Purpose of review This review considers the literature on ethical and conceptual issues in eating disorders from the last 18 months. Some reference to earlier work is necessary in order to provide context for the recent findings from research that is ongoing. -/- Recent findings Empirical ethics research on anorexia nervosa includes novel ethical and conceptual findings on the role of authenticity and personal identity in individuals’ reports of their experience, as well as new evidence on the role of affective (...) states and values in decision making at later stages of the illness. Evidence points to the hypothesis that anorexia nervosa may be a distinct affective syndrome that organizes feelings and emotions in accordance with a fixed idea. -/- Summary There has been impressive progress in empirical ethics research on anorexia nervosa, with important implications for ethical and conceptual issues that surround decision-making capacity and our understanding of the illness. (shrink)

The author argued elsewhere that a necessary condition that John Fischer and Mark Ravizza offer for moral responsibility is too strong and that the sufficient conditions they offer are too weak. This article is a critical examination of their reply. Topics discussed include blameworthiness, irresistible desires, moral responsibility, reactive attitudes, and reasons responsiveness.

What makes a choice hard? I discuss and criticize three common answers and then make a proposal of my own. Paradigmatic hard choices are not hard because of our ignorance, the incommensurability of values, or the incomparability of the alternatives. They are hard because the alternatives are on a par; they are comparable, but one is not better than the other, and yet nor are they equally good. So understood, hard choices open up a new way of thinking about what (...) it is to be a rational agent. (shrink)

According to what Douglas calls ‘the consent requirement’, neuro-correctives can only permissibly be provided with the valid consent of the offender who will undergo the intervention. Some of those who endorse the consent requirement have claimed that even though the requirement prohibits the imposition of mandatory neurocorrectives on criminal offenders, it may yet be permissible to offer offenders the opportunity to consent to undergoing such an intervention, in return for a reduction to their penal sentence. I call this the neurocorrective (...) offer. In this chapter I consider the coercion-based objection to the neurocorrective offer, which claims that offenders cannot provide valid consent to undergoing a neurocorrective on the basis of this offer because it is inherently coercive. Having outlined early formulations of this argument, I point out that there are in fact two different versions of this objection, which appeal to different understandings of the concepts of coercion, consent and voluntariness. (shrink)

The concept of autonomy plays a central role in bioethics,1 but there is no consensus as to how we should understand it beyond a general notion of self-determination. The conception of autonomy deployed in applied ethics2 can have crucial ramifications when it is applied in real-world scenarios, so it is important to be clear. However, this clarity is often lacking when autonomy is discussed in the bioethics literature. In this paper we outline three different conceptions of autonomy, and argue that (...) a substantive, perfectionist approach meets the theoretical requirements for an account of autonomy and also provides practical guidance. As Rebecca Walker argues, bioethics requires a more conceptually adequate account... (shrink)

Interventions that modify a person’s motivations through chemically or physically influencing the brain seem morally objectionable, at least when they are performed nonconsensually. This chapter raises a puzzle for attempts to explain their objectionability. It first seeks to show that the objectionability of such interventions must be explained at least in part by reference to the sort of mental interference that they involve. It then argues that it is difficult to furnish an explanation of this sort. The difficulty is that (...) these interventions seem no more objectionable, in terms of the kind of mental interference that they involve, than certain forms of environmental influence that many would regard as morally innocuous. The argument proceeds by comparing a particular neurointervention with a comparable environmental intervention. The author argues, first, that the two dominant explanations for the objectionability of the neurointervention apply equally to the environmental intervention, and second, that the descriptive difference between the environmental intervention and the neurointervention that most plausibly grounds the putative moral difference in fact fails to do so. The author concludes by presenting a trilemma that falls out of the argument. (shrink)

