It seems natural to choose whether to have a child by reflecting on what it would be like to actually have a child. I argue that this natural approach fails. If you choose to become a parent, and your choice is based on projections about what you think it would be like for you to have a child, your choice is not rational. If you choose to remain childless, and your choice is based upon projections about what you think it (...) would be like for you to have a child, your choice is not rational. This suggests we should reject our ordinary conception of how to make this life-changing decision, and raises general questions about how to rationally approach important life choices. (shrink)

Since its introduction in the 1980s, futility as a concept has held contested meaning and applications throughout medicine. There has been little discussion within the psychiatric literature about the use of futility in the care of individuals experiencing severe and persistent mental illness, despite some tacit acceptance that futility may apply in certain cases of psychiatric illness. In this paper, we explore the literature surrounding futility and argue that its connotation within medicine is to describe situations where patients believe that (...) interventions will almost certainly provide no meaningful benefit. We then provide two arguments in support of the use of futility within the care of individuals experiencing SPMI: that some SPMI can be considered a terminal illness, and that the risk-benefit ratio is a dynamic entity such that futility can help describe what Gillett calls the ‘risk of unacceptable badness’ when it comes to considering how an intervention might impact a patient’s quality of life. We posit that capacity should not pose an obstacle to declaring futility when caring for individuals experiencing SPMI and explain how futility is not antithetical to recovery in mental health. Finally, we describe how using futility within psychiatric practice can allow for a reorientation of care by signalling the need to shift to a palliative approach. (shrink)

In February 1999, I received a call from a lawyer at Hill Abra Dewar stating that she had instructions to retain my services as an expert witness in the case of Sawatzky v. Riverview Health Centre. She was representing the Manitoba League of Persons with Disabilities which had intervenor status.In Canada the admission of expert testimony depends upon the application of four criteria outlined in R. v. Mohan by Justice Sopinka. These criteria are: relevance; necessity in assisting the trier of (...) fact, the absence of any exclusionary rule; and a properly qualified expert. The lawyer believed that I could provide the court with relevant, reliable ethics testimony about surrogate decision-making and about medical futility-information that likely would be outside the experience and knowledge of the trier of fact. (shrink)

It is often challenging for mental health‐care providers and health organizations to perform their various roles and to meet their varied obligations. In complex mental health‐care circumstances the concurrent application of relevant ethical principles and values often leads to the emergence of completing obligations that need to be carefully weighed and balanced in the making of care‐related decisions. Although some clinical circumstances, such as those potentially triggering the duty to warn, are adequately guided by existing rules based on legal precedents, (...) there is a gap in decision‐making support in other mental health‐care domains. This article proposes that a set of targeted, decision‐making approaches be developed to assist in the handling of specific, challenging circumstances. By way of illustration, two novel approaches are introduced; that is, choosing to work within a moral relational space of optimal therapeutic engagement (at the micro level of clinical practice), and the use of a health policy development approach that instantiates deliberative engagement (at the meso and macro levels of health organization). (shrink)

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa. A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations of capacity (...) in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile. (shrink)

We develop a broader, more fine-grained taxonomy of forms of ‘transformative experience’ inspired by the work of L.A. Paul. Our vulnerability to such experiences arises, we argue, due to the vulnerability, dependence, and affliction intrinsic to the human condition. We use this trio to distinguish a variety of positively, negatively, and ambivalently valenced forms of epistemically and/or personally transformative experiences. Moreover, we argue that many transformative experiences can arise gradually and cumulatively, unfolding over the course of longer periods of time.

Eating disorders are mental illnesses that can have a significant and persistent physical impact, especially for those who are not treated early in their disease trajectory. Although many persons w...

In February 1999, I received a call from a lawyer at Hill Abra Dewar stating that she had instructions to retain my services as an expert witness in the case of Sawatzky v. Riverview Health Centre. She was representing the Manitoba League of Persons with Disabilities which had intervenor status.In Canada the admission of expert testimony depends upon the application of four criteria outlined in R. v. Mohan by Justice Sopinka. These criteria are: relevance; necessity in assisting the trier of (...) fact, the absence of any exclusionary rule; and a properly qualified expert. The lawyer believed that I could provide the court with relevant, reliable ethics testimony about surrogate decision-making and about medical futility-information that likely would be outside the experience and knowledge of the trier of fact. (shrink)

Talk of harm reduction has expanded horizontally, to apply to an ever-widening range of policy domains, and vertically, becoming part of official legal and political discourse. This expansion calls for philosophical theorization. What is the best way in which to characterize harm reduction? Does it represent a distinctive ethical position? How is it best morally justified, and what are its moral limits? I distinguish two varieties of harm reduction. One of them, technocratic harm reduction, is premised on the fact of (...) non-enforceability of prohibitionist policies. The second, deliberative harm reduction, is premised on the fact of reasonable disagreement, grounded in the fact that reasonable persons disagree about a range of controversial behaviours. I argue that deliberative harm reduction better accounts for some of harm reduction’s most attractive features, and provides a plausible way of accounting for harm reductions’s justificatory grounds and limits. (shrink)