This article discusses Philip Pettit’s neo-republicanism in light of the criterion of self-sustenance: the requirement that a political theory be capable of serving as a self-sustaining public philosophy for a pluralist democracy. It argues that this criterion can only be satisfied by developing an adequate politics of virtue. Pettit’s theory is built around the notion of freedom as non-domination, and he does not say much about the virtues of citizens or the policies the state may employ to encourage their development. (...) In order to explain the motivation to comply with republican laws that promote non-domination, Pettit relies on the phenomenon of civility and the mechanism of the intangible hand. But to understand what underlies an adequate level of robust civility one needs to focus on the more basic phenomenon of personal virtue. Policies that aim to promote non-domination should take into account the need to cultivate virtue among citizens, as well as the full range of conditions that favor its exercise. (shrink)

Autonomous Agents addresses the related topics of self-control and individual autonomy. "Self-control" is defined as the opposite of akrasia-weakness of will. The study of self-control seeks to understand the concept of its own terms, followed by an examination of its bearing on one's actions, beliefs, emotions, and personal values. It goes on to consider how a proper understanding of self-control and its manifestations can shed light on personal autonomy and autonomous behaviour. Perspicuous, objective, and incisive throughout, Alfred Mele makes a (...) convincing case for the value of individual autonomy. (shrink)

Virtually any appraisal of a person’s welfare, integrity, or moral status, as well as the moral and political theories built on such appraisals, will rely crucially on the presumption that her preferences and values are in some important sense her own. In particular, the nature and value of political freedom is intimately connected with the presupposition that actions one is left free to do flow from desires and values that are truly an expression of the ‘self-government’ of the agent. However, (...) we all know that no person is self-made in the sense of being a fully formed and intact ‘will’ blossoming out of nowhere. Our values and preferences are explained by essential reference to a variety of influences that have come to bear on our development throughout our personal histories. What is needed, then, is to establish an account of self-determination or autonomy that would help determine just when and if the values and preferences we find ourselves with deserve the centrality that moral and political theories place on them. (shrink)

There is concern that the use of neuroenhancements to alter character traits undermines consumer's authenticity. But the meaning, scope and value of authenticity remain vague. However, the majority of contemporary autonomy accounts ground individual autonomy on a notion of authenticity. So if neuroenhancements diminish an agent's authenticity, they may undermine his autonomy. This paper clarifies the relation between autonomy, authenticity and possible threats by neuroenhancements. We present six neuroenhancement scenarios and analyse how autonomy accounts evaluate them. Some cases are considered (...) differently by criminal courts; we demonstrate where academic autonomy theories and legal reasoning diverge and ascertain whether courts should reconsider their concept of autonomy. We argue that authenticity is not an appropriate condition for autonomy and that new enhancement technologies pose no unique threats to personal autonomy. (shrink)

ABSTRACT There is concern that the use of neuroenhancements to alter character traits undermines consumer's authenticity. But the meaning, scope and value of authenticity remain vague. However, the majority of contemporary autonomy accounts ground individual autonomy on a notion of authenticity. So if neuroenhancements diminish an agent's authenticity, they may undermine his autonomy. This paper clarifies the relation between autonomy, authenticity and possible threats by neuroenhancements. We present six neuroenhancement scenarios and analyse how autonomy accounts evaluate them. Some cases are (...) considered differently by criminal courts; we demonstrate where academic autonomy theories and legal reasoning diverge and ascertain whether courts should reconsider their concept of autonomy. We argue that authenticity is not an appropriate condition for autonomy and that new enhancement technologies pose no unique threats to personal autonomy. (shrink)

How should modern medicine's dramatic new powers to sustain life be employed? How should limited resources be used to extend and improve the quality of life? In this collection, Dan Brock, a distinguished philosopher and bioethicist and co-author of Deciding for Others (Cambridge, 1989), explores the moral issues raised by new ideals of shared decision making between physicians and patients. The book develops an ethical framework for decisions about life-sustaining treatment and euthanasia, and examines how these life and death decisions (...) are transformed in health policy when the focus shifts from what is best for a patient to what is just for all patients. Professor Brock combines acute philosophical analysis with a deep understanding of the realities of clinical health policy. This is a volume for philosophers concerned with medical ethics, health policy professionals, physicians interested in bioethics, and undergraduate courses in biomedical ethics. (shrink)