Sterilisation requests made by young, childfree adults are frequently denied by doctors, despite sterilisation being legally available to individuals over the age of 18. A commonly given reason for denied requests is that the patient will later regret their decision. In this paper I examine whether the possibility of future regret is a good reason for denying a sterilisation request. I argue that it is not and hence that decision-competent adults who have no desire to have children should have their (...) requests approved. It is a condition of being recognised as autonomous that a person ought to be permitted to make decisions that they might later regret, provided that their decision is justified at the time that it is made. There is also evidence to suggest that sterilisation requests made by men are more likely to be approved than requests made by women, even when age and number of children are factored in. This may indicate that attitudes toward sterilisation are influenced by gender discourses that define women in terms of reproduction and mothering. If this is the case, then it is unjustified and should be addressed. There is no good reason to judge people’s sterilisation requests differently in virtue of their gender. (shrink)

Although some healthcare professionals have the legal right to conscientiously object to authorise or perform certain lawful medical services, they have an associated duty to provide the patient with enough information to seek out another professional willing to authorise or provide the service (the ‘duty to refer’). Does the duty to refer morally undermine the professional's conscientious objection (CO)? I narrow my discussion to the National Health Service in Britain, and the case of a general practitioner (GP) being asked by (...) a pregnant woman to authorise an abortion. I will be careful not to enter the debate about whether abortion should be legalised, or the debate about whether CO should be permitted—I will take both as given. I defend the objecting GP's duty to refer against those I call the ‘conscience absolutists’, who would claim that if a state is serious enough in permitting the GP's objection in the first place (as is the UK), then it has to recognise the right to withhold any information about abortion. (shrink)

A long tradition of psychological research has explored the distinction between characteristics that are part of the self and those that lie outside of it. Recently, a surge of research has begun examining a further distinction. Even among characteristics that are internal to the self, people pick out a subset as belonging to the true self. These factors are judged as making people who they really are, deep down. In this paper, we introduce the concept of the true self and (...) identify features that distinguish people’s understanding of the true self from their understanding of the self more generally. In particular, we consider recent findings that the true self is perceived as positive and moral, and that this tendency is actor-observer invariant and cross-culturally stable. We then explore possible explanations for these findings and discuss their implications for a variety of issues in psychology. (shrink)

This essay challenges the widely accepted principle that a person is morally responsible for what he has done only if he could have done otherwise. The author considers situations in which there are sufficient conditions for a certain choice or action to be performed by someone, So that it is impossible for the person to choose or to do otherwise, But in which these conditions do not in any way bring it about that the person chooses or acts as he (...) does. In such situations the person may well be morally responsible for what he chooses or does despite his inability to choose or to do otherwise. Finally the author considers certain suggestions for revising the principle he rejects or for replacing it with a principle of an altogether different kind. (shrink)

It is a common assumption that lack of autonomy is incompatible with decisional capacity and mental health. However, there are two general conceptions of autonomy, one value-neutral and the other value-laden, which imply different notions of mental health. I argue that the value-neutral notion of autonomy is independently inadequate and that it also provides an inadequate foundation for judging whether someone is decisionally incapable or mentally disordered. I propose an alternative, value-laden account which posits ten capabilities required for basic human (...) functioning. I then defend this account against objections and highlight its practical utility in designing optimal treatment. (shrink)

History's judgment on the success of bioethics will not depend solely on the conceptual creativity and innovation in the field at the level of ethical and political theory, but this intellectual work is not insignificant. One important new development is what I shall refer to as the relational turn in bioethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices (...) and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around. The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. It moves away from individualism, but not from the value of individuality.In this review essay, I shall focus on how the relational turn has manifested itself in work on core concepts in bioethics, especially liberty and autonomy. Following a general review, I conclude with a brief consideration of two important recent books in this area: Jennifer Nedelsky's Law's Relations and Rachel Haliburton's Autonomy and the Situated Self. (shrink)

