytic clinical evidence (II). Inquiry 7: 37... (shrink)

The article focuses on the impact of the concept of self-care on persons who are understood as incapable of self-care due to their physical and/or mental ‘incapacity’. The article challenges the idea of this health care concept as empowerment and highlights the difficulties for persons who do not fit into this concept. To exemplify this, the self-care concept is discussed with regard to persons with Alzheimer’s disease (AD). In the case of persons with AD, self-care is interpreted in (...) many different ways—depending on the point of view, for instance as an affected person or a carer. To prevent a marginalisation of the growing group of elderly persons with dementia, the article argues that concepts such as those of personhood, wellbeing, autonomy, rationality and normality have to be re-thought with regard to an increasingly ageing population. Taking into account that AD as a socio-medical construct has to be understood in the context of power relations, the article focuses on the mutual influence between the concepts of self-care and of AD and its possible impact on governing dementia and AD in particular. Michel Foucault’s considerations on ‘technologies of the self’ provide the basis for the discussion of the self-care concept within existing societal power relations. (shrink)

In this chapter, we investigate whether psychopathy is a mental disorder. We argue that addressing this question requires engaging, at least, with three principal issues that have conceptual, empirical, and normative dimensions. First, it must be established whether current measures of psychopathy individuate a unitary class of individuals. By this we mean that persons classifed as psychopaths should share some relevant similarities that support explanation, prediction, and treatment. Second, it must be proven that psychopathy harms the person who has (...) it. Third, it must be established that the harm associated with psychopathy is relevant for the ascription of disorder status. Regarding this latter issue, we argue that psychopathy should be considered a disorder if its harmfulness derives from certain incapacities or limited capacities. These incapacities should affect basic competences that are justifably required for conducting a preferable type of life. Within this framework, we tentatively advance the hypothesis that some normatively justifed conclusions and empirical evidence about psychopathy, that needs nonetheless to be further investigated, might support the claim that people with psychopathy have a mental disorder. (shrink)

BackgroundInformed consent is a key element of ethical clinical research. Addicted population may be at risk for impaired consent capacity. However, very little research has focused on their comprehension of consent forms. The aim of this study is to assess the capacity of addicted individuals to provide consent to research.Methods53 subjects with DSM-5 diagnoses of a Substance Use Disorder and 50 non psychiatric comparison subjects participated in the survey from December 2014 to March 2015. This cross-sectional study was carried out (...) at a community-based Outpatient Treatment Center and at an urban-located Health Centre in Spain. A binary judgment of capacity/incapacity was made guided by the MacArthur Competence Assessment Tool for Clinical Research and a clinical interview. Demographics and clinical characteristics were assessed by cases notes and the Mini-Mental State Examination, the Global Assessment Functional Scale and the Clinical Global Impression Scale.ResultsNPCs performed the best on the MacCAT–CR, and patients with SUD had the worst performance, particularly on the Understanding and Appreciation subscales. 32.7 % SUD people lacked research-related decisional capacity. There were no statistically significant differences between the groups in terms of capacity to consent to research.ConclusionsThe findings of our study provide evidence that a large proportion of individuals with SUD had decisional capacity for consent to research. It is therefore inappropriate to draw conclusions about capacity to make research decisions on the basis of a SUD diagnosis. In the absence of advanced cognitive impairment, acute withdrawal or intoxication, we should assume that addicted persons possess decision-making capacity. Thus, the view that people with SUD would ipso facto lose decision-making power for research consent is flawed and stigmatizing. (shrink)

This paper proposes a novel method for identifying the public evaluative standards that contribute to the classification of certain conditions as mental disabilities. Public evaluative standards could contribute to ascertaining disabilities by outlining characteristics whose presence beyond a threshold is fundamentally important for the life of a person and whose absence or reduced occurrence constitutes a disability. Additionally, they can participate in determining disabilities by delineating particularly grave difficulties, impairments, or incapacities. Our method relies on a model of public (...) justification of evaluative standards that is inspired by Gerald Gaus’s theory of public reason. Thus, our approach recommends the justification of evaluative standards through sound deliberative routes from reasons accessible to all persons who participate in the process of justification and the convergence of what is justified in this way to each of them. We deem that disabilities could be caused both by problems in the internal characteristics of a person as well as by unfairness or a lack of hospitality in external circumstances. This is why the method of justification is applied to the assessment of those circumstances as well. If social or environmental circumstances cannot be justified through the convergence of reasons accessible to all persons involved in the process of justification, we have reasons to exclude the presence of a disability and ascertain the presence of inadequate external conditions. (shrink)

Aphantasia is a recently discovered disorder characterised by the total incapacity to generate visual forms of mental imagery. This paper proposes that aphantasia raises important theoretical concerns for the ongoing debate in the philosophy and science of consciousness over the nature of dreams. Recent studies of aphantasia and its neurobehavioral correlates reveal that the majority of aphantasics, whilst unable to produce visual imagery while awake, nevertheless retain the capacity to experience rich visual dreams. This finding constitutes a novel (...) explanandum for theories of dreaming. Specifically, I argue that the recent dream reports of aphantasics constitute an empirical challenge to the emerging family of views which claim that dreams are essentially imaginative experiences, constitutively involving the kinds of mental imagery which aphantasics, ex-hypothesi, lack. After presenting this challenge in the context of Jonathan Ichikawa’s recent arguments for this view, I argue that this empirical challenge may be overcome if the imagination theorist abandons Ichikawa’s account of dreaming in favour of a modified version. This involves the claim that dreams are essentially inactive and constitutively involve non voluntary forms of imagination. I conclude with a suggestion for further research which can test the viability of this alternative hypothesis, and move the debate forward. (shrink)

Limits to paternalism are, in the liberal democracies, partially defined by the concepts of decision-making capacity/incapacity (mental competence/incompetence). The paper is a response to Ian Wilkss (1997) recent attempt to defend the idea that the standards for decisional capacity ought to vary with the degree of risk incurred by certain choices. Wilkss defense is based on a direct appeal to the logical features of examples and analogies, thus attempting to by-pass earlier criticisms (e.g., Culver Gert, 1990) of risk-based (...) standards. Wilkss argument is found wanting on the grounds that he misconstrues the logic of such capacity, especially in accounting for conceptual and pragmatic ties with issues of decisional authority. A diagnosis is offered as to the source of Wilkss error (the assumption that mental competence is a species of wider genus of competence), and an alternative way of accounting for risk within the predominant contemporary legal framework is sketched. (shrink)

In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and coercion.The (...) article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention. (shrink)

There has been a general failure among mental health theorists and social psychologists to understand the etiology of work-engendered depression. Yet the condition is increasingly prevalent in highly industrialized societies, where an exclusionary focus upon work, money, and the things that money can buy has displaced values that traditionally exerted a liberating and humanizing influence. Social critics have called the result an impoverishment of the spirit, a state of cultural bankruptcy, and an incapacity for genuine leisure. From a (...) clinical perspective, the condition has been diagnosed as widespread narcissism and obsessive work. -/- Acedia, a concept developed by the Scholastics, throws clarifying light on the origin of this form of depression. (shrink)

This paper investigates, from a philosophical perspective, whether high functioning autists are legally responsible for the crimes they may commit. We do this from the perspective of the Croatian legal system. According to Croatian Criminal Law, but also criminal laws adopted in many other countries, the legal responsibility of the person is undermined due to insanity when two conditions are satisfied. The first may be called the incapacity requirement. It states that a person, when committing the crime, suffers cognitive (...) or volitional incapacities or limited capacities that are relevant for exculpation. The second, we may call the mental disorder requirement, which states that these exculpatory incapacities are due to the presence of a mental disorder. In this paper we focus on the incapacity requirement. The review of the studies on executive functions deficits associated with high-functioning autism suggests that many autists should not be held categorically responsible for the crimes they may commit. Nonetheless, we argue that these impairments in executive functions generally do not provide an unqualified excuse. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychopathy, Other-Regarding Moral Beliefs, and ResponsibilityLloyd Fields (bio)AbstractIn this paper I seek to show that at least one kind of psychopath is incapable of forming other-regarding moral beliefs; hence that they cannot act for other-regarding moral reasons; and hence that they are not appropriate subjects for the assessment of either moral or legal responsibility. Various attempts to characterize psychopaths are considered and rejected, in particular the widely held view (...) that psychopaths are, in general, incapable of understanding moral concepts. The particular disability proposed here, the incapacity to form other-regarding moral beliefs, is then derived from an analysis of what is required for someone to be a responsible agent. This is illustrated with a detailed case history. A defect of this kind is shown to vitiate moral responsibility, because it renders the psychopath irresponsive to the social pressures which normally ensure respect for moral norms. It is also shown that the psychopath is not a suitable subject for the assessment of legal responsibility, because he lacks the capacity to act from common prudence to avoid sanctions. I conclude that the attempt to characterize particular defects from among the heterogeneity of psychopathic subjects, could lead to better targeted, and hence to more effective, management of particular cases.KeywordsCriminality, mental illness, personality disorder, blame, liability, moral beliefs, guilt, social moralityIntroductionThe term “psychopath” has been used with a wide variety of different meanings and, no doubt, covers a heterogeneous group of subjects (Criminal behaviour and mental health 1992). My aim in this paper is to argue that at least a subgroup of those subjects are characterized by an inability to form other-regarding moral beliefs—and hence, for this particular reason, are not morally responsible agents—and that they also lack the capacity for prudence, and hence are not legally responsible agents.I begin by distinguishing the particular sense in which I will be using the term “psychopathy.” I then consider some suggestions in the literature regarding the defect by which psychopaths might be characterized—that they are mentally ill, or incapable of understanding moral concepts. In rejecting these, I come to the suggestion that the relevant defect is an inability to form other-regarding moral beliefs, a defect which is graphically illustrated by a case report from the literature. I explore the implication of this kind of defect for [End Page 261] moral responsibility as a socially-embedded notion, and the implication of the psychopath’s inability to exercise prudence in relation to legal liability.Nothing in this paper should be taken to suggest that psychopaths are irredeemable. On the contrary, as I argue in an endnote, correctly characterizing the defect from which they suffer leads directly to forms of treatment whose effectiveness has acquired a measure of empirical support.The Nature of PsychopathyPsychopathy is not a homogeneous concept; there are different types of psychopaths. For example, Henderson identified a type of psychopath who he classified as “Predominantly Creative,” exemplified by such figures as T. E. Lawrence and Joan of Arc. In people of this type genius is associated with heightened sensitivity, psychosexual immaturity and emotional instability (Henderson 1939, 108–20; Henderson and Gillespie 1969, 317). Predominantly creative psychopaths do not come within my purview.By “psychopathy” I shall mean the specific form of personality disorder described by Cleckley in his book, The Mask of Sanity (Cleckley 1964). Cleckley’s description forms the basis of Hare’s Revised (20-item) Psychopathy Checklist. The Checklist includes the following personality traits and deviant behaviors:1. Glibness/superficial charm.2. Grandiose sense of self-worth.3. Need for stimulation/proneness to boredom.4. Pathological lying.5. Conning/manipulative.6. Lack of remorse or guilt.7. Shallow affect.8. Callous/lack of empathy.9. Parasitic lifestyle.10. Poor behavioral controls.11. Promiscuous sexual behavior.12. Early behavior problems.13. Lack of realistic, long-term plans.14. Impulsivity.15. Irresponsibility.16. Failure to accept responsibility for own actions.17. Many short-term marital relationships.18. Juvenile delinquency.19. Revocation of conditional release.20. Criminal versatility (Hare 1986, 18). 1This conceptualization resembles in many respects the category of Antisocial Personality Disorder as described in the American Psychiatric... (shrink)