Criminal offenders may be offered to participate in voluntary rehabilitation programs aiming at correcting undesirable behaviour, as a condition of early release. Behavioural treatment may include direct intervention into the central nervous system (CNS). This article discusses under which circumstances voluntary rehabilitation by CNS intervention is justified. It is argued that although the context of voluntary rehabilitation is a coercive circumstance, consent may still be effective, in the sense that it can meet formal criteria for informed consent. Further, for a (...) consent to be normatively valid (“take the wronging out of the act”) under a coercive circumstance, the subject to be treated must (1) have the sovereign authority to consent, and (2) the offer-giver must be in the right normative position to make the offer. While I argue that subjects do have the sovereign authority to consent to treatment, I also argue that inappropriate offers yield invalid consents. Considerations on inappropriate offers should therefore inform which kinds of CNS intervention-based rehabilitation schemes the state may propose as part of the criminal justice system. Yet as I conclude in this paper, while there are some intrinsic constraints on voluntary rehabilitation programs, the main constraints on voluntary rehabilitation are likely to be contingent overriders. However, CNS intervention is not ruled out as such in the context of voluntary rehabilitation. (shrink)

This article explores the notion of the dislocated self following deep brain stimulation (DBS) and concludes that when personal identity is understood in dynamic, narrative, and relational terms, the claim that DBS is a threat to personal identity is deeply problematic. While DBS may result in profound changes in behaviour, mood and cognition (characteristics closely linked to personality), it is not helpful to characterize DBS as threatening to personal identity insofar as this claim is either false, misdirected or trivially true. (...) The claim is false insofar as it misunderstands the dynamic nature of identity formation. The claim is misdirected at DBS insofar as the real threat to personal identity is the discriminatory attitudes of others towards persons with motor and other disabilities. The claim is trivially true insofar as any dramatic event or experience integrated into one’s identity-constituting narrative could then potentially be described as threatening. From the perspective of relational personal identity, when DBS dramatically disrupts the narrative flow, this disruption is best examined through the lens of agency. For illustrative purposes, the focus is on DBS for the treatment of Parkinson’s disease. (shrink)

It is my view that one essential difference between persons and other creatures is to be found in the structure of a person's will. Besides wanting and choosing and being moved to do this or that, men may also want to have certain desires and motives. They are capable of wanting to be different, in their preferences and purposes, from what they are. Many animals appear to have the capacity for what I shall call "first-order desires" or "desires of the (...) first order," which are simply desires to do or not to do one thing or another. No animal other than man, however, appears to have the capacity for reflective self-evaluation that is manifested in the formation of second-order desires. (shrink)

These four volumes address the question of the kinds of conduct may the state make criminal without infringing on the moral autonomy of individual citizens.

John Christman has argued that constitutively relational accounts of autonomy, as defended by some feminist theorists, are problematically perfectionist about the human good. I argue that autonomy is constitutively relational, but not in a way that implies perfectionism: autonomy depends on a dialogical disposition to hold oneself answerable to external, critical perspectives on one's action-guiding commitments. This type of relationality carries no substantive value commitments, yet it does answer to core feminist concerns about autonomy.

Some maintain that voluntariness is a value-neutral concept. On that view, someone acts involuntarily if subject to a controlling influence or has no acceptable alternatives. I argue that a value-neutral conception of voluntariness cannot explain when and why consent is invalid and that we need a moralized account of voluntariness. On that view, most concerns about the voluntariness of consent to participate in research are not well founded.