Belief is a central focus of inquiry in the philosophy of religion and indeed in the field of religion itself. No one conception of belief is central in all these cases, and sometimes the term 'belief' is used where 'faith' or 'acceptance' would better express what is intended. This paper sketches the major concepts in the philosophy of religion that are expressed by these three terms. In doing so, it distinguishes propositional belief (belief that) from both objectual belief (believing something (...) to have a property) and, more importantly, belief in (a trusting attitude that is illustrated by at least many paradigm cases of belief in God). Faith is shown to have a similar complexity, and even propositional faith divides into importantly different categories. Acceptance differs from both belief and faith in that at least one kind of acceptance is behavioral in a way neither of the other two elements is. Acceptance of a proposition, it is argued, does not entail believing it, nor does believing entail acceptance in any distinctive sense of the latter term. In characterizing these three notions (and related ones), the paper provides some basic materials important both for understanding a person's religious position and for appraising its rationality. The nature of religious faith and some of the conditions for its rationality, including some deriving from elements of an ethics of belief, are explored in some detail. (shrink)

Authenticity has recently emerged as an important issue in discussions of mental disorder. We show, on the basis of personal accounts and empirical studies, that many people with psychological disorders are preoccupied with questions of authenticity. Most of the data considered in this paper are from studies of people with bipolar disorder and anorexia nervosa. We distinguish the various ways in which these people view the relationship between the disorder and their sense of their authentic self. We discuss the principal (...) modern ac-counts of authenticity within the analytic philosophical tradition. We argue that accounts based on autonomous, or wholehearted, endorsement of personal characteris-tics fail to provide an adequate analysis of authenticity in the context of mental disorder. Significant elements of true self accounts of authenticity are required. The concept of authenticity is a basic one that can be of particular value, in the context of self-development, to people with mental disorder and to others experiencing substantial inner conflict. (shrink)

This essay contends that the constitutive elements of well-being are plural, partly objective, and separable. The essay argues that these elements are pleasure, friendship, significant achievement, important knowledge, and autonomy, but not either the appreciation of beauty or the living of a morally good life. The essay goes on to attack the view that elements of well-being must be combined in order for well-being to be enhanced. The final section argues against the view that, because anything important to say about (...) well-being could be reduced to assertions about these separable elements, the concept of well-being or personal good is ultimately unimportant. (shrink)

There are a number of premises underlying much of the vigorous debate on pharmacological cognitive enhancement. Among these are claims in the enhancement literature that such drugs exist and are effective among the cognitively normal. These drugs are deemed to enhance cognition specifically, as opposed to other non-cognitive facets of our psychology, such as mood and motivation. The focus on these drugs as cognitive enhancers also suggests that they raise particular ethical questions, or perhaps more pressing ones, compared to those (...) raised by other kinds of neuroenhancement. Finally, the use of these drugs is often claimed to be significant and increasing. Taken together, these premises are at the heart of the flurry of debate on pharmacological cognitive enhancement. In this article, it is argued that these are presumptions for which the evidence does not hold up. Respectively, the evidence for the efficacy of these drugs is inconsistent; neurologically it makes little sense to distinguish the cognitive from non-cognitive as separate targets of pharmacological intervention; ethically, the questions raised by cognitive enhancement are in fact no different from those raised by other kinds of neuroenhancement; and finally the prevalence rates of these drugs are far from clear, with the bulk of the claims resting on poor or misrepresented data. Greater conceptual clarity along with a more tempered appreciation of the evidence can serve to deflate some of the hype in the associated literature, leading to a more realistic and sober assessment of these prospective technologies. (shrink)

I take as my starting point the “one very simple principle” proclaimed by Mill in On Liberty … “That principle is, that the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. He cannot rightfully be compelled to do (...) or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right.”. (shrink)

The ways in which we exercise intentional agency are varied. I take the domain of intentional agency to include all that we intentionally do versus what merely happens to us. So the scope of our intentional agency is not limited to intentional action. One can also exercise some intentional agency in omitting to act and, importantly, in producing the intentional outcome of an intentional action. So, for instance, when an agent is dieting, there is an exercise of agency both with (...) respect to the agent’s actions and omissions that constitute her dieting behavior and in achieving the intended outcome of losing weight. In our mental lives we exercise intentional agency both in performing mental actions and when we intentionally produce certain outcomes at which our mental actions are aimed. The nature and scope of our intentional agency in our mental lives with respect to controlling the acquisition of mental states such as belief, desire, and intention is a topic that is of interest in its own right. In this essay, I will focus solely on our control over coming to believe. Understanding what sort of control we have our beliefs has far-reaching implications. For instance, theorizing about self-deception and wishful thinking is aided by theorizing about what if any intentional agency we can exercise with respect to acquiring beliefs. Another often mentioned concern that motivates thinking about doxastic agency comes from religion (when conversion requires a change of belief). We also hold persons morally and epistemically responsible for beliefs they have or fail to have. Finally, some deontological theories of epistemic justification require that agents be able to exercise a robust form of doxastic control. Fruitful work on any of these problems requires that we have an account of our intentional agency in acquiring beliefs. There are at least three loci of doxastic control. The first is over acquiring beliefs. The second is over maintaining beliefs. The third is over how we use our beliefs. I am chiefly concerned with the first locus of doxastic control in this essay, but I will say something about the second locus along the way. Also, I will only consider one way we might exercise control over acquiring beliefs. Specifically, I will present an argument against direct doxastic voluntarism (DDV). By “DDV” I mean to refer to the thesis that it is conceptually possible for agents to consciously exercise the same sort of direct voluntary control over coming to acquire a doxastic attitude—such as belief, suspension of belief, and disbelief—that they exercise over uncontroversial basic actions. If DDV is correct, then coming to believe can be a basic action-type. DDV, or something very close to it, was Bernard Williams’ target in his 1973 paper, “Deciding to Believe.” Williams’s argument is widely regarded as having been a failure. But I think that Williams was on to something in his paper. Hence, in this paper, while I do not attempt to resurrect Williams’s argument, I develop and defend a revised argument for a thesis that is quite close to Williams’s. I will proceed as follows. First, I will discuss Bernard Williams’ (1973) failed attempt at showing that DDV is conceptually impossible. This will be followed by a discussion of some constraints on our belief-forming activities. I will then clarify my target a bit more than Williams does in his original paper. Finally, I will present my own argument against the conceptual possibility of DDV. (shrink)

Personal autonomy is often taken to consist in self-government or self-determination. Personal autonomy thus seems to require self-control. However, there is reason to think that autonomy is compatible with the absence of self-control. Akratic action, i.e., action performed against the agent’s better judgement, can be free. And it is also plausible to think that free actions require autonomy. It is only when you determine what you do yourself that you act freely. It follows that akratic actions can be autonomous. At (...) least in some cases, it is the agent herself, and not some alien part of her, who determines her akratic actions. But akratic actions are usually thought to be paradigm cases of self-control failure. Thus, we have reason both to conclude that autonomy requires self-control and that autonomy is compatible with the absence of self-control. My aim is to discuss the main solutions to this paradox. (shrink)

Clinicians and health researchers frequently encounter opportunities to rescue people. Rescue cases can generate a moral duty to aid those in peril. As such, bioethicists have leveraged a duty to rescue for a variety of purposes. Yet, despite its broad application, the duty to rescue is under-analyzed. In this paper, we assess the state of theorizing about the duty to rescue. There are large gaps in bioethicists’ understanding of the force, scope, and justification of the two most cited duties to (...) rescue—the individual duty of easy rescue and the institutional rule of rescue. We argue that the duty of easy rescue faces unresolved challenges regarding its force and scope, and the rule of rescue is indefensible. If the duty to rescue is to help solve ethical problems, these theoretical gaps must be addressed. We identify two further conceptions of the duty to rescue that have received less attention—an institutional duty of easy rescue and the professional duty to rescue. Both provide guidance in addressing force and scope concerns and, thereby, traction in answering the outstanding problems with the duty to rescue. We conclude by proposing and propose research priorities for developing accounts of duties to rescue in bioethics. (shrink)

