Harm minimisation has been proposed as a means of supporting people who self-injure. When adopting this approach, rather than trying to stop self-injury immediately the person is allowed to injure safely whilst developing more appropriate ways of dealing with distress. The approach is controversial as the health care professional actively allows harm to occur. This paper will consider a specific objection to harm minimisation. That is, it is a misguided collaboration between the health care professional and the person who self-injures (...) that is morally and clinically questionable. The objection has two components. The first component is moral in nature and asserts that the health care professional is complicit in any harm that occurs and as a result they can be held morally responsible and subject to moral blame. The second component is clinical in nature and suggests that harm minimisation involves the health care professional in colluding in the perpetuation of self-injury. This element of the objection i... (shrink)

Should mental health insurance cover only disorders found in DSM‐IV, or should it be extended to treatment for ordinary shyness, unhappiness, and other responses to life's hard knocks?

Can delusions, in the context of psychosis, enhance a person’s sense of meaningfulness? The case described here suggests that, in some circumstances, they can. This prompts further questions into the complexities of delusion as a lived phenomenon, with important implications for the clinical encounter. While assumptions of meaninglessness are often associated with concepts of ’disorder’, ’harm’ and ’dysfunction’, we suggest that meaning can nonetheless be found within what is commonly taken to be incomprehensible or even meaningless. A phenomenological and value-based (...) approach appears indispensable for clinicians facing the seemingly paradoxical coexistence of harmfulness and meaningfulness. (shrink)

New and proposed medical technologies continually challenge our vision of what constitutes appropriate medical treatment. As scholars and consumers grapple with the meaning of innovation, one common critical theme to surface is that it constitutes undesirable medicalization. But we are embodied creatures who can often benefit from medical knowledge; in addition, rejection of medicalization may be in some cases based on an untenable appeal to nature. Harnessing the power of medicine for women’s welfare requires us to rethink the goals of (...) medicine as well as implement fundamental reforms. (shrink)

Democracy has recently been criticized by several philosophers on grounds of poor epistemic performance. The proposed alternative – epistocracy – faces criticism for failing to uphold and express the core democratic values of civic equality and individual autonomy. In response, proposals have been offered that try to achieve epistocratic performance while retaining democratic inclusion. This paper raises two problems for such proposals, relating to the selection of experts and the incentive-compatibility of the system. Given these failures, I sketch what I (...) call the Wiki-Model. I argue that the Wiki-Model has desirable epistemic properties; realizes our democratic ideals; while also avoiding the two problems that other hybrid models face. (shrink)

Evidence-based medicine has always required integration of patient values with ‘best’ clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored.

The question of whether a patient has insight is among the first to be considered in psychiatric contexts. There are several competing conceptions of clinical insight, which broadly refers to a patient’s awareness of their mental illness. When a patient is described as lacking insight, there are significant implications for patient care and to what extent the patient is trusted as a knower. Insight is currently viewed as a multidimensional and continuous construct, but competing conceptions of insight still lack consensus (...) on the specifics. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. A number of crucial questions remain unanswered. After outlining some of the key theoretical disagreements about what insight means, I highlight ethical issues that have not received much attention in the literature. Given the conceptual ambiguities and the absence of standardised bedside tools, there are significant ethical concerns about insight assessments. I highlight two main ethical concerns, specifically that these assessments risk: marginalising patients by setting unattainable ideals for self-knowledge and minimising the patient’s own perspective on their mental health. I close with recommendations for documenting and responding to concerns about poor insight, so patients who are vulnerable to losing epistemic trust are better supported in their therapeutic relationships. (shrink)

This article offers the critical concept misfit in an effort to further think through the lived identity and experience of disability as it is situated in place and time. The idea of a misfit and the situation of misfitting that I offer here elaborate a materialist feminist understanding of disability by extending a consideration of how the particularities of embodiment interact with the environment in its broadest sense, to include both its spatial and temporal aspects. The interrelated dynamics of fitting (...) and misfitting constitute a particular aspect of world-making involved in material-discursive becoming. The essay makes three arguments: the concept of misfit emphasizes the particularity of varying lived embodiments and avoids a theoretical generic disabled body; the concept of misfit clarifies the current feminist critical conversation about universal vulnerability and dependence; the concept of misfitting as a shifting spatial and perpetually temporal relationship confers agency and value on disabled subjects. (shrink)

Epistemic injustice is a harm done to a person in their capacity as an epistemic subject by undermining her capacity to engage in epistemic practices such as giving knowledge to others or making sense of one’s experiences. It has been argued that those who suffer from medical conditions are more vulnerable to epistemic injustice than the healthy. This paper claims that people with mental disorders are even more vulnerable to epistemic injustice than those with somatic illnesses. Two kinds of contributory (...) factors for epistemic injustice in psychiatric patients are outlined: global and specific. Some suggestions are made to counteract the effects of these contributory factors, for instance we suggest that physicians should participate in groups where the subjective experience of patients is explored, and learn to become more aware of their own unconscious prejudices towards psychiatric patients. (shrink)

There has recently been a resurgence of philosophical and scientific interest in the foundations of self-consciousness, with particular focus on its altered, anomalous forms. This paper looks at the altered forms of self-awareness in Depersonalization Disorder (DPD), a condition in which people feel detached from their self, their body and the world (Derealisation). Building upon the phenomenological distinction between reflective and pre-reflective self-consciousness, we argue that DPD may alter thetransparencyof basic embodied forms of pre-reflective self-consciousness, as well as the capacity (...) to flexibly modulate and switch between the reflective and pre-reflective facets of self-awareness. Empirical evidence will be invoked in support of the idea that impaired processing of bodily signals is characteristic of the condition. We provide first-hand subjective reports describing the experience of self-detachment or fracture between an observing and an observed self. This split is compared with similar self-detachment phenomena reported in certain Buddhist-derived meditative practices. We suggest that these alterations and changes may reveal the underlying and tacit transparency that characterises the embodied and basic pre-reflective forms of self-consciousness, in the same way that a crack in a transparent glass may indicate the presence of an unnoticed window. (shrink)

The concept of medical necessity plays a central role in many healthcare systems, including Canada's, by helping determine which healthcare services will receive funding. Despite its significance in health policy frameworks, medical necessity has proven to be notoriously difficult to define and operationalise. A shift toward a more personalised and genetically‐informed approach to the provision of healthcare seems likely to heighten associated policy challenges. One of the stated goals of personalised medicine is to save healthcare systems money by facilitating the (...) use of less and more effective treatments. However, any cost saving potential may ultimately be thwarted by physicians' legal and ethical obligations, given that physicians will inevitably be required to implement and define the bounds of genetically‐informed medical necessity for their patients. (shrink)

Many psychiatrists tell their clients that any mental disorder is ‘‘a disease, just like diabetes’’. This slogan appears to suggest that mental states and behavior that are classified ‘‘mental disorders’’ are somehow radically different from other mental states and behaviors—both when it comes to simply understanding people and when it comes to moral assessments of mental states and of actions. After all, mental illness is just like diabetes, while other human conditions are not. That sounds like a huge difference. I (...) think this suggestion is misleading. (shrink)