The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

The terms health, disease and illness are frequently used in clinical medicine. This has misled philosophers into believing that these concepts are important for clinical thinking and decision making. For instance, it is held that decisions about whether or not to treat someone or whether to relieve someone of moral responsibility depend on whether the person has a disease. In this paper it is argued that the crucial role of the disease concept is illusory. The health/disease distinction is irrelevant for (...) most decisions and represents a conceptual straightjacket. Sophisticated and mature clinical decision making requires that we free ourselves from the concept of disease. (shrink)

Introduction -- Introducing the concept of diagnostic cultures -- Psychiatric diagnoses as epistemic objects -- Languages of suffering -- Psychiatric diagnoses as semiotic mediators -- "Do more, feel better, live longer": being a psychiatric subject -- Interpreting the epidemics -- Towards a comprehensive understanding of mental disorder -- General conclusions.

Addressing distributive justice issues in health policy—ranging from the allocation of health system funding to the allocation of scarce COVID-19 interventions like intensive care unit beds and vaccines—involves the application of ethical principles. Should a principle of sustainability be among them? I suggest that while the value of temporal neutrality underlying such a principle is compelling, it is already implicit in the more basic principle of equal treatment. Munthe et al imagine sustainability accompanying four other principles: need, prognosis, equal treatment (...) and cost-effectiveness. Some are spelled out, however, in ways that are ambiguous or incomplete. (shrink)

In this peer commentary on Maura Priest's "Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm", I argue against the "mismatch" model of trans identity. On this model, which is prevalent in institutional and medical contexts, to be trans is to have one's gender identity "mismatch" with one's sexed body.

Medicalization appears to be an issue that is both ubiquitous and unquestionably problematic as it seems to signal at once a social and existential threat. This perception of medicalization, however, is nothing new. Since the first main writings in the 1960s and 1970s, it has consistently been used to describe inappropriate or abusive instances of medical authority. Yet, while this standard approach claims that medicalization is a growing problem, it assumes that there is simply one “medical model” and that the (...) expanding realm of “the medical” can be more or less clearly delineated. Moreover, while intended to establish the reality of this growing threat, this research often requires making arbitrary or unjustified distinctions between different practices. To better clarify the concept of medicalization, I will focus more on capturing the variety of medical practices than on the sociological aspects of medical discourse. In doing so, I will explore the distinction between medicalization and pathologization, a distinction that is often overlooked and that brings with it many conceptual and practical implications. After defining these terms, I will use some examples to show that while pathologizing is closely tied to medicalizing, both can occur independently. I will then further develop this distinction in terms of the different individual and social effects of these practices. (shrink)

"Why are there 'transsexuals' but not 'transracials'?" "Why is there an accepted way to change sex, but not to change race?" I have repeatedly heard these questions from theorists puzzled by the phenomenon of transsexuality. Feminist thinkers, in particular, often seem taken aback that in the case of category switching the possibilities appear to be so different. Behind the question is sometimes an implicit concern: Does not the (hypothetical or real) example of individual “transracialism” seem politically troubling? And, if it (...) is, does not the case of transsexuality merit equivalent critique? Or, conversely, if one accepts transsexuals as people with legitimate demands (e.g., on medical resources or single-sex spaces), then would one not also be committed to accepting the putative transracial in analogous ways? Understanding the ontological constraints and possibilities with regard to transforming one’s identity is, I suggest, a project that should accompany ethical evaluation of those transformations. Under what circumstances is it (un)ethical to leave behind a gender or racial group with which one has once been affiliated? This question is, again, especially pressing for radical thinkers who endorse the claims that race and gender taxonomies are internally hierarchical and constituted through relations of oppression, domination, and normalization. Changing one’s identity under these circumstances will surely always be linked, however tenuously, to consideration of the larger political and cultural milieu in which such changes are advantageous or disadvantageous, complicit with oppressive norms and/or resistant to them. To illuminate these larger questions, in this paper, I first provide three examples of the analogy thesis in feminist thinking about race and sex change, each of which draws ethical conclusions about individual motivation, political strategy, or public policy, premised on the assumption that race and sex change are equivalent phenomena. None of these accounts consider the genealogy of each category as significant to contemporary possibilities. I next offer a descriptive analysis that highlights different norms at play in contemporary North American understandings: Sex–gender, I argue, is essentialized as a property of the individual’s body, while race is essentialized with reference to both the body and ancestry. This analysis, I conclude, shows politically significant disanalogies between the categories, and reveals the importance of genealogical accounts of race and sex in thinking ethically about changing ourselves. (shrink)