Fichte offers separate analyses of the conditions for the possibility of representing or referring to (i) material objects and (ii) other minds – extra-subjective entities of importantly distinct sorts. These analyses are importantly akin, in that both postulate, as a necessary condition for the mental accomplishment under consideration, some sort of basic incapacity or limitation that is partly constitutive of human rationality. But the two accounts also involve interestingly different understandings of the nature and implications of the basic (...) constraints in question. As a first approximation, we can say that, for Fichte, (i) a rational being posits a putatively mind-independent object only if that being’s self-initiated mental activity encounters a pre- or proto-objective “check” or “affront” (Anstoß), and (ii) a rational being can first become concretely conscious of its own capacity for rational self-determination only as the addressee of a “summons” (Aufforderung) that calls upon it to actuate that very capacity. -/- In this essay I roughly reconstruct the indicated arguments. In the process, I endeavor to show that Fichte does not suppose that either argument firmly backs philosophical assent to the existence of material objects or of other minds. On the contrary: the goal of his professed ‘deductions’ of our everyday ‘convictions’ concerning such things is not to philosophically legitimate those prephilosophical beliefs. Instead, the aim of these arguments is to vindicate Fichte’s transcendental idealism – which, if anything, epistemically undermines said beliefs – by demonstrating that any experience that is putatively ‘of’ such things has, as its necessary and sufficient conditions, nothing but states and activities of the I. Thus, in the case of material objects, a radical difference manifest within the I – self-initiated rational activity versus “simple sensation” – is ‘set forth’ (vorgestellt) in a representation (Vorstellung) of an extra-subjective bearer of sensed qualities. And – much more controversially – in the case of other minds, a demand that the I (qua pure reason, constitutively committed to its own unlimited self-activity and efficacy) makes upon itself (qua rational individual capable of intelligent self-determination) is outwardly depicted as an appeal originating from an extra-subjective source. (shrink)

Decision-making capacity (DMC) is normally taken to include (1) understanding (and appreciation); (2) the ability to deliberate or weigh up; and (3) the ability to express a choice. In an article published recently in PPP, Jacinta Tan and her colleagues (2006) suggest that DMC requires also (4) the absence of 'pathological values' (i.e., values that arise from mental disorder). In this paper, I argue that although (1)–(3) might be necessary for DMC, (4) is not necessary (barring cases where pathological (...) values interfere with (1)–(3)). My argument will simply be that (4) fails to be supported by the empirical data provided by Tan et al., which I claim supports the view that people with pathological values do often have DMC. I also consider but reject the claim that pathological values entail incapacity because they are not 'authentic' to the person. I conclude that the absence of pathological values does not constitute an additional element of DMC and that we cannot justify compulsory treatment of people who have (1)–(3), but not (4), on the grounds they lack DMC. (shrink)