This chapter discusses some concerns regarding the effects of enhancement technologies on autonomy and authenticity, insofar as authenticity relates to autonomy. As a preliminary, it describes how enhancement and autonomy should be understood in this context along with some examples of enhancement. The chapter moves on to explain why enhancement can promote autonomy. Three types of concerns regarding the effect of enhancement technologies on autonomy are raised: (i) that medical technologies should not be used to enhance autonomy, since this is (...) not the proper use of such technologies; (ii) that some enhancement technologies are inimical to our authenticity; and (iii) that the widespread use of some enhancement technologies have negative overall consequences on people's autonomy. Different kinds of enhancements typically arouse different kinds of concerns as regards autonomy. These include cognitive, mood, physical, and aesthetic enhancement. (shrink)

Adaptive preference formation is the unconscious altering of our preferences in light of the options we have available. Jon Elster has argued that this is bad because it undermines our autonomy. I agree, but think that Elster's explanation of why is lacking. So, I draw on a richer account of autonomy to give the following answer. Preferences formed through adaptation are characterized by covert influence (that is, explanations of which an agent herself is necessarily unaware), and covert influence undermines our (...) autonomy because it undermines the extent to which an agent's preferences are ones that she has decided upon for herself. This answer fills the lacuna in Elster's argument. It also allows us to draw a principled distinction between adaptive preference formation and the closely related phenomenon of character planning. (shrink)

Internalists about reasons following Bernard Williams claim that an agent’s normative reasons for action are constrained in some interesting way by her desires or motivations. In this paper, I offer a new argument for such a position—although one that resonates, I believe, with certain key elements of Williams’ original view. I initially draw on P.F. Strawson’s famous distinction between the interpersonal and the objective stances that we can take to other people, from the second-person point of view. I suggest that (...) we should accept Strawson’s contention that the activity of reasoning with someone about what she ought to do naturally belongs to the interpersonal mode of interaction. I also suggest that reasons for an agent to perform some action are considerations which would be apt to be cited in favor of that action, within an idealized version of this advisory social practice. I then go on to argue that one would take leave of the interpersonal stance towards someone—thus crossing the line, so to speak—in suggesting that she do something one knows she wouldn’t want to do, even following an exhaustive attempt to hash it out with her. An internalist necessity constraint on reasons is defended on this basis. (shrink)

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

Increasingly, bioethicists defend informed consent as a safeguard for trust in caretakers and medical institutions. This paper discusses an ‘ideal type’ of that move. What I call the trust-promotion argument for informed consent states:1. Social trust, especially trust in caretakers and medical institutions, is necessary so that, for example, people seek medical advice, comply with it, and participate in medical research.2. Therefore, it is usually wrong to jeopardise that trust.3. Coercion, deception, manipulation and other violations of standard informed consent requirements (...) seriously jeopardise that trust.4. Thus, standard informed consent requirements are justified.This article describes the initial promise of this argument, then identifies challenges to it. As I show, the value of trust fails to account for some commonsense intuitions about informed consent. We should revise the argument, commonsense morality, or both. (shrink)

This paper argues that we should replace the common classification of theories of welfare into the categories of hedonism, desire theories, and objective list theories. The tripartite classification is objectionable because it is unduly narrow and it is confusing: it excludes theories of welfare that are worthy of discussion, and it obscures important distinctions. In its place, the paper proposes two independent classifications corresponding to a distinction emphasised by Roger Crisp: a four-category classification of enumerative theories (about which items constitute (...) welfare), and a four-category classification of explanatory theories (about why these items constitute welfare). (shrink)

This chapter identifies and explores a series of challenges raised by the clinical concept of delusion for theories which conceive autonomy as an agency rather than a status concept. The first challenge is to address the autonomy-impairing nature of delusions consistently with their role as grounds for full legal and ethical excuse, on the one hand, and psychopathological significance as key symptoms of psychoses, on the other. The second challenge is to take into account the full logical range of delusions, (...) which may take the form of true or false factual beliefs, positive or negative evaluations, as well as the paradoxical delusion of mental illness. The third and final challenge is to make room for non-pathological or, autonomy-preserving delusions and to offer a credible way of distinguishing between these and pathological or, autonomy-impairing delusions. By setting out these challenges, we are able to, firstly, distinguish between two separate conceptions of objectivity that may be at work in existing accounts of delusions and, secondly, to put a spotlight on an elusive yet inescapable notion of agential success that underlies our thinking about autonomy as well as mental disorder. (shrink)