Current and future possibilities for enhancing human physical ability, cognition, mood, and lifespan raise the ethical question of whether we should enhance normal human capacities in these ways. This chapter offers such an account of enhancement. It begins by reviewing a number of suggested accounts of enhancement, and points to their shortcomings. The chapter then identifies two key senses of “enhancement”: functional enhancement, the enhancement of some capacity or power (e.g. vision, intelligence, health) and human enhancement, the enhancement of a (...) human being's life. The latter notion is the notion of enhancement most relevant to ethical debate. The chapter argues that it is best understood in welfarist terms. It illustrates this welfarist approach to enhancement by applying it to the case of cognitive enhancement. Unlike the sociological pragmatic and functional approaches, the welfarist account is inherently normative. It ties enhancement to the value of well‐being. (shrink)

The terms "health", "disease" and "illness" are frequently used in clinical medicine. This has misled philosophers into believing that these concepts are important for clinical thinking and decision making. For instance, it is held that decisions about whether or not to treat someone or whether to relieve someone of moral responsibility depend on whether the person has a disease. In this paper it is argued that the crucial role of the 'disease' concept is illusory. The health/disease distinction is irrelevant for (...) most decisions and represents a conceptual straightjacket. Sophisticated and mature clinical decision making requires that we free ourselves from the concept of disease. (shrink)

The enhancement debate in neuroscience and biomedical ethics tends to focus on the augmentation of certain capacities or functions: memory, learning, attention, and the like. Typically, the point of contention is whether these augmentative enhancements should be considered permissible for individuals with no particular “medical” disadvantage along any of the dimensions of interest. Less frequently addressed in the literature, however, is the fact that sometimes the _diminishment_ of a capacity or function, under the right set of circumstances, could plausibly contribute (...) to an individual's overall well-being: more is not always better, and sometimes less is more. Such cases may be especially likely, we suggest, when trade-offs in our modern environment have shifted since the environment of evolutionary adaptation. In this article, we introduce the notion of “diminishment as enhancement” and go on to defend a _welfarist_ conception of enhancement. We show how this conception resolves a number of definitional ambiguities in the enhancement literature, and we suggest that it can provide a useful framework for thinking about the use of emerging neurotechnologies to promote human flourishing. (shrink)

Although informed consent models for prescribing hormone replacement therapy are becoming increasingly prevalent, many physicians continue to require an assessment and referral letter from a mental health professional prior to prescription. Drawing on personal and communal experience, the author argues that assessment and referral requirements are dehumanising and unethical, foregrounding the ways in which these requirements evidence a mistrust of trans people, suppress the diversity of their experiences and sustain an unjustified double standard in contrast to other forms of clinical (...) care. Physicians should abandon this unethical requirement in favour of an informed consent approach to transgender care. (shrink)

Our understanding of the neurochemical bases of human love and attachment, as well as of the genetic, epigenetic, hormonal, and experiential factors that conspire to shape an individual's sexual orientation, is increasing exponentially. This research raises the vexing possibility that we may one day be equipped to modify such variables directly, allowing for the creation of “high-tech” conversion therapies or other suspect interventions. In this article, we discuss the ethics surrounding such a possibility, and call for the development of legal (...) and procedural safeguards for protecting vulnerable children from the application of such technology. We also consider the more difficult case of voluntary, adult “conversion” and argue that in rare cases, such attempts might be permissible under strict conditions. (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)

The ‘born this way’ movement for sexual orientation minority rights is premised on the view that sexual orientation is something that can neither be chosen nor changed. Indeed, current sexual orientation change efforts appear to be both harmful and ineffective. But what if ‘high-tech conversion therapies’ are invented in the future that are effective at changing sexual orientation? The conceptual basis for the movement would collapse. In this chapter, we argue that the threat of HCT should be taken seriously, motivating (...) a change in tactics for proponents of sexual orientation minority rights. We also discuss some of the practical-ethical and public-policy issues surrounding HCT, in case the technology is one day developed. (shrink)

The welfarist account of enhancement and disability holds enhanced and disabled states on a spectrum: the former are biological or psychological states that increase the chances of a person leading a good life in the relevant set of circumstances, while the latter decrease those chances. Here, I focus on a particular issue raised by this account: what should we count as part of an individual’s relevant set of circumstances when thinking about enhanced and disabled states? Specifically, is social prejudice relevant (...) to an individual’s circumstances in regards to how disabled or enhanced they are? For instance, if an individual is discriminated against on the basis of their skin colour, and this leads to a reduction in their well-being, the welfarist account suggests that their skin colour is a disability. To avoid such a seeming mislabel, Savulescu and Kahane have argued for excluding social prejudice from counting as a relevant circumstance to their welfarist definition of disability. I argue, however, that this exclusion of social prejudice is unsatisfactory and incompatible with the goals of this account. (shrink)

The terms of debate over insurance coverage of transition-related interventions, which includes facial feminization surgery (FFS), has been defined through the reconstructive versus cosmetic dichot...

Advances in psychopharmacology raise the prospects of enhancing neurocognitive functions of humans by improving attention, memory, or mood. While general ethical reflections on psychopharmacological enhancement have been increasingly published in the last years, ethical criteria characterizing physicians’ role in neurocognitive enhancement and guiding their decision-making still remain highly unclear. Here it will be argued that also in the medical domain the use of cognition-enhancing drugs is not intrinsically unethical and that, in fact, physicians should assume an important role in gating (...) their usage. For finding normative orientation, concepts of disease, normality or medicine will not be helpful since—due to their cryptonormative nature—they rather hamper than allow targeted discussion and decision-making. As an alternative, the common and widely accepted bioethical criteria of beneficence, non-maleficence, autonomy and distributive justice allow a clinically applicable, highly differentiated context- and case-sensitive approach. By embedding decision-making in a participative physician–patient relationship extrinsic objections against neurocognitive enhancement (e.g. invalid perceptions about efficacy, benefit or risk; questionable voluntariness; restrained decision-making capacity) can be curtailed. (shrink)

Philosophers have long been involved in the pursuit of a goal shared by researchers in psychiatry and the cognitive sciences: understanding the relationship between the functioning of the human mind and human well-being or suffering. For this reason there is a very large area of overlap between philosophical and psychiatric research. The overlap is particularly significant in the domain of practical ethics, which is concerned with understanding the moral dimension of policies and actions in the real world. This chapter reviews (...) two distinct domains in which psychiatry and practical ethics overlap. First, issues in practical ethics arise out of new advances in psychopharmacology, including clinical and non-clinical use of new antidepressants drugs, the clinical use of placebo medications, and psychiatric drugs which enhance human cognition; these issues are frequently grouped under the banner of "neuroethics." Second, the understanding of fundamental questions in moral philosophy is being driven forward by evidence from psychology and psychiatry. Evidence from autism and the personality disorders is shedding light on the nature of moral motivation, while evidence from addiction and compulsion is generating progress in understanding moral responsibility. Finally, some areas are highlighted in which the science of psychiatry may benefit from the application of existing work in moral philosophy and practical ethics. (shrink)

"Some patients find it difficult to be in the present because they are stuck in the past; others, by contrast, struggle to remain connected with the past and are suspended in a so-called present that is effectively atemporal, that is out of time”.1 For psychoanalysts, the most profound and ultimately ethical way that we can help individuals, is by helping them know themselves. This involves discovering how they were shaped by their past and how their ongoing self-experience cannot be understood (...) in isolation from its constitutive contexts. Psychoanalysts help patients explore foundational questions such as: ‘Who am I?’ ‘How did I get here?’ ‘How am I implicated in my own suffering?’ ‘How can I grow and flourish and truly engage with my life?’. The answers to these questions emerge from a detailed exploration of the persons lived relational history, their current social and relational context and the political systems within which they are embedded. It is via this expansion of self-awareness that individuals can access agency and true freedom of choice. The clinical approach presented by Notini et al 2 is grounded in a completely different, radically decontextualised understanding of human experience. Their conceptualisation of Phoenix’s gender identity is ahistorical and atemporal: it is indeed ‘out of time’. For these authors, gender identity is assumed to be an immutable core essence, much like Ehrensaft’s3 ‘true gender self….there from birth’. It simply ‘is’. This is a …. (shrink)

Here, a moral case is presented as to why sign languages such as Auslan should be made compulsory in general school curricula. Firstly, there are significant benefits that accrue to individuals from learning sign language. Secondly, sign language education is a matter of justice; the normalisation of sign language education and use would particularly benefit marginalised groups, such as those living with a communication disability. Finally, the integration of sign languages into the curricula would enable the flourishing of Deaf culture (...) and go some way to resolving the tensions that have arisen from the promotion of oralist education facilitated by technologies such as cochlear implants. There are important reasons to further pursue policy proposals regarding the prioritisation of sign language in school curricula. (shrink)

Notini _et al_ 1 offer a timely addition in the wake of a significant increase in young people identifying as transgender and gender diverse. The authors focus specifically on the case of 18-year-old Phoenix’s request for ongoing puberty suppression to affirm a non-binary gender identity. A central issue raised by Phoenix’s predicament, and that I suggest we can extend to ethical consideration of requests for other types of medical intervention by binary and non-binary TGD individuals, is whether we should ‘affirm’ (...) the claims made by TGD young people about what promotes their well-being. As a clinician working with TGD young people who have undergone a range of medical interventions to align their bodies with their gender identity, my starting presumption is that it is important to respect what people think will help them: there are some TGD... (shrink)

Notini et al 1 offer a timely addition in the wake of a significant increase in young people identifying as transgender and gender diverse. The authors focus specifically on the case of 18-year-old Phoenix’s request for ongoing puberty suppression to affirm a non-binary gender identity. A central issue raised by Phoenix’s predicament, and that I suggest we can extend to ethical consideration of requests for other types of medical intervention by binary and non-binary TGD individuals, is whether we should ‘affirm’ (...) the claims made by TGD young people about what promotes their well-being. As a clinician working with TGD young people who have undergone a range of medical interventions to align their bodies with their gender identity, my starting presumption is that it is important to respect what people think will help them: there are some TGD young people for whom, all things considered, medical interventions to affirm gender identity promote their well-being. Well-being has become an important conceptual currency in ethical debates and lies at the core of the authors’ analysis of Phoenix’s case. While the authors do not ground their argument in favour of OPS in a specific theory of well-being, welfarist considerations 2 appear to underpin …. (shrink)

There is an apparent epidemic of mental illness. At the end of 2011, untreated mental disorders accounted for 13% of the total global burden of disease, and for 25.3% and 33.5% of all years lived with a disability in low-and middle-income countries, respectively. Depression affects 350 million people globally and is the leading cause of disability. One in five U.S. adults takes psychiatric medication. One study found that by age 32, 50% of people surveyed qualified for an anxiety disorder, more (...) than 40% for a mood disorder, and more than 30% for substance dependence. Another study reported that... (shrink)