John McMillan's article raises numerous important points about the ethics of surgical castration of sex offenders.1 In this commentary, we focus solely on and argue against the claim that the offer of release from detention conditional upon surgical castration is a coercive offer that compromises the validity of the offender's consent. We take no view on the question as to whether castration for sex offenders is ethically permissible. But, we reject the claim that it is ethically permissible only if competing (...) ethical considerations outweigh worries about coercion. For in the situation described, the proposal is not coercive at all.McMillan states that if offenders agree to castration because they fear long-term detention, then ‘it seems, intuitively, as if agreeing to be castrated under these conditions makes the decision coerced in some way.’1 He adds that if castration is ‘the only way that they will be released back into the community, the status of this decision as a genuine expression of their autonomy is questionable.’1 In defence of his claim, he uses two analogies that he borrows from Joel Feinberg. First, if a governor offers to commute a death sentence if the prisoner agrees to participate in a medical experiment, then ‘it's clear that the governor is coercing the prisoner.’1 Second, if a millionaire offers to give a woman $1 000 000 …. (shrink)

In the subsequent pages, I want to develop a distinction between wanting and valuing which will enable the familiar view of freedom to make sense of the notion of an unfree action. The contention will be that, in the case of actions that are unfree, the agent is unable to get what he most wants, or values, and this inability is due to his own "motivational system." In this case the obstruction to the action that he most wants to do (...) is his own will. It is in this respect that the action is unfree: the agent is obstructed in and by the very performance of the action. (shrink)

Deep brain stimulation is an invasive technique designed to stimulate certain deep brain regions for therapeutic purposes and is currently used mainly in patients with neurodegenerative disorders, such as Parkinson’s disease. However, DBS is also used increasingly for other experimental applications, such as the treatment of psychiatric disorders, weight reduction. Apart from its therapeutic potential, DBS can cause severe adverse effects, some that might also have a significant impact on the patient’s personality and autonomy by the external stimulation of DBS (...) which effects lie beyond the individual’s control and free will. The article’s purpose is to outline the procedures of DBS currently used in therapeutic and experimental applications and to discuss the ethical concerns regarding this procedure. It will address the clinical benefit-risk-ratio, the particular ethics of research in this field, and the ethical issues raised by affecting a patient’s or an individual’s personality and autonomous behaviour. Moreover, a potential ethical guideline, the Ulysses contract is discussed for the field of clinical application as well as the question of responsibility. (shrink)

Book reviewed in this article: Life and Death: Philosophical Essays in Biomedical Ethics. By Dan W. Brock.

Although philosophers have explored several connections between neuroscience and moral responsibility, the issue of how real-world neurological modifications, such as Deep Brain Stimulation, impact moral responsibility has received little attention. In this article, we draw on debates about the relevance of history and manipulation to moral responsibility to argue that certain kinds of neurological modification can diminish the responsibility of the agents so modified. We argue for a historicist position - a version of the history-sensitive reflection view - and defend (...) that account against a rival, relational view of responsibility. We conclude that DBS can, under certain conditions, diminish responsibility, and explore the circumstances under which this might be so. We conclude by suggesting that philosophical debates about moral responsibility, manipulation, and history have greater practical relevance than is sometimes thought, and that attention to practical cases can help inform and deepen this body of scholarship. (shrink)

Much of the literature devoted to the topics of agent autonomy and agent responsibility suggests strong conceptual overlaps between the two, although few explore these overlaps explicitly. Beliefs of this sort are commonplace, but they mistakenly conflate the global state of being autonomous with the local condition of acting autonomously or exhibiting autonomy in respect to some act or decision. Because the latter, local phenomenon of autonomy seems closely tied to the condition of being responsible for an act, we tend (...) to think of the former, global phenomenon as a condition of responsibility as well. But one can act autonomously, or manifest autonomy with respect to some occurrent state, without satisfying the conditions for autonomous agency. Autonomous agency and responsible agency are logically distinct in part due to the varient conceptions of rationality each calls for. Both agent responsibility and holding a person responsible imply a fairly ``thick'''' form of rationality, where rationality embodies a normative component and is a matter of satisfying criteria that are objective in the sense that they are independent of what a person happens to want or to value. But autonomous agency calls for a quite different, ``thin'''' conception of instrumental rationality. (shrink)

The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment have conducted visits and written reports criticising the surgical castration of sex offenders in the Czech Republic and Germany. They claim that surgical castration is degrading treatment and have called for an immediate end to this practice. The Czech and German governments have published rebuttals of these criticisms. The rebuttals cite evidence about clinical effectiveness and point out this is an intervention that must be requested (...) by the sex offender and cannot occur without informed consent. This article considers a number of relevant arguments that are not discussed in these reports but which are central to how we might assess this practice. First, the article discusses the possible ways in which sex offenders could be coerced into castration and whether this is a decisive moral problem. Then, it considers a number of issues relevant to determining whether sex offenders are harmed by physical castration. The article concludes by arguing that sex offenders should not be coerced into castration, be that via threats or offers, but that there is no reason to think that this is occurring in the Czech Republic or Germany. In some cases, castration might be useful for reconfiguring a life that has gone badly awry and where there is no coercion, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment are mistaken about this being degrading treatment. (shrink)

There is preliminary evidence, from case reports and investigational studies, to suggest that Deep Brain Stimulation could be used to treat some patients with Anorexia Nervosa. Although this research is at an early stage, the invasive nature of the intervention and the vulnerability of the potential patients are such that anticipatory ethical analysis is warranted. In this paper, we first show how different treatment mechanisms raise different philosophical and ethical questions. We distinguish three potential mechanisms alluded to in the neuroscientific (...) literature, relating to desire, control, and emotion, respectively. We explain why the precise nature of the mechanism has important implications for the patient’s autonomy and personal identity. In the second part of the paper, we consider practical dimensions of offering DBS to patients with AN in certain cases. We first discuss some limited circumstances where the mere offering of the intervention might be perceived as exerting a degree of coercive pressure that could serve to undermine the validity of the patient’s consent. Finally, we consider the implications of potential effects of DBS for the authenticity of the patient’s choice to continue using stimulation to ameliorate their condition. (shrink)

This collection of original essays explores the social and relational dimensions of individual autonomy. Rejecting the feminist charge that autonomy is inherently masculinist, the contributors draw on feminist critiques of autonomy to challenge and enrich contemporary philosophical debates about agency, identity, and moral responsibility. The essays analyze the complex ways in which oppression can impair an agent's capacity for autonomy, and investigate connections, neglected by standard accounts, between autonomy and other aspects of the agent, including self-conception, self-worth, memory, and the (...) imagination. (shrink)

Brain implants, such as Deep Brain Stimulation (DBS), which are designed to improve motor, mood and behavioural pathology, present unique challenges to our understanding of identity, agency and free will. This is because these devices can have visible effects on persons' physical and psychological properties yet are essentially undetectable when operating correctly. They can supplement and compensate for one's inherent abilities and faculties when they are compromised by neuropsychiatric disorders. Further, unlike talk therapy or pharmacological treatments, patients need not ‘do’ (...) anything for the treatment to take effect. If one accepts, as we argue here, that brain implants are unique among implantable types of devices, then this can have significant implications for what it means to persist as the same person and be the source of one's thoughts and actions. By examining two of the most common indications for DBS in current use, namely in the motor (Parkinson's Disease) and psychiatric (Major Depression) domains, we further argue that although DBS, as it is currently applied, does not necessarily represent a unique threat to personal identity and agency per se, it introduces an unprecedented ‘third party’ into the debate on these concepts. In this way, DBS can be used as a tool to begin probing, both conceptually and empirically, some of philosophy's most perennial metaphysical questions. (shrink)