In this chapter, I articulate the structure of a general concept of autonomy and then reply to possible objections with reference to Ulysses arrangements in psychiatry. The line of argument is as follows. Firstly, I examine three alternative conceptions of autonomy: value-neutral, value-laden, and relational. Secondly, I identify two paradigm cases of autonomy and offer a sketch of its concept as opposed to the closely related freedom of action and intentional agency. Finally, I explain away the autonomy paradox, to which (...) the previously identified pair of paradigm cases seems to give rise in the context of mental disorder. By addressing this paradox, we learn two valuable lessons. The first is about the relationships between the three conceptions of autonomy above. The second is about the relationship between autonomy and mental disorder. (shrink)

In what sense are persons equal, such that it is appropriate to treat them as equals? This difficult question has been strangely neglected by political philosophers. A plausible answer can be found by adopting a particular interpretation of the idea of respect. Central to this interpretation is the thought that in order to respect persons we need to treat them as ‘opaque', paying attention only to their outward features as agents. This proposed basis of equality has important implications for the (...) currency of egalitarian justice, ruling out a number of the equalizanda favored by contemporary egalitarians. (shrink)

The majority of current attention on the question of autonomy has focused on the internal reflection of the agent. The quality of an agent’s reflection on her potential action (or motivating desire or value) is taken to determine whether or not that action is autonomous. In this paper, I argue that there is something missing in most of these contemporary accounts of autonomy. By focusing overwhelmingly on the way in which the agent reflects, such accounts overlook the importance of what (...) the agent is reflecting upon. Whichever of these current formulations of autonomy we accept, reflection could be undertaken in full accordance with the conditions set, and yet the action fail to be autonomous. This will occur, I argue, if the agent is mistaken about the object of her reflection. More precisely, if she has a particular kind of false belief about the action she is contemplating undertaking, then no amount of reflection can render that action autonomous. This suggests the need for externalist conditions to be incorporated into an account of autonomy. (shrink)

Epistemic deontology is the view that the concept of epistemic justification is deontological: a justified belief is, by definition, an epistemically permissible belief. I defend this view against the argument from doxastic involuntarism, according to which our doxastic attitudes are not under our voluntary control, and thus are not proper objects for deontological evaluation. I argue that, in order to assess this argument, we must distinguish between a compatibilist and a libertarian construal of the concept of voluntary control. If we (...) endorse a compatibilist construal, it turns out that we enjoy voluntary control over our doxastic attitudes after all. If, on the other hand, we endorse a libertarian construal, the result is that, for our doxastic attitudes to be suitable objects of deontological evaluation, they need not be under our voluntary control. (shrink)

This article challenges Jennifer Jackson's recent defence of doctors' rights to deceive patients. Jackson maintains there is a general moral difference between lying and intentional deception: while doctors have a prima facie duty not to lie, there is no such obligation to avoid deception. This paper argues 1) that an examination of cases shows that lying and deception are often morally equivalent, and 2) that Jackson's position is premised on a species of moral functionalism that misconstrues the nature of moral (...) obligation. Against Jackson, it is argued that both lying and intentional deception are wrong where they infringe a patient's right to autonomy or his/her right to be treated with dignity. These rights represent 'deontological constraints' on action, defining what we must not do whatever the functional value of the consequences. Medical ethics must recognise such constraints if it is to contribute to the moral integrity of medical practice. (shrink)

