In this paper, we make the case that a person who is considering or has already made a decision that appears seriously harmful to that person should in some cases be judged incapable of making that...

If a person is competent to consent to a treatment, is that person necessarily competent to refuse the very same treatment? Risk relativists answer no to this question. If the refusal of a treatment is risky, we may demand a higher level of decision-making capacity to choose this option. The position is known as asymmetry. Risk relativity rests on the possibility of setting variable levels of competence by reference to variable levels of risk. In an excellent 2016 article inJournal of (...) Medical Ethics(JME), Rob Lawlor defends asymmetry of this kind by defending risk relativity, using and developing arguments and approaches found in earlier work such as that of Wilks. He offers what we call the two-scale approach: a scale of risk is to be used to set a standard of competence on a scale of decision-making difficulty. However, can this be done in any rational way? We argue it cannot, and in this sense, and to this extent, risk relativity is a nonsense. (shrink)

In their article “Three Kinds of Decision-Making Capacity for Refusing Medical Interventions,” Navin et al. (2022) argue that we should recognize two forms of decision-making capacity (DMC) besides...

Because autonomy is regarded as central to modern bioethics; there is a considerable focus on the criteria by which autonomy may be judged. The most significant criterion used in day-to-day practic...

Introduction : the existence of mental illness -- The likeness argument -- The categorical argument -- Metaphor -- Two metaphors from physical medicine -- The metaphor of mental illness -- Attention deficit hyperactivity disorder, social construction, and metaphor -- Metaphors and models.

In their recent article “A Gentle Ethical Defence of Homeopathy,” Levy, Gadd, Kerridge, and Komesaroff use the claim that “lack of evidence is not equivalent to evidence of lack” as a component of their ethical defence of homeopathy. In response, this article argues that they cannot use this claim to shore up their ethical arguments. This is because it is false.

Should we be Roschians about the concept of disease, rather than taking a classical approach? A classical concept of disease defines disease in terms of necessary and sufficient conditions; any things and only things which meet this definition are members of the class. In Roschian concepts of disease, it is supposed that degree of similarity to a prototype determines membership in the class of diseases. In this paper, the two approaches are pitched against one another in a series of tests (...) which appear on first sight to favor Roschian accounts.These tests are 1) the capacity to accommodate the variety of the class of disease, 2) the capacity to explain controversies about disease attribution, and 3) the capacity to... (shrink)

I WOULD LIKE TO respond to the four commentaries in turn. In each case I have started by setting out what I think the commentaries are claiming; in doing so, I may reveal that I have misunderstood or misconstrued, and I apologize where this is the case. My responses in many cases are provisional: the commentaries have given me much to think about. Also, my responses are selective—there are many points not touched upon here that deserve consideration. Finally, the order (...) of my responses is arbitrary. (shrink)

In two of his great poems, “Ambulances” and “The Building,” Philip Larkin considers a deep fear about human individuality. The fear is that the human self is contingent and disjunctive, lacking any integrity or unity. The arrival of an ambulance on an urban curb and a visit to the hospital are the occasion of reflection on this form of human fragility. But more significant, the ambulance and the hospital are imagined as contexts in which the contingency of the human individual (...) is brought out and laid before us. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.1 (2005) 1-7 [Access article in PDF] Clinical Practice, Science, and the Unconscious Douglas McConnell Neil Pickering Keywords psychotherapy, cognitive science, neuroscience, computational view of mind. This volume of Philosophy, Psychiatry, & Psychology is devoted to questions about the unconscious mind. The philosophical complexities and difficulties associated with the unconscious are many and, despite widespread confusion and disagreement as to the nature of the unconscious (...) mind, it is used as a concept informing psychotherapy. It is therefore not surprising that papers in a special edition on the unconscious might be weighted heavily toward uncovering a justifiable conceptual niche for the unconscious and elaborating on some of the main conceptual connections. Although this makes for a slightly more philosophical edition of PPP than usual, those perhaps less interested in philosophy and more interested in actual psychiatric practice can incorporate the concepts and insights developed in these papers into their practice as they see fit.The three main articles take three quite distinct approaches to the unconscious. Schechtman (2005) addresses the need for a theory of personal identity to incorporate the unconscious and presents one that does so by developing some central Lockian intuitions. Church (2005) investigates whether the kinds of things happening in the unconscious can be explained by cognitive operations not normally associated with consciousness, specifically, spatial structuring of experience. McConnell and Gillett (2005) clarify some of Lacan's ontology of the mind where the language encountered and used by the subject provides the structure for their unconscious.The aim of this introduction is to ask and try to answer a question that logically precedes those raised in the articles in the light of the therapeutic use of the unconscious. When dealing with psychoanalysis or psychoanalytic concepts in an Anglo-American context, the struggle that psychoanalysis has had and continues to have in a psychiatric domain ruled by science is never far from the spotlight. Indeed Hinshelwood (2005) also picks up the importance of this conflict when replying to McConnell and Gillett. It seems to be historically true that the unconscious has fallen out of favor in scientific and psychiatric circles (it is no surprise that psychiatric training is largely based in "hard," that is, biological and biochemical science) particularly over the last 50 years or so. But is the scientific skepticism to be found about the use of the unconscious well-founded? And how does the continued utilization [End Page 1] of the unconscious by the therapist fit into current practice given this skepticism? Psychotherapy and the Unconscious In psychotherapy, the therapist and the client together construct a story that explains why the client is having some form of difficulty in his or her life. The stated aim is to enable the client to overcome this difficulty by gaining an understanding of what has generated it. Doing so may be a first step to dealing with that conflict. For example, an office worker who is scared of the boss and whose life at work is a misery as result may come to think that the boss is a reminder of some threatening figure from childhood and that the reaction is a regression to infantile behavior. Knowing this, the fear of the boss can be revisited—perhaps reconfigured, perhaps overcome—and life may improve. In the process of therapy, the relation of the figure from childhood to the boss is made conscious. But it was still operative before it was made explicit, even though the client did not realize it and some would say that the client's unconscious had somehow buried the memory from childhood or hidden from the client the relation of this memory of a threatening figure to the boss.A description of the content of the unconscious is, then, an intentional description involving the client's thought life, one made to help an individual understand otherwise unintelligible (to that individual) feelings, beliefs, desires, actions, and so on. Subjects' intentions are their normatively structured mental representations of, and attitudes toward, the world (e.g., "He is my boss"; "I am afraid of him"). An intentional unconscious description then takes an intentional form... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics CommentaryNeil Pickering, Senior LecturerA doctor whose practice may threaten the well-being of his patients must surely be reported to the proper authorities. But the case of Dr. G opens up some deeper issues. Dr. G can legitimately be understood as a clear case of mental illness, but there is another possible view of what is going on, that he has had a religious experience. With respect to Dr. (...) G’s fitness to practice, psychiatrists will have rather different responsibilities depending on which of these views of his experiences they take. A difficulty that has to be faced in cases like that of Dr. G is how to make the distinction between mental illness and religious experience, and beyond that, to what extent society can make room for both.It is understandable that the psychiatrist and other health workers who come into contact with this patient would think he has a psychosis and would want him to take anti-psychotic medication. What else are they to think of this man who hears voices (one of the possible diagnostic criteria for schizophrenia), which have become more frequent and insistent over time, and now seem to be exercising control over his actions (another of the possible diagnostic criteria for schizophrenia) — commanding him to walk along the expressway and telling him that he will one day be a saint? This pattern of behaviour must surely be very familiar to them, from their textbooks and to some extent in their day-to-day practice, though no doubt the details vary from patient to patient.In Dr. G’s case, much about what has happened — and perhaps ought to happen — fits in with the practices of major societal institutions such as the police and the health authorities, and fits well with patterns [End Page 245] of behaviour witnessed before and which professionals have been trained to recognise and to respond to. Moreover, the “mental health” response is a well-practised one, and one which, I would venture to say, has done much good in the lives of many, and may perhaps do much good in the life of Dr. G, for example by enabling him to return to his usual life and practise as a doctor.But are these the only possible reactions in Dr. G’s case — and are they the right ones? One need not subscribe to any kind of scepticism in general about mental illness to raise questions about the standard reactions of police and health services in a case such as this. To understand Dr. G’s actions, one could appeal, instead, to another familiar enough pattern — though it is perhaps rather weakly represented in more secular forms of modern thinking — into which Dr. G’s sort of behaviour may also fit. The idea of someone receiving a revelation from God and altering their whole life is a common enough trope of religious teaching. In the Christian tradition, Jesus’ disciples were plucked, as it were, from their various ordinary lives — fishermen becoming fishers of men — and seemingly overnight they took on a new life. There was something in the voice of Jesus which called to them, and which convinced them of its authority.An interesting case, with some parallels to that of Dr. G, is reported by Maurice O’Connor Drury. From 1947, Drury practised as a psychiatrist (Danger of Words: xxviii),1 but had earlier been a philosophy student of Wittgenstein, and retained a strong relationship with him up until the philosopher’s death in 1951. Here is the case as he introduces it:Mr. D was sixty-seven years of age, a retired civil servant, a man of great piety who devoted his retirement to prayer and works of charity. His wife had no sympathy for what she regarded as a morbid religiousness. One morning at Mass he heard the words of the Gospel: ‘Go and sell all that thou hast and give to the poor and thou shalt have treasure in heaven, and come and follow me.’ These words spoke to him like a command. And straightaway he left the church, putting all the money that was on him into the poor-box at the... (shrink)

Mental health legislation that requires patients to accept ‘care’ has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. (...) We also examine how the doctor is legally obligated to compound the epistemic problems by the knowledge they prioritise and the failure to generate new knowledge. Specifically, we describe the problems of testimonial epistemic injustice, epistemic silencing, and epistemic smothering, and address the possible justification provided by epistemic paternalism. We suggest that there is no reasonable epistemic justification for mental health legislation that creates an environment that fundamentally unbalances the doctor–patient relationship. Significant positive reasons to counterbalance this are needed to justify the continuation of such legislation. (shrink)

In New Zealand, there are adolescents who are at risk of pregnancy and who do not want to become pregnant, but are not using contraception. Cost and other barriers limit access to contraception. To address the gap between contraceptive need and contraceptive access, this paper puts forward the concept of proactive contraception provision, where adolescents are offered contraceptives directly. To strengthen the case for proactive contraception provision, this paper addresses a series of potential objections. One is that such a programme (...) would cause harm; another that such a programme would not have sufficient benefit. In rebutting these objections, the conclusion is reached that proactive contraception provision is a model worth pursuing as a means of meeting the needs of the New Zealand adolescent population and may be of interest more widely. (shrink)

A fundamental issue in the philosophy of psychiatry is that of the reality of mental illness: is there any such thing as mental illness? The dominant means of resolving this issue—either for or against—is the likeness argument. This states that mental illness exists, or does not, depending on the extent to which putative mental illnesses (such as alcoholism or schizophrenia) are like universally accepted illnesses (such as pneumonia). To succeed, this argument has to assume (1) that the features of conditions (...) such as schizophrenia will decide whether they are illnesses or not and (2) that the existence of these features can be determined independently of the question whether they are illnesses or not. Both assumptions can be questioned. A weaker objection to the likeness argument questions the first, but it is possible to overcome it. A stronger objection questions the second assumption, and is successful in undermining it. This also undermines the first assumption. As a result, the likeness argument will fail. Two major objections to the stronger objection are considered and accommodated. (shrink)

This feature in Philosophy, Psychiatry, & Psychology (PPP) is intended to provide ongoing commentary on main articles previously published in PPP. The essay by Pickering below is a response to Bengt Brülde’s paper in PPP (14, no. 2:93–102).

In lieu of an abstract, here is a brief excerpt of the content:ConclusionNeil PickeringAs mentioned in my Introduction, and I am delighted to repeat now, the commentaries provided by Calvin Ho and Chua Hong Choon are both excellent. In reading them, some further thoughts were raised for me, and I briefly reflect on these now.In his legal commentary, Calvin Ho makes a plausible argument that Mr. T has the capacity (and hence the right) to make decisions in his current state (...) about his healthcare, and refers to two legal tests of decision-making competency laid down in the Singapore Mental Capacity Act (2008), which he believes Mr. T would pass. A question arises from each of the legal tests which Ho described.The first test involves the question of whether there is any “impairment of, or disturbance in the functioning of Mr. T’s mind or brain”. The claim made by Ho is that there is no impairment or dysfunction of Mr. T’s mind or brain. But, this raises a question: what are the functions of the mind? Christopher Boorse suggested that “We may surely assume … that the main function of perceptual and intellectual processes is to give us knowledge about the world” and against this standard “schizophrenia and all other psychoses with thought disorders look objectively unhealthy”.1 Further — and here is the specific point of discussion in relation to Mr. T — does his continuing denial that he is ill (his lack of insight) also constitute such a dysfunction? Is one function of our mind to tell us things about the functioning of our minds — to correct errors, spot illusions and self-deceptions, and respond to beliefs which are odd? If so, then perhaps Mr. T’s lack of insight indicates the presence of a dysfunction.The second test which (mainly for the sake of completeness) Calvin Ho refers to comprises a list of requirements for decision-making capacity. These are relevant if a dysfunction is identified by the first test. These are:(1). Understand information given to him;(2). Retain that information long enough to make the decision;(3). Use or weigh up that information as part of the process of decision-making; and(4). Communicate his decision.These requirements are familiar from other accounts of decision [End Page 222] making capacity, but at least some of these accounts have added a further requirement, “the ability to appreciate the nature of the situation and its likely consequences”.2 This is not merely the ability to understand what one is being told but also the ability “to apply the information abstractly understood to [one’s] own situation”. Potentially, Mr. T would fail this test. He frequently lacks insight into the fact that he is unwell, that is to say, he does not seem to appreciate that the information he is being given is true of him.I turn now to the clinical commentary by Dr. Chua. What chiefly struck me from this was the determination to engage with the patient as a person. Medication is not the first resort; rather, many other interpersonal approaches can and should be tried first. Medication is of course one aspect of treatment — and in some cases, any hope of any sort of engagement with a patient may rely upon some medical intervention succeeding. Perhaps Mr. T will turn out to be a patient of this kind, who can only be engaged in conversation about his experiences and the state of his mind if he has first taken a course of pills. But it has, over a number of years of speaking to psychiatrist colleagues, been borne in upon me that the psychiatrist himself or herself is a fundamental element of mental healthcare. The psychiatrist is not merely a route to help, the dispenser of prescriptions for pills, but someone with whom the patient can talk to and explore his or her experiences. In short, part of the therapeutic relationship which psychiatrists seek to establish is just a personal relationship. I am sure this is simply obvious to most clinicians and indeed to those who suffer from mental ill health and their caregivers. But sometimes, the obvious is worth pointing out.Indeed, the desire to engage with Mr. T as a person... (shrink)

In a recent JME article, Guidry-Grimes, Dean and Victor offer some signal and challenging insights into the ethical analysis of covert medication and in particular when administered via food. They warn of impacts on identity likely to emerge from using food in this way. In particular, they caution against allowing families to be involved in covert medication, in the light of their central role in sustaining identity. Their analysis has particular purchase in resource rich contexts and those contexts where individual (...) identity is a central concern. But it is less clear that the article’s insights are relevant to other contexts. This article places the analysis of covert medication and identity in a wider context, arguing both that the focus on identity is equally significant when analysing potential alternatives to covert medication, such as coercion; and that the ethical analysis of covert medication offered by Guidry-Grimes, Dean and Victor lacks global applicability. It seems to lack application particularly in resource-poor contexts, and in cultures where identity and community are interconstituted. (shrink)

Thomas Szasz, the radical critic of state-supported psychiatry, and root and branch sceptic about mental illness, died in September 2012. Based on the obituary1 and editorial comment in The Lancet2 and the response his work commonly elicits, it is evident that there will be mixed reviews of his impact and of the cogency of his position.Certainly, some have seen him as a notable figure from the past. There is a sense in which, as far as Szasz's critique of psychiatry goes, (...) it did not really change at all in its essence from the time it was first explicitly expressed in his writings of the 1960s right up to his last publications and talks in the 2010s. He started his 1960 paper The Myth of Mental Illness3 with the assertion that there is no such thing as mental illness, and this has been an underlying pedal note to all his many pronouncements in this area ever since. Personally, I have always found his written interventions in debates right up to the present to be highly readable and intellectually sharp; he was adept at creating variations on the Szaszian theme. In one of his earlier book length texts, The Manufacture of Madness,4 he likens the contemporary idea that people have mental illness to the historical idea that some people were witches, and he parallels the institutions of modern state-supported psychiatry to those of the Inquisition. In articles he later published in the Journal of Medical Ethics, he likened mental illness to ‘phlogiston’—the non-existent substance that supposedly explained combustion5 and claimed the term ‘mental …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics CommentaryNeil Pickering, Senior LecturerThe underlying problem for Mr. T’s doctors and his wife is that Mr. T seems unable for much of the time to realise that he is ill. This gives his doctors and other mental health workers, and indeed his wife, very little room for manoeuvre with him. His illness apparently makes him dangerous, because of his beliefs that others are involved in conspiracies against him, (...) which seem to arise from his condition, and this danger particularly affects his wife who has been subject to threats by Mr. T. The initial question is whether Mr. T’s doctors should support or collude in Mrs. T’s proposal to medicate her husband surreptitiously — and if not, what is the alternative? A no less important question is how Mrs. T’s safety might be assured. Underlying these issues is a wider question about the relation between the mentally ill and their doctors, relations (partners and other family members) and society. Mr. T’s behaviours threaten to isolate him from his loved ones and from society.Presumably, Mrs. T’s hope is that giving Mr. T medication will keep his symptoms under control, ensuring her safety and enabling him to retain his relationship with her and perhaps with others; in short, maintaining his place in society. There is also strong evidence that a delay in psychiatric treatment is related to poorer outcomes in terms of, for example, increased morbidity.1 Moreover, some form of long-term medication does seem to be the main hope of achieving a desirable outcome in Mr. T’s case. It seems from the case description that some control of Mr. T’s symptoms results from his taking his medication, and his return to delusions comes only when he gives up on it. It is not made clear, however, why he does give up on it. [End Page 212]From the description of Mr. T, one gets the strong impression of behaviours dominated by the command hallucinations and the paranoid delusions that seem to gather around them. However, there are also, perhaps, periods where other motivations and beliefs have some grip on his life. We are told he has a job, and of course he has the relationship with his wife. What seems to happen is that, at least as far as the latter goes, when his illness reasserts itself, the meaning of his wife’s relationship to him becomes changed in his mind, and Mrs. T becomes part of the conspiracy he believes aims to kill him.Nonetheless, it is unacceptable for Mr. T’s doctors to support Mrs. T’s plan or to collude in it. The primary reason for this is not that it will be a potential disaster — though it stands a good chance of failing and going terribly wrong. There may be dangers to those who administer covert medication if discovered by a paranoid patient in addition to dangers for Mr. T who may misinterpret the side effects of the drugs he is unaware he is taking, or take other drugs that may interact with the drug he is receiving covertly.2 The primary objection to psychiatrists’ colluding in this is that using a third person to surreptitiously deliver medication to Mr. T is to betray his trust in the medical profession, and that this is unacceptable.Mr. T seems to have at best an ambivalent relationship with the medical profession. He seems unable to develop any long-term trust in them, and after a short time off his medication, any trust he may have developed disappears and he turns to his own judgement as to whether he is ill or not, ignoring the advice of his psychiatrist. The trust that the medical profession enjoys from patients is partly responsible for giving it its authority over their actions; and is partly why doctors and other health workers are offered great access to details about a person’s private life. Since this is so basic to the success of the doctor-patient relationship, but is also rather fragile, it is incumbent upon doctors to seek to retain their patients’ trust.So, in the usual situation, the patient and doctor... (shrink)

The role of literature and imagination in medicine and medical ethics is currently under discussion. This paper argues that the role of literature is not to furnish generalisable examples for guidance. Rather, engagement with literature parallels moral engagement with other people. The work of the imagination, in this context, is not to hypothesise, but to grant life to the characters and world of literature. In doing this, one may develop one's moral life.

In this short response to Gray’s article Capacity and Decision Making we double down on our argument that risk-relativity is a nonsense. Risk relativity is the claim that we should set a higher standard of competence for a person to make a risky choice than to make a safe choice. Gray’s response largely involves calling attention to the complexities, ramifications and multiple value implications of decision-making, but we do not deny any of this. Using the notion of quality of care (...) mentioned by Gray, we construct an argument that might be used to support risk relativity. But it is no more persuasive than the arguments put forward by risk-relativists. (shrink)

This paper aims to explore some key methodological issues in comparative and cross-cultural bioethics, through a discussion of a particular example: childhood and adolescent Attention Deficit Hyperactivity Disorder.1 At its heart, this paper makes an argument for a transcultural approach to bioethics. The argument starts with the examination of a conceptually mistaken and empirically unsustainable belief that culture is inevitably a force for difference. This “difference presumption” appears in various guises, for example in the belief that West and East have (...) altogether different “mentalities” and ethical ideas, reflective of a number of dichotomies such as individualization vs communitarianism. This... (shrink)

Are there any characteristics by which we can reliably identify and distinguish quackery from genuine medicine? A commonly offered criterion for the distinction between medicine and quackery is science: genuine medicine is scientific; quackery is non-scientific. But it proves to be the case that at the boundary of science and non-science, there is an entanglement of considerations. Two cases are considered: that of homoeopathy and that of the Quantum Booster. In the first case, the degree to which reported phenomena that (...) question established theory should be doubted arises; in the second case, the status of pleomorphism as a scientifically plausible doctrine is discussed. The application of the criterion of being scientific to these cases reveals something of the nature and density of the entanglement. (shrink)

It is commonly thought that mental disorder is a valid concept only in so far as it is an extension of or continuous with the concept of physical disorder. A valid extension has to meet two criteria: determination and coherence. Essentialists meet these criteria through necessary and sufficient conditions for being a disorder. Two Wittgensteinian alternatives to essentialism are considered and assessed against the two criteria. These are the family resemblance approach and the secondary sense approach. Where the focus is (...) solely on the characteristics or attributes of things, both these approaches seem to fail to meet the criteria for valid extension. However, this focus on attributes is mistaken. The criteria for valid extension are met in the case of family resemblance by the pattern of characteristics associated with a concept, and by the limits of intelligibility of applying a concept. Secondary sense, though it may have some claims to be a good account of the relation between physical and mental disorder, cannot claim to meet the two criteria of valid extension. (shrink)