In this article, I explore select case studies of Parkinson patients treated with deep brain stimulation in light of the notions of alienation and authenticity. While the literature on DBS has so far neglected the issues of authenticity and alienation, I argue that interpreting these cases in terms of these concepts raises new issues for not only the philosophical discussion of neuro-ethics of DBS, but also for the psychological and medical approach to patients under DBS. In particular, I suggest that (...) the experience of alienation and authenticity varies from patient to patient with DBS. For some, alienation can be brought about by neurointerventions because patients no longer feel like themselves. But, on the other hand, it seems alienation can also be cured by DBS as other patients experience their state of mind as authentic under treatment and retrospectively regard their former lives without stimulation as alienated. I argue that we must do further research on the relevance of authenticity and alienation to patients treated with DBS in order to gain a deeper philosophical understanding, and to develop the best evaluative criterion for the behavior of DBS patients. (shrink)

While deep brain stimulation (DBS) for patients with Parkinson's disease has typically raised ethical questions about autonomy, accountability and personal identity, recent research indicates that we need to begin taking into account issues surrounding the patients’ feelings of authenticity and alienation as well. In order to bring out the relevance of this dimension to ethical considerations of DBS, I analyse a recent case study of a Dutch patient who, as a result of DBS, faced a dilemma between autonomy and authenticity. (...) This case study is meant to point out the normatively meaningful tension patients under DBS experience between authenticity and autonomy. (shrink)

Deep brain stimulation is a well-accepted treatment for movement disorders and is currently explored as a treatment option for various neurological and psychiatric disorders. Several case studies suggest that DBS may, in some patients, influence mental states critical to personality to such an extent that it affects an individual’s personal identity, i.e. the experience of psychological continuity, of persisting through time as the same person. Without questioning the usefulness of DBS as a treatment option for various serious and treatment refractory (...) conditions, the potential of disruptions of psychological continuity raises a number of ethical and legal questions. An important question is that of legal responsibility if DBS induced changes in a patient’s personality result in damage caused by undesirable or even deviant behavior. Disruptions in psychological continuity can in some cases also have an effect on an individual’s mental competence. This capacity is necessary in order to obtain informed consent to start, continue or stop treatment, and it is therefore not only important from an ethical point of view but also has legal consequences. Taking the existing literature and the Dutch legal system as a starting point, the present paper discusses the implications of DBS induced disruptions in psychological continuity for a patient’s responsibility for action and competence of decision and raises a number of questions that need further research. (shrink)

In his most recent book, Philip Pettit presents and defends a “republican” political philosophy that stems from a tradition that includes Cicero, Machiavelli, James Harrington, Locke, Montesquieu, Rousseau, and Madison. The book provides an interpretation of what is distinctive about republicanism—namely, Pettit claims, its notion of freedom as nondomination. He sketches the history of this notion, and he argues that it entails a unique justification of certain political arrangements and the virtues of citizenship that would make those arrangements possible. Of (...) historical and philosophical interest, he stresses, is the fundamental contrast between freedom as nondomination and slavery. Joseph Priestly, for instance, invoked this contrast in defending the cause of the American Revolution, and in 1769 declared, incredibly, that if the parliament of Great Britain continued to tax the American colonies, “the colonists will be reduced to a state of as complete servitude, as any people of which there is an account in history”. Those opposed to American independence, among them Jeremy Bentham, relied instead on a Hobbesian notion of freedom as noninterference, using it to argue that the colonists were no more interfered with by the British government than were citizens of Britain. Drawing out this contrast, Pettit aims to establish that a republican view of freedom better supports the institutions of a constitutional democracy than does liberalism. His account of the distinguishing characteristics and strengths of republicanism is, however, only partially successful. Neither his case that a republican notion of freedom provides for a more solid defense of democratic institutions and constitutional protections than is available within liberalism, nor his argument that republicanism can better address “private” injustices, is convincing. (shrink)

Perhaps the best way to understand the novelty of Berofsky’s approach is to discuss two prevailing views about autonomy he rejects. On one of these views, we have the following picture: Autonomous agents develop powers to critically reflect upon and evaluate their past and present motivations. Such reflection inevitably leads to conflicts between reflective evaluation and existing motivation. The workaholic judges that he should spend more time with his family; the smoker does not want to have the craving for cigarettes (...) she does have. When such conflicts arise, one exercises autonomy by choosing in favor of the evaluations or higher-order desires over one’s first-order desires. Reason wins out over desire, or the higher self—the “true” or “real” self—wins out over the lower self. (shrink)

This paper explores the ethical and conceptual implications of the findings from an empirical study (reported elsewhere) of decision-making capacity in anorexia nervosa. In the study, ten female patients aged thirteen to twenty-one years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semistructured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient-participants were also tested using the (...) MacArthur Competence Assessment Tool—Treatment test of competence. This is a formalized, structured, interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief, self-administered questionnaires to assess their levels of psychopathology. The issues identified from the interviews are described under two headings: difficulties with thought processing and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches. (shrink)

Rapid advancements in human neuroscience and neurotechnology open unprecedented possibilities for accessing, collecting, sharing and manipulating information from the human brain. Such applications raise important challenges to human rights principles that need to be addressed to prevent unintended consequences. This paper assesses the implications of emerging neurotechnology applications in the context of the human rights framework and suggests that existing human rights may not be sufficient to respond to these emerging issues. After analysing the relationship between neuroscience and human rights, (...) we identify four new rights that may become of great relevance in the coming decades: the right to cognitive liberty, the right to mental privacy, the right to mental integrity, and the right to psychological continuity. (shrink)

Brain–computer interfacing technologies are used as assistive technologies for patients as well as healthy subjects to control devices solely by brain activity. Yet the risks associated with the misuse of these technologies remain largely unexplored. Recent findings have shown that BCIs are potentially vulnerable to cybercriminality. This opens the prospect of “neurocrime”: extending the range of computer-crime to neural devices. This paper explores a type of neurocrime that we call brain-hacking as it aims at the illicit access to and manipulation (...) of neural information and computation. As neural computation underlies cognition, behavior and our self-determination as persons, a careful analysis of the emerging risks of malicious brain-hacking is paramount, and ethical safeguards against these risks should be considered early in design and regulation. This contribution is aimed at raising awareness of the emerging risk of malicious brain-hacking and takes a first step in developing an ethical and legal reflection on those risks. (shrink)

In this article, we explore how deep brain stimulation (DBS) devices designed to “close the loop”—to automatically adjust stimulation levels based on computational algorithms—may risk taking the individual agent “out of the loop” of control in areas where (at least apparent) conscious control is a hallmark of our agency. This is of particular concern in the area of psychiatric disorders, where closed-loop DBS is attracting increasing attention as a therapy. Using a relational model of identity and agency, we consider whether (...) DBS designed for psychiatric regulation may require special attention to agency. To do this, we draw on philosophical work on relational identity and agency, connecting it with reports from people using first-generation DBS devices for depression and obsessive-compulsive disorder. We suggest a way to extend a notion of relational agency to encompass neural devices. (shrink)

Deep brain stimulation (DBS) of the globus pallidus interna and subthalamic nucleus has restored some degree of motor control in many patients in advanced stages of Parkinson’s disease. DBS has also been used to treat dystonia, essential tremor (progressive neurological condition causing trembling), chronic pain, obsessive-compulsive disorder, Tourette’s syndrome, major depressive disorder, obesity, cerebral palsy, and the minimally conscious state. Although the underlying mechanisms of the technique are still not clear, DBS can modulate underactive or overactive neural circuits and restore (...) disrupted communication between and among groups of neurons in interacting regions of the brain. This can control and relieve many symptoms associated with a range of neurological and psychiatric disorders.But the procedures of implanting and stimulating the electrodes are brain-invasive and entail significant risks. Some patients receiving DBS have experienced intracerebral hemorrhage, infection, cognitive disturbances such as impulsive behavior, and affective disturbances such as mania. It is not known whether continuous electrical stimulation of the brain would reshape synaptic connectivity and permanently alter neural circuits in ways that may not be salutary. The risk of these effects indicates that DBS should be used only when a patient’s condition is refractory to all other interventions and when there is a high probability that the technique will benefit the patient and improve his or her quality of life. If a patient’s quality of life is poor and all other treatment options have been exhausted, then the likelihood of benefit can justify physicians’ exposing patients to some risk. The clinical and ethical significance of the risk in DBS underscores the obligation of physicians to obtain fully informed consent from patients undergoing the procedure. (shrink)

The phenomenological effects of deep brain stimulation (DBS) on the self of the patient remains poorly understood and under described in the literature, despite growing evidence that a significant number of patients experience postoperative neuropsychiatric changes. To address this lack of phenomenological evidence, we conducted in-depth, semistructured interviews with 17 patients with Parkinson's disease who had undergone DBS. Exploring the subjective character specific to patients' experience of being implanted gives empirical and conceptual understanding of the potential phenomenon of DBS-induced self-estrangement. (...) Our study concluded that (1) the more patients preoperatively felt alienated by their illness, the more they experienced postoperative self-estrangement, and (2) the notion of self-estrangement seems to exist in association with certain common qualitative characters, namely, loss of control, which reflects a deteriorative estrangement, and distorted perception of capacities, which reveals a restorative estrangement. These findings indicate that subjective self-reports help us to understand some aspects of the potential phenomenon of DBS-induced self-estrangement. (shrink)

The goal of this article is to shed light on Deep Brain Stimulation (DBS) postoperative suicidality risk factors within Treatment Resistant Depression (TRD) patients, in particular by focusing on the ethical concern of enrolling patient with history of self-estrangement, suicide attempts and impulsive–aggressive inclinations. In order to illustrate these ethical issues we report and review a clinical case associated with postoperative feelings of self-estrangement, self-harm behaviours and suicide attempt leading to the removal of DBS devices. Could prospectively identifying and excluding (...) patients with suicidality risk factors from DBS experimental trials—such as history of self-estrangement, suicide attempts and impulsive–aggressive inclinations—lead to minimizing the risk of suicidality harm? (shrink)

Despite growing evidence that a significant number of patients living with Parkison’s disease experience neuropsychiatric changes following Deep Brain Stimulation treatment, the phenomenon remains poorly understood and largely unexplored in the literature. To shed new light on this phenomenon, we used qualitative methods grounded in phenomenology to conduct in-depth, semi-structured interviews with 17 patients living with Parkinson’s Disease who had undergone DBS. Our study found that patients appear to experience postoperative DBS-induced changes in the form of self-estrangement. Using the insights (...) from patients’ subjective perceptions of postoperative self-change provides a potent explanation of potential DBS-induced self-estrangement. (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)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

This is the first volume in which an account of personal autonomy is developed that both captures the contours of this concept as it is used in social philosophy and bioethics, and is theoretically grounded in, and a part of, contemporary autonomy theory. James Stacey Taylor’s account is unique as it is explicitly a political one, recognizing that the attribution of autonomy to agents is dependent in part on their relationships with others and not merely upon their own mental states. (...) The volume is distinctive in its examples, which touch on the ethics of using inducements to encourage persons to participate in medical research, the ethical issues associated with the use of antibiotics, and the ethical basis for both patient confidentiality and informed consent. (shrink)

This is the first full-length presentation of a republican alternative to the liberal and communitarian theories that have dominated political philosophy in recent years. The latest addition to the acclaimed Oxford Political Theory series, Pettit's eloquent and compelling account opens with an examination of the traditional republican conception of freedom as non-domination, contrasting this with established negative and positive views of liberty. The first part of the book traces the rise and decline of this conception, displays its many attractions, and (...) makes a case for why it should still be regarded as a central political ideal. The second part of the book looks at what the implementation of the ideal would imply for substantive policy-making, constitutional and democratic design, regulatory control and the relation between state and civil society. Prominent in this account is a novel concept of democracy, under which government is exposed to systematic contestation, and a vision of relations between state and society founded upon civility and trust. Pettit's powerful and insightful new work offers not only a unified, theoretical overview of the many strands of republican ideas, but also a new and sophisticated perspective on studies in related fields including the history of ideas, jurisprudence, and criminology. (shrink)