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more obviously problematic. (...) Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Spiritual Experience and PsychopathologyMike Jackson and K. W. M. Fulford (bio)AbstractA recent study of the relationship between spiritual experience and psychopathology (reported in detail elsewhere) suggested that psychotic phenomena could occur in the context of spiritual experiences rather than mental illness. In the present paper, this finding is illustrated with three detailed case histories. Its implications are then explored for psychopathology, for psychiatric classification, and for our understanding of (...) the concept of mental illness. It is argued that pathological and spiritual psychotic phenomena cannot be distinguished by 1) form and content alone (as in traditional psychopathology), 2) by their relationship either with other symptoms or with pathological causes (as in psychiatric classification), or 3) by reference to the descriptive criteria of mental illness implied by the “medical” model. The distinction is shown to depend, rather, on the way in which psychotic phenomena themselves are embedded in the values and beliefs of the person concerned. This in turn is shown to have implications for diagnosis (it shows the need for clinicians to attend to the values and beliefs of individual patients), for treatment (it points to a cognitive problem-solving model), and for research in psychopathology (especially as related to the emerging sciences of dynamic brain imaging and cognitive neuroscience).Keywordsfirst rank symptoms, schizophrenia, delusion, hallucination, thought disorder, religious experience, mystical experienceIntroductionThis paper explores some of the conceptual and practical implications of the finding that phenomena which in a medical context would probably be diagnosed as psychotic symptoms, may occur in the context of non-pathological, and indeed essentially benign, spiritual experiences.The existence of non-pathological psychotic experiences of this kind (we will call them “psychotic phenomena” as distinct from “psychotic symptoms”—see also Endnote 1, terminology) was a key finding in a study carried out by one of us (MJ) at the Alister Hardy Research Centre (AHRC) in Oxford. Details are given elsewhere both of the overall empirical findings of the study, including the relationship between spiritual experience and personality variables, and of a hypothetical cognitive problem-solving model of these phenomena (Jackson 1991, and forthcoming a and b). In the present paper, 1) the background to the study is described briefly in relation to earlier work on the possible links between spiritual experience and psychopathology; 2) some of the psychotic phenomena identified are illustrated with three detailed case histories; 3) the significance of these phenomena is reviewed for our understanding respectively of psychopathology, of diagnostic syndromes, and of the concept of mental illness; and 4) some of the practical implications of the study for clinical work and research in psychiatry are indicated.BackgroundIt has long been recognized that there are similarities between spiritual and psychotic experiences. [End Page 41] William James (1902), for example, argued that “in delusional insanity, paranoia as they sometimes call it, we may have a kind of diabolical mysticism, a sort of religious mysticism turned upside down” (426). Other commentators have noted a wide variety of phenomena, such as time distortion, synesthesias, loss of self-object boundaries and the transition from a state of conflict and anxiety to one of sudden “understanding,” all of which are reported in both spiritual and psychotic experiences (Buckley 1981; Watson 1982; Wapnick 1969; and Wootton and Allen 1983).Yet the similarities notwithstanding, the distinction between these two kinds of experience can be crucially important. Spiritual experiences, whether welcome or unwelcome, and whether or not they are psychotic in form, have nothing (directly) to do with medicine (Fulford 1996a). It would be quite wrong, then, to “treat” spiritual psychotic experiences with neuroleptic drugs, just as it is quite wrong to “treat” political dissidents as though they were ill (Fulford, Smirnoff and Snow, 1993). Pathological psychotic experiences, on the other hand, or psychotic symptoms, are by definition a proper object of medical treatment, sometimes even against the wishes of the person concerned. Hence it would be both negligent and, as Wing (1978) put it, morally “repellent,” to leave untreated someone who is genuinely ill (244).Given how much turns on the distinction between spiritual experience and psychopathology, it is perhaps not surprising that scholarly discussion of the relationship between them has at times... (shrink)

I [try] to understand identification by appeal to phenomena of deciding to treat, and of treating, a desire of one's as reason-giving in one's practical reasoning, planning, and action. Is identification, so understood, "fundamental," as Frankfurt says, "to any philosophy of mind and of action"? Well, we have seen reason to include in our model of intentional agency such phenomena of deciding to treat, and of treating, certain of one's desires as reason-giving. Identification, at bottom, consists in such phenomena — (...) or so I have proposed. Given that such phenomena are important in our practical lives, we may agree with Frankfurt that identification is, in this sense, "fundamental.". (shrink)

According to the principle of patient autonomy, patients have the right to be self-determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions.In this paper I examine this claim in light of theories of practical (...) rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision-making, and that this same criterion can be applied to a patient's decision-guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case. (shrink)