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)

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 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 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)

PurposeMedical assistance in dying (MAiD) in Canada places the medical provider at the centre of the process. The MAiD provider holds primary responsibility for determining eligibility and becomes acquainted with patients’ inner desires and expressions of suffering. This is followed by the MAiD procedure of administering the lethal agent and being present at the death of eligible patients. We report participants’ perceptions of the emotional and moral impacts of this role.MethodologyTwo years after MAiD was legalised in Canada, 22 early-adopting physician (...) providers were interviewed. Data were examined using both phenomenological analysis and a novel ChatGPT-enhanced analysis of an anonymised subset of interview excerpts.FindingsParticipants described MAiD as emotionally provocative with both challenges and rewards. Providers expressed a positive moral impact when helping to optimise a patient’s autonomy and moral comfort with their role in relieving suffering. Providers experienced tensions around professional duty and balancing self with service to others. Personal choice and patient gratitude enhanced the provider experience, while uncertainty and conflict added difficulty.ConclusionsParticipants described MAiD provision as strongly aligned with a patient-centred ethos of practice. This study suggests that, despite challenges, providing MAiD can be a meaningful and satisfying practice for physicians. Understanding the emotional and moral impact and factors that enhance or detract from the providers’ experience allows future stakeholders to design and regulate assisted dying in ways congruent with the interests of patients, providers, families and society. (shrink)