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Jefferson A. "Terminal Anorexia", Treatment Refusal and Decision-Making Capacity. Camb Q Healthc Ethics 2024:1-12. [PMID: 39463268 DOI: 10.1017/s0963180124000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2024]
Abstract
Whether anorexic patients should be able to refuse treatment when this refusal potentially has a fatal outcome is a vexed topic. A recent proposal for a new category of "terminal anorexia" suggests criteria when a move to palliative care or even physician-assisted suicide might be justified. The author argues that this proposed diagnosis presents a false sense of certainty of the illness trajectory by conceptualizing anorexia in analogy with physical disorders and stressing the effects of starvation. Furthermore, this conceptualization is in conflict with the claim that individuals who meet the diagnostic criteria for terminal anorexia have decision-making capacity. It should therefore be rejected.
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Affiliation(s)
- Anneli Jefferson
- School of English, Communication and Philosophy, Cardiff University, Cardiff, UK
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Henden E. Addiction and autonomy: Why emotional dysregulation in addiction impairs autonomy and why it matters. Front Psychol 2023; 14:1081810. [PMID: 36844354 PMCID: PMC9945912 DOI: 10.3389/fpsyg.2023.1081810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/16/2023] [Indexed: 02/08/2023] Open
Abstract
An important philosophical issue in the study of addiction is what difference the fact that a person is addicted makes to attributions of autonomy (and responsibility) to their drug-oriented behavior. In spite of accumulating evidence suggesting the role of emotional dysregulation in understanding addiction, it has received surprisingly little attention in the debate about this issue. I claim that, as a result, an important aspect of the autonomy impairment of many addicted individuals has been largely overlooked. A widely shared assumption in the philosophical literature is that for addiction to impair a person's autonomy it has to make them (in some sense) take drugs against their will. So-called "willing addicts" are therefore usually seen as exempted from the autonomy impairment believed to characterize "unwilling addicts," the latter being those who "truly want" to stop using drugs but find their attempts repeatedly derailed by failures of self-control. In this article, I argue that the association between addiction and emotional dysregulation shows why this assumption is false. Emotional dysregulation is not only consistent with the possibility that many addicts take drugs "willingly," it supports the hypothesis that they use drugs because they truly want to. The article proposes an explanation for why emotional dysregulation should nevertheless be seen as an aspect of their loss of control and an important reason why they have impaired autonomy. I end by exploring some implications of this account for addict's decision-making capacity when they are prescribed the drugs to which they are addicted.
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El-Alti L. Shared Decision Making in Psychiatry: Dissolving the Responsibility Problem. HEALTH CARE ANALYSIS 2022; 31:65-80. [PMID: 36462103 PMCID: PMC10126083 DOI: 10.1007/s10728-022-00451-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/04/2022]
Abstract
AbstractPerson centered care (PCC) invites ideas of shared responsibility as a direct result of its shared decision making (SDM) process. The intersection of PCC and psychiatric contexts brings about what I refer to as the responsibility problem, which seemingly arises when SDM is applied in psychiatric settings due to (1) patients’ potentially diminished capacities for responsibility, (2) tension prompted by professional reasons for and against sharing responsibility with patients, as well as (3) the responsibility/blame dