Psychiatric Ethics

This article is a reply to an article by Jennifer Radden in which she argues that given certain unusual features of anorexia nervosa, it may simply not be possible to justify paternalistic intervention with such patients, even to save their lives. In other words, we may simply have to accept that even when their practices of restricting food intake result in dangerously low body weights, their decisions must be honored in the same way that we honor preferences of other competent (...) adults. What makes anorexia unique is the fact that many, perhaps most, adult persons with anorexia satisfy the criteria for decision-making capacity at most points in their illness. However, while it is true that it is much harder to justify intervention with competent patients, it is not impossible to offer such justifications. Here I argue that it is possible to justify limited paternalistic intervention with such patients without departing from basic liberal values. (shrink)

Brief description of Freud's life and work, emphasising the role of fictive belief and experience (phantasy) in his account of mental disorder.

In ‘Psychotherapy, Placebos and Informed Consent’, I argued that the minimal standard for informed consent in psychotherapy requires that ‘patients understand that there is currently no consensus about the mechanisms of change in psychotherapy, and that the therapy on offer…is based on disputed theoretical foundations’, and that the dissemination of this information is compatible with the delivery of many theory-specific forms of psychotherapy (including cognitive behavioural therapy [CBT]). I also argued that the minimal requirements for informed consent do not include (...) information about the role of therapeutic common factors in healing (e.g., expectancy effects and therapist effects); practitioners may discuss the common factors with patients, but they are not part of the ‘core set’ of information necessary to obtain informed consent. In a recent reply, Charlotte Blease criticises these two arguments by claiming they are not supported by empirical findings about the therapeutic common factors. Blease’s response is based on serious misunderstandings of both CBT and what the common factor findings actually find. Nevertheless, addressing the reasons for these misunderstandings is instructive and gives us an opportunity to clarify what, exactly, needs to be explained to patients in order to obtain informed consent for psychotherapy. (shrink)

Under the current Mental Health Act of England and Wales, it is lawful to perform deep brain stimulation in the absence of consent and independent approval. We argue against the Care Quality Commission's preferred strategy of addressing this problematic issue, and offer recommendations for deep brain stimulation-specific provisions in a revised Mental Health Act.

Deep Brain Stimulation is currently being investigated as an experimental treatment for patients suffering from treatment-refractory AN, with an increasing number of case reports and small-scale trials published. Although still at an exploratory and experimental stage, initial results have been promising. Despite the risks associated with an invasive neurosurgical procedure and the long-term implantation of a foreign body, DBS has a number of advantageous features for patients with SE-AN. Stimulation can be fine-tuned to the specific needs of the particular patient, (...) is relatively reversible, and the technique also allows for the crucial issue of investigating and comparing the effects of different neural targets. However, at a time when DBS is emerging as a promising investigational treatment modality for AN, lesioning procedures in psychiatry are having a renaissance. Of concern it has been argued that the two kinds of interventions should instead be understood as rivaling, yet “mutually enriching paradigms” despite the fact that lesioning the brain is irreversible and there is no evidence base for an effective target in AN. We argue that lesioning procedures in AN are unethical at this stage of knowledge and seriously problematic for this patient group, for whom self-control is particularly central to wellbeing. They pose a greater risk of major harms that cannot justify ethical equipoise, despite the apparent superiority in reduced short term surgical harms and lower cost. (shrink)

What is it to be mentally healthy? In the ongoing movement to promote mental health, to reduce stigma and to establish parity between mental and physical health, there is a clear enthusiasm about this concept and a recognition of its value in human life. However, it is often unclear what mental health means in all these efforts and whether there is a single concept underlying them. Sometimes the initiatives for the sake of mental health are aimed just at reducing mental (...) illness, thus implicitly identifying mental health with the absence of diagnosable psychiatric disease. More ambitiously, there are high-profile proposals to adopt a positive definition, identifying mental health with psychic or even overall wellbeing. We argue against both: a definition of mental health as mere absence of mental illness is too thin, too undemanding, and too closely linked to psychiatric value judgments, while the definition in terms of wellbeing is too demanding and potentially oppressive. As a compromise we sketch out a middle position. On this view mental health is a primary good, that is the psychological preconditions of pursuing any conception of the good life, including wellbeing, without being identical to wellbeing. (shrink)

Advocates of physician-assisted suicide often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions. This claim is justified on the basis that psychiatric illnesses have certain morally relevant characteristics and/or implications that distinguish them from their somatic counterparts. In this paper, I address three arguments of this sort. First, that psychiatric conditions compromise a person’s decision-making capacity. Second, that we cannot have sufficient certainty that (...) a person’s psychiatric condition is untreatable. Third, that the institutionalisation of PAS for mental illnesses presents morally unacceptable risks. I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable. (shrink)

Florence Ashley has argued that requiring patients with gender dysphoria to undergo an assessment and referral from a mental health professional before undergoing hormone replacement therapy is unethical and may represent an unconscious hostility towards transgender people. We respond, first, by showing that Ashley has conflated the self-reporting of symptoms with self-diagnosis, and that this is not consistent with the standard model of informed consent to medical treatment. Second, we note that the model of informed consent involved in cosmetic surgery (...) resembles the model Ashley defends, and that psychological assessment and referral is recognised as an important aspect of such a model. Third, we suggest that the increased prevalence of psychiatric morbidity in the transgender population arguably supports the requirement of assessment and referral from a mental health professional prior to undergoing HRT. (shrink)

What is the relationship between negative experience, artistic production, and prudential value? If it were true that (for some people) artistic creativity must be purchased at the price of negative experience (to be clear: currently no one knows whether this is true), what should we conclude about the value of such experiences? Are they worth it for the sake of art? The first part of this essay considers general questions about how to establish the positive extrinsic value of something intrinsically (...) negative. The second part emphasizes the importance of various distinctions within the realm of the negative. We must distinguish between adversity (which is non-mental) and negative mental states, and between negative thoughts (or attitudes) and negative affect. Within the realm of negative affect, we must distinguish between negative emotions and moods, on the one hand, and negative affective perspectives on the other, and then between mildly negative affective perspectives and severely negative ones (for which I reserve the term ‘suffering’). These distinctions matter greatly, since different types of negative experience have very different degrees of prudential disvalue. Although many types of negative experience may be “worth it”—because their positive extrinsic value outweighs their negative value—this is rarely true of severe suffering. (shrink)

Mindfulness exercises are presented as being compatible with almost any spiritual, religious or philosophical beliefs. In this paper, we argue that they in fact involve imagining and conceptualising rather striking and controversial claims about the self, and the self’s relationship to thoughts and feelings. For this reason, practising mindfulness exercises is likely to be in tension with many people’s core beliefs and values, a tension that should be treated as a downside of therapeutic interventions involving mindfulness exercises, not unlike a (...) side effect. Clients ought to be informed of these metaphysical aspects of the exercises, and mental health providers ought to take them into account in assessing which course of treatment to recommend. Given these concerns, the casual way in which mindfulness exercises are presently distributed by mental health providers to the general public is inappropriate. (shrink)

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of (...) Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. (shrink)

Deep brain stimulation has been of considerable interest to bioethicists, in large part because of the effects that the intervention can occasionally have on central features of the recipient’s personality. These effects raise questions regarding the philosophical concept of authenticity. In this article, we expand on our earlier work on the concept of authenticity in the context of deep brain stimulation by developing a diachronic, value-based account of authenticity. Our account draws on both existentialist and essentialist approaches to authenticity, and (...) Laura Waddell Ekstrom’s coherentist approach to personal autonomy. In developing our account, we respond to Sven Nyholm and Elizabeth O’Neill’s synchronic approach to authenticity, and explain how the diachronic approach we defend can have practical utility, contrary to Alexandre Erler and Tony Hope’s criticism of autonomy-based approaches to authenticity. Having drawn a distinction between the authenticity of an individual’s traits and the authenticity of that person’s values, we consider how our conception of authenticity applies to the context of anorexia nervosa in comparison to other prominent accounts of authenticity. We conclude with some reflections on the prudential value of authenticity, and by highlighting how the language of authenticity can be invoked to justify covert forms of paternalism that run contrary to the value of individuality that seems to be at the heart of authenticity. (shrink)

Respect for autonomy and beneficence are frequently regarded as the two essential principles of medical ethics, and the potential for these two principles to come into conflict is often emphasised as a fundamental problem. On the one hand, we have the value of beneficence, the driving force of medicine, which demands that medical professionals act to protect or promote the wellbeing of patients or research subjects. On the other, we have a principle of respect for autonomy, which demands that we (...) respect the self-regarding decisions of individuals. As well as routinely coming into opposition with the demands of beneficence in medicine, the principle of respect for autonomy in medical ethics is often seen as providing protection against beneficial coercion (i.e. paternalism) in medicine. However, these two values are not as straightforwardly opposed as they may appear on the surface. In fact, the way that we understand autonomy can lead us to implicitly sanction a great deal of paternalistic action, or can smuggle in paternalistic elements under the guise of respect for autonomy. -/- This paper is dedicated to outlining three ways in which the principle of respect for autonomy, depending on how we understand the concept of autonomy, can sanction or smuggle in paternalistic elements. As the specific relationship between respect for autonomy and beneficence will depend on how we conceive of autonomy, I begin by outlining two dominant conceptions of autonomy, both of which have great influence in medical ethics. I then turn to the three ways in which how we understand or employ autonomy can increase or support paternalism: firstly, when we equate respect for autonomy with respect for persons; secondly, when our judgements about what qualifies as an autonomous action contain intersubjective elements; and thirdly, when we expect autonomy to play an instrumental role, that is, when we expect people, when they are acting autonomously, to act in a way that promotes or protects their own wellbeing. I then provide a proposal for how we might work to avoid this. I will suggest that it may be impossible to fully separate paternalistic elements out from judgements about autonomy. Instead, we are better off looking at why we are motivated to use judgements about autonomy as a means of restricting the actions of patients or research subjects. I will argue that this is a result of discomfort about speaking directly about our beneficent motivations in medical ethics. Perhaps we can reduce the incentive to smuggle in these beneficent motivations under the guise of autonomy by talking directly about beneficent motivations in medicine. This will also force us to recognise paternalistic motivations in medicine when they appear, and to justify paternalism where it occurs. (shrink)

Nancy Jecker and Andrew Ko (2017) wish to present an account of personal identity which captures what matters to the patient and places the patient at the center of medical decisions. They focus particularly on medical interventions in the brain that can cause drastic changes in personality; under what circumstances should we say the patient has 'survived' these changes? More specifically, how can we best understand the notion of survival in a way that captures what is of concern to the (...) patient? This goal is laudable, however, their chosen account of narrative identity is ill-suited to this task for one reason in particular; it does not give sufficient guidance in predicting which medical decisions are likely to be experienced as disruptive to identity. (shrink)

A book chapter exploring the potential consquences and ethical ramifications of using coercive measures within community mental healthcare. We argue that, althogh the move towards 'care in the community' may have had liberalising motivations, the subsequent reduction in inpatient or other supported residential provision, means that there has been an increasing move towards coercive measures outside of formal inpatient detention. We consider measures such as Community Treatment Orders, inducements, and other forms of leverage, explaining the underlying concepts, aims, and exploring (...) adverse consequences and ethical difficulties. (shrink)

Values-based practice (VBP), developed as a partner theory to evidence-based medicine (EBM), takes into explicit consideration patients’ and clinicians’ values, preferences, concerns and expectations during the clinical encounter in order to make decisions about proper interventions. VBP takes seriously the importance of life narratives, as well as how such narratives fundamentally shape patients’ and clinicians’ values. It also helps to explain difficulties in the clinical encounter as conflicts of values. While we believe that VBP adds an important dimension to the (...) clinician’s reasoning and decision-making procedures, we argue that it ignores the degree to which values can shift and change, especially in the case of psychiatric disorders. VBP does this in three respects. First, it does not appropriately engage with the fact that a person’s values can change dramatically in light of major life events. Second, it does not acknowledge certain changes in the way people value, or in their modes of valuing, that occur in cases of severe psychiatric disorder. And third, it does not acknowledge the fact that certain disorders can even alter the degree to which one is capable of valuing anything at all. We believe that ignoring such changes limits the degree to which VBP can be effectively applied to clinical treatment and care. We conclude by considering a number of possible remedies to this issue, including the use of proxies and written statements of value generated through interviews and discussions between patient and clinician. (shrink)

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts (...) to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research. (shrink)

his article develops a set of recommendations for the psychiatric and medical community in the treatment of mental disorders in response to the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, that is, DSM-5. We focus primarily on the limitations of the DSM-5 in its individuation of Complicated Grief, which can be diagnosed as Major Depression under its new criteria, and Post-Traumatic Stress Disorder (PTSD). We argue that the hyponarrativity of the descriptions of these disorders (...) in the DSM-5, defined as the abstraction of the illness categories from the particular life contingencies and personal identity of the patient (e.g., age, race, gender, socio-economic status), constrains the DSM-5's usefulness in the development of psychotherapeutic approaches in the treatment of mental disorders. While the DSM-5 is useful in some scientific and administrative contexts, the DSM's hyponarrativity is problematic, we argue, given that the DSMs are designed to be useful guides for not only scientific research, but also for the education of medical practitioners and for treatment development. our goal therefore is to offer suggestions for mental health practitioners in using the DSM-5, so that they can avoid or eliminate the problems that may stem from the limitations of hyponarrativity. When such problems are eliminated, we believe that effective psychotherapeutic strategies can be developed, which would be successful in repairing the very relationships that are strained in mental disorder: the patient's relationship to herself, her physical environment, and her social environment. (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)

Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and ‘ordinary’ experience to escape the fear-related prejudices associated with the imagined ‘otherness’ of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’ and (...) ‘unlikeness-based’ conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns. (shrink)

Recent events have revived questions about the circumstances that ought to trigger therapists' duty to warn or protect. There is extensive interstate variation in duty to warn or protect statutes enacted and rulings made in the wake of the California Tarasoff ruling. These duties may be codified in legislative statutes, established in common law through court rulings, or remain unspecified. Furthermore, the duty to warn or protect is not only variable between states but also has been dynamic across time. In (...) this article, we review the implications of this variability and dynamism, focusing on three sets of questions: first, what legal and ethics-related challenges do therapists in each of the three broad categories of states (states that mandate therapists to warn or protect, states that permit therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect. (shrink)

Decisional capacity evaluations (DCEs) occur in clinical settings where it is unclear whether a consumer of medical services has the capacity to make an informed decision about the relevant medical options. DCEs are localized interventions, not the global loss of competence, that assign a surrogate decision maker to make the decision on behalf of the medical consumer. We maintain that one important necessary condition for a DCE to be morally justified, in cases of medical necessity, is that the health care (...) consumer under evaluation is incapable of expressing a preference for a certain outcome. (shrink)

This dissertation seeks to examine the validity of the justification commonly offered for a coercive (1) psychiatric intervention, namely that the intervention was in the ‘best interests’ of the subject and/or that the subject posed a danger to others. As a first step,it was decided to analyse justifications based on ‘best interests’ [the ‘Stage 1’ argument] separately from those based on dangerousness [the ‘Stage 2’ argument]. Justifications based on both were the focus of the ‘Stage 3’ argument. Legal and philosophical (...) analyses of coercive psychiatric interventions generally regard such interventions as embodying a benign paternalism occasioning slight, if any, ethical concern. Whilst there are some dissenting voices even at the very heart of academic and professional psychiatry, the majority of psychiatrists also appear to share such views. The aim of this dissertation is to show that such a perspective is mistaken and that such interventions raise philosophical and ethical questions of the profoundest importance.(2) The philosophical well-spring of the Stage 1 dissertation argument lay in an observation made by Philippa Foot (3) that the “… right to be let free from unwanted interference” is one of the most fundamental and distinctive rights of persons, a right which takes precedence over any “… action we would dearly like to take for his sake.” This – in conjunction with the recognition that some coercive psychiatric interventions are of a gravity as to result in the personhood of the subject being severely damaged if not destroyed – suggested that the concept of personhood play a central role in the formulation of the dissertation argument. For ease of analysis it was presumed that the term ‘person’ could be defined by a set of necessary and sufficient conditions of which ‘minimum levels of rationality’ and ‘ability to communicate’ were the only conditions relevant to the formulation of justifications for coercive psychiatric interventions. This presumption was explicated into a number of postulates which enabled the construction of a rigorous foundation on which to develop the dissertation argument. This argument then sought to determine whether psychiatric assessments of irrationality were accurate and reliable. In furtherance of this analysis it was necessary to examine the reliability of psychiatric determinations in other areas of claimed expertise namely diagnosis, treatment and assessment of dangerousness. This ‘crossing of the disciplinary threshold’ brought to light the dearth of studies on psychiatric misdiagnosis and iatrogenic harm. A variant of the Precautionary Principle was developed to enable the extent of such harms to be estimated. The not insignificant levels of psychiatric misdiagnosis and iatrogenic harm and erroneous assessments of dangerousness which were thus found are of considerable relevance to any ethical analysis of the justification for coercive psychiatric intervention and serve to undermine simple paternalistic justifications. --- (1)The term ‘coercive’ (rather than ‘non-consensual’) is used to indicate an intervention carried out against the explicit and contemporaneous objections of the subject (2)Not least because the number of individuals detained in Irish psychiatric hospitals is of a comparable order of magnitude to the number detained in Irish prisons subsequent to a criminal conviction (3)See Foot (1977), p.102. (shrink)

The essay aims to analyse the gradual historical process of the partial overlap, replacement and expansion of the theoretical paradigm of depression with respect to that of melancholy. The first part is devoted to analysing some of the central features of the multivalent thematizations of melancholy drawn up during modernity, also with relation to the spirit of capitalism (in its Weberian acceptation). This is followed by an overview of the birth of the modern category of depression, and the process that (...) during the twentieth century led to its transformation into a theoretical and nosological paradigm which in the end replaced that of melancholy. The second part is the attempt to draw up a Zeitdiagnose: the aim is to assess the ‘depressive’ psychosocial impact exercised by particular socio-economic mechanisms and cultural trends, with particular reference to what has been defined as the ‘new spirit of capitalism’, as well as the new forms of individualism and their paradoxical dynamics. In conclusion, I will form a bridge between the history of the two aforesaid paradigms and the contemporary psychosocial dynamics correlated to the phenomenon today interpreted as a ‘depression epidemic’. Der Aufsatz zielt darauf, der Prozess der historischen Überlagerung, Substitution und Verbreitung des theoretischen Paradigmas der Depression gegenüber jenem der Melancholie darzustellen. Im ersten Teil wird versucht, einige der einschneidenden Eigenschaften der Thematisierungen der Melancholie in der Frühen Neuzeit anzugeben, auch im Verhältnis zum Geist des Kapitalismus. Nachdem eine Skizze der Entstehung der moderne Kategorie der Depression, geht es darum, den Verlauf nachzuzeichnen, der im 20. Jahrhundert zu ihrer Transformation in ein weitläufiges theoretisches Paradigma geführt hat, das schließlich jenes der Melancholie ersetzt hat. Der zweite Teil stellt den Versuch dar, eine Zeitdiagnose umzureißen: An dieser Stelle ist die psychosoziale Bedeutung bestimmter sozioökonomischer und kultureller Mechanismen zu untersuchen, unter besonderem Hinweis auf das, was als »der neue Geist des Kapitalismus« bezeichnet worden ist, sowie auf neue Formen des Individualismus und ihre paradoxen Dynamiken. Abschließend wird eine Brücke geschlagen, zwischen der Geschichte der beiden bezeichneten Paradigmen und der zeitgenössischen psychosozialen Dynamiken, die mit dem als »depressive Epidemie« interpretierten Phänomen verbunden sind. (shrink)

Recent work in neuroimaging suggests that some patients diagnosed as being in the persistent vegetative state are actually conscious. In this paper, we critically examine this new evidence. We argue that though it remains open to alternative interpretations, it strongly suggests the presence of consciousness in some patients. However, we argue that its ethical significance is less than many people seem to think. There are several different kinds of consciousness, and though all kinds of consciousness have some ethical significance, different (...) kinds underwrite different kinds of moral value. Demonstrating that patients have phenomenal consciousness — conscious states with some kind of qualitative feel to them — shows that they are moral patients, whose welfare must be taken into consideration. But only if they are subjects of a sophisticated kind of access consciousness — where access consciousness entails global availability of information to cognitive systems — are they persons, in the technical sense of the word employed by philosophers. In this sense, being a person is having the full moral status of ordinary human beings. We call for further research which might settle whether patients who manifest signs of consciousness possess the sophisticated kind of access consciousness required for personhood. (shrink)

A pressing and difficult practical problem concerns the general issue of the right social response to offenders classified as having antisocial personality disorder. This paper approaches this general problem by focusing, from a philosophical perspective, on the still relevant but more approachable question whether psychopathic offenders are morally responsible. In particular, I investigate whether psychopaths possess moral understanding. A plausible way to approach the last question requires a satisfactory philosophical interpretation of the empirical evidence that appears to show that psychopaths (...) fail to draw the distinction between conventional and moral norms. Specifically, I will consider a recent philosophical debate polarized between supporters of rationalist and sentimentalist accounts of moral understanding. These opponents have discussed whether the case of psychopathy offers empirical support for their account and undermine the rival view. I will argue that the available empirical data leave the outcome of this discussion indeterminate. However, this implies that both these principal theories of moral understanding, if independently motivated, would imply that psychopaths have certain deficits that might affect their moral understanding and, consequently, their moral responsibility. (shrink)

The essay aims to analyse the gradual historical process of the partial overlap, replacement and expansion of the theoretical paradigm of depression with respect to that of melancholy. The first part is devoted to analysing some of the central features of the multivalent thematizations of melancholy drawn up during modernity, also with relation to the spirit of capitalism (in its Weberian acceptation). This is followed by an overview of the birth of the modern category of depression, and the process that (...) during the twentieth century led to its transformation into a theoretical and nosological paradigm which in the end replaced that of melancholy. The second part is the attempt to draw up a Zeitdiagnose: the aim is to assess the ‘depressive’ psychosocial impact exercised by particular socio-economic mechanisms and cultural trends, with particular reference to what has been defined as the ‘new spirit of capitalism’, as well as the new forms of individualism and their paradoxical dynamics. In conclusion, I will form a bridge between the history of the two aforesaid paradigms and the contemporary psychosocial dynamics correlated to the phenomenon today interpreted as a ‘depression epidemic’. Il saggio mira ad analizzare il graduale processo storico di parziale sovrapposizione, sostituzione ed ampliamento del paradigma teoretico della depressione rispetto a quello della melanconia. La prima parte è dedicata ad analizzare alcuni dei tratti nevralgici delle polivalenti tematizzazioni della malinconia avvenuti nel corso della modernità, anche in relazione allo spirito del capitalismo (nella sua accezione weberiana). Segue una panoramica sulla nascita della categoria moderna di depressione, e del processo che nel corso del XX secolo l’ha condotta alla sua trasformazione in un paradigma teoretico e nosologico che ha infine sostituito quello della melanconia. La seconda parte rappresenta il tentativo di elaborare una Zeitdiagnose: l’obiettivo è valutare l’impatto psicosociale di natura ‘depressiva’ esercitato da particolari meccanismi socioeconomici e tendenze culturali, con particolare riferimento a ciò che è stato definito il «nuovo spirito del capitalismo», nonché alle nuove forme dell’individualismo e alle loro dinamiche paradossali. In conclusione viene gettato un ponte tra la storia dei due suddetti paradigmi e le dinamiche psicosociali contemporanee correlate al fenomeno oggi interpretato quale «epidemia depressiva». (shrink)

In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and gender issues; (...) rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)

Children and young people under 18 years old should no longer be regarded as incompetent to give or withhold consent in decisions involving their health care, Recent research suggests a functional test of cognitive and emotional maturity, rather than a strict age cut-off point. However, it is often difficult to implement these recommendations in practice, not least because the law is, if anything, increasingly 'hard-line' about children's autonomy.

In this article we explore the underpinnings of what we view as a recent "backlash" in English law, a judicial reaction against considering children's and young people's expressions of their own feelings about treatment as their "true" wishes. We use this case law as a springboard to conceptual discussion, rooted in (a) empirical psychological work on child development and (b) three key philosophical ideas: rationality, autonomy and identity. Using these three concepts, we explore different understandings of our central theme, true (...) wishes. These different conceptual interpretations, we argue, help to elucidate important clinical questions in the area of children's informed consent to treatment. For example, how much should a child's own wishes count in making medical decisions? Does it make a difference if the child or young person is undergoing psychiatric treatment?—if in some sense her wishes are abnormal, not "true" expressions of what she really wants? If the child's wishes do not count, why not? If they do matter but count for less, how much less? We conclude by advocating functional tests of a young person's true wishes, applicable on a case-by-case basis, rather than a black-and-white distinction between "incompetent" children and "competent" adults. (shrink)

Anomaly in English law between age of children's permitted consent to treatment and much lower age of criminal responsibility.

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child's refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case (...) that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children's consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice. (shrink)