Human beings pass through a series of life stages since birth. These stages beginning at the infancy even in the mother’s womb are accompanied with a period extending to the senescence and the last stages of the life. Creation of human beings and various stages of the life are mentioned in the Qurʾān. Besides, it is referred to the senescence. In addition to the expressions sheikh, shayb, ʽajūz and kibar indicating to the senescence, ardhal al-ʿumur is also pointed out in (...) the Qurʾān in this regard. This article aims to identify in which context and meaning the wording regarding ardhal al-ʿumur and senescence are used in the Qurʾān and to reveal the relation between these terms. Since, the term ardhal al-ʿumur and senile dementia are directly correlated in the commentaries usually and the interpretations build the perception that these two expressions are almost synonyms. Are ardhal al-ʿumur and dementia closely associated with each other? Are the other terms in the Qurʾān indicating to the senescence correlated with the dementia? Our study aims to explain the expression ardhal al-ʿumur in the Qurʾān in this regard. Furthermore, the other terms regarding the senescence expressed in the Qurʾān are reviewed in this respect. SUMMARY The Qurʾān tells the creation of human beings and refers to the various stages of their lives as well. The explanations beginning with the creation state the prenatal period, infancy and childhood, adolescence and adulthood of human beings. The Qurʾān refers to the senescence as well, the last stage of the life. In this regard, ardhal al-ʿumur, sheikh, shayb, ʽajūz and kibar are the terms in the Qurʾān associated with the senescence. Especially nowadays, the senescence is a considerable focus of the science, besides being mentioned in the Qurʾān. This article discusses the subject scientifically as well. The senescence is defined with various aspects since it expresses a period having physical, psychological and social dimensions. Furthermore, certain classifications regarding the senescence are made and physiological changes associated with the chronological age are more emphasized. It has been indicated that the senescence is divided into two: biological and chronological aging. According to this chronological aging is the same for everyone while biological aging varies from individual to individual. The senescence is acknowledged as the last development stage of the human life in terms of social sciences and considered as an on-going universal process between birth and death. Therefore, the senescence is interpreted relatively while the aging is interpreted universally. So, everyone gets old; however, the senescence means a life period varying from individual to individual. The senescence affects the individual both health-wise and psychologically, sociologically and economically. In other words; the senescence, a tough period, is a phenomenon which deeply affects the human beings and all their characteristics making them exist. The senescence is addressed in the Qurʾān with various expressions. Ardhal al-ʿumur, foremost among these, is mentioned twice in the Qurʾān (al-Nakhl 16/70, al-Ḥac 22/5). The exegetes generally consider ardhal al-ʿumur as the physiological exhaustion of an individual due to aging and as the period when dementia is experienced. The characteristics of the stage called as ardhal al-ʿumur in the Qurʾān are explained with the following statement: turning into a person who does not know anything from the person who used to know many things. Just because of this sentence, ardhal al-ʿumur is construed with dementia. Are arzali’l-ʽumur and dementia directly interrelated? This article also reviews the other terms stated in the Qurʾān regarding the senescence from this aspect. Sheikh, another expression stated in the Qurʾān regarding the senescence, is mentioned four times (Hūd 11/72, Yūsuf 12/78, al-Qaṣaṣ 28/23, al-Muʼmin 40/67) and it is described with the word kabīr in two of them. The lexical meaning of sheikh is an old person in terms of age and appearance. Moreover, sheikh is used as an adjective to describe the individuals who have wisdom in customs. So, the word sheikh both means an individual who is well on in life and is the expression of supremacy in terms of knowledge and experience. Shayb, another expression stated in the Qurʾān regarding the senescence, is mentioned three times (Maryam 19/4, al-Rūm 30/54, al-Muzzammil 73/17) and means hair greying and describes a physiological change in the senescence. ʽAjūz stated in the Qurʾān for the senescence is mentioned in four different chapters (Hūd 11/72, al-Shuʽarā’ 26/171, al-Ṣāffāt 37/135, al-Dhāriyāt 51/29) and expresses incapacity of performing many actions. ʽAjūz is another expression in the Qurʾān meaning elderliness. The senescence is implied with this expression too; however, the dementia is not mentioned. Kibar, the last wording associated with the senescence, is mentioned in six verses (al-Baqara 2/266; Āl-i-ʽImrān 3/40, Ibrāhim 14/39, al-Hicr 15/54, al-Isrā 17/23, Maryam 19/8). The word kibar means the senescence and physical power loss; nevertheless, is not interpreted as dementia. To our knowledge, the explanations regarding the senescence and dementia in most of the commentaries cannot be corresponded in the Qurʾān as if they are synonyms. This perception can be generated due to the statements pointing out the dementia in the lexical meaning of ardhal al-ʿumur. It is understood in the light of the data acquired by today’s science that the dementia is not a natural result of the senescence but rather one of its risks, which is already proved by the fact that the science discusses the dementia separately from normal aging process. Therefore, there is not a general picture of dementia including all elders. Thus, it is possible to define ardhal al-ʿumur as a later part of life which includes some elders and affects them physiologically, psychologically, sociologically, etc., in addition, they lose their mental faculties in that period. Each expression regarding the senescence in the Qurʾān reveals the picture of the senescence pursuant to the integrity of the Qurʾān. The senescence in the Qurʾān is an ineluctable reality. The fact that this period is clearly expressed in the verses aims that this reality can be perceived by human beings and they can be prepared for this period. Some problems that elders experience are also mentioned in the Qurʾān. When the other terms in the Qurʾān associated with the senescence apart from ardhal al-ʿumur are reviewed, it is seen that the aforementioned problems that may be observed at later ages are hair greying, bone diseases, incapability and weakness in doing some actions. Today, there are various disciplines concerning the elders and the information obtained from these disciplines shows that these problems are a lot more than the ones mentioned in the Qurʾān. However, it is not expected that the Qurʾān discusses the facts as a science book since it is a holy book. When ardhal al-ʿumur is evaluated in the light of scientific data, it appears as a sickness period when some elders experience mental problems such as dementia/blackout. On the one hand, there will be elders who experience these problems; on the other hand, there will be some who do not. All expressions regarding the senescence in the Qurʾān do not lead to the fact that the aging leads to the dementia directly. Ardhal al-ʿumur within the integrity of the Qurʾān expresses that senile dementia affects some individuals while it has not any impact on the others. Therefore, ardhal al-ʿumur is one of the life stages affecting not every elder but some of them. The fact that different terms are stated in the Qurʾān regarding the elders points out various aspects of the aging process creating different effects. The second important reason why the aging is mentioned in the Qurʾān is to emphasize the value of the elders and the respect that should be showed to them. Besides, it is also underlined in the Qurʾān that the elders are so precious that they cannot be left alone socially and psychologically. Furthermore, the elders are the individuals worthy of love and being valued. Thus, it is suggested in the Qurʾān to love, respect and honour the elders and to live with them regardless of whether they will experience ardhal al-ʿumur or not. Therefore, the human beings are reminded to look after the elders, esteem them materially and morally, as they deserve, and to act considering the characteristics of this period. (shrink)

This Article falls into three general parts. The first part starts with an important question: is the insanity defense constitutionally required? The United States Supreme Court will finally try to answer this question next term in the case of Kahler v. Kansas. -/- I say “finally” because the Court refused to answer this question in 2012 when it denied certiorari to an appeal brought by John Joseph Delling, a severely mentally ill defendant who was sentenced to life in prison three (...) years earlier for two murders. Delling never had the opportunity to plead the insanity defense because his home state, Idaho, had abolished it in 1982. -/- By depriving Delling of the right to plead insanity, Idaho violated Delling’s Fourteenth Amendment right to due process and his Eighth Amendment right against “cruel and unusual” punishment. Naturally, the same is true for many other mentally ill and disabled defendants who have been prosecuted in Idaho and in the other three states that have abolished the insanity defense: Kansas, Montana, and Utah. -/- The second general part of this Article notes an insight that I stumbled upon in the course of researching the first part: the insanity defense and the mistake of law defense both require ignorance of the law, what I refer to as “normative ignorance.” Indeed, normative ignorance is what makes both of these defenses exculpatory in the first place. -/- Given this critical connection, there is a way for Idaho, Kansas, Montana, and Utah to resume compliance with the Constitution. Instead of reinstating the insanity defense per se, which might be politically unpopular, they should just broaden their mistake of law defense to include normative ignorance caused by cognitive incapacity that is itself caused by mental illness or disability. -/- Still, this Article is not merely directed at these four western states. It is directed at the other forty-six states as well. Because they already have an insanity defense, they need not incorporate it into their mistake of law defense. But in the third general part, I will argue that they should still expand their mistake of law defense to cover defendants who either lack a reasonable opportunity to learn the law or reasonably but mistakenly infer from widely accepted norms or ethics that their conduct is lawful. (shrink)

Differences in guidance from various organisations is preventing uniform standards of practiceThe emphasis in medical law and ethics on protecting the patient’s right to choose is at an all time high. Apart from circumscribed situations, for instance where the Mental Health Act 19831 is applicable, the only justification for medically treating an adult patient against his or her wishes is on the basis of common law, using the principle of best interests, and only when he or she lacks capacity (...) to refuse treatment. As a result, it is important that clinicians should be able to assess capacity to refuse treatment. Given that judgements of incapacity involve deciding that a person does not have the ability to refuse treatment, a great deal of care needs to go into the assessment and characterisation of incapacity.There is divergence between the characterisation of capacity that is used by the courts and that which is recommended by the British Medical Association . The BMA usefully expands on the first element of capacity as set out in the standard legal definition of capacity in the Re C judgment2 but ignores the other two elements. By doing this, the BMA makes it unclear whether it is rejecting these as relevant to capacity; it also misses the opportunity to expand on these elements in a clinically useful way.We will begin with a description of the BMA’s advice3 and the standard English legal definition of capacity.2,4 Then we will show that there are important discrepancies between these two sources of advice. We think that the BMA ought to clarify its position on capacity in order to safeguard the interests of physicians, healthcare workers, and patients.THE RE C TESTMr C was a patient in a psychiatric secure hospital who had chronic paranoid schizophrenia with …. (shrink)

According to property-emergentism, consciousness is an emergent property of certain aggregate neurological constructions, whereas substance-emergentism maintains that the emergence of consciousness depends on the emergence of mental substance or soul. In this article, we presented some arguments supporting substance-emergentism by analysing various properties of consciousness, including the first-person perspective, referral state, qualia, being active, causative, non-atomic, interpretative, inferential and inventive. We also explored the impossibility of representing big images on the small monitor and the incapacity of physical entities (...) being conscious because of their intrinsic multiplicity, absence and deficiency. These arguments, which apply the philosophy of Mulla Sadra, could be considered by philosophers of mind and religion, as well as theologians who follow some religious beliefs such as the afterlife on existence and survival of the soul. Also, we attempted to respond to property-emergentists' objections to substance-emergentism.CONTRIBUTION: This research contributes to prove and accept the emergence of the immaterial soul after the stages of natural evolution of the body. It uses the basics of emergentism, including natural evolution, to link science and religion in believing the existence of the immaterial soul. Demonstrating the immaterial reality of human existence provides the ground for theological issues such as afterlife and religious morality. (shrink)

Nonadherence to treatment continues to be one of psychiatry's greatest challenges. To improve adherence and thus improve the care of patients, clinicians and patients' family members sometimes resort to hiding medication in food or drink, a practice referred to as covert/ surreptitious medication. The practice of covert drug administration in food and beverages is well known in the treatment of psychiatrically ill world-wide but no prevalence rates exist. Covert medication may seem like a minor matter, but it touches on legal (...) and ethical issues of a patient's competence, autonomy, and insight. Medicating patients without their knowledge is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of care giving. The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent. Ethically, covert/surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Covert medication contravenes contemporary ethical practice. Legally, treatment without consent is permissible only where common law or statute provides such authority. The practice of covert administration of medication is not specifically covered in the mental health legislation in developing countries. Many of the current dilemmas in this area have come to public attention because of two important developments in medical ethics and the law - the increasing importance accorded to respect for autonomy and loss of the parens patriae jurisdiction of the courts [parens patriae means 'parent of the country'; it permitted a court to consent or refuse treatment on behalf of an 'incapacity', or alternatively to appoint a guardian with such powers]. (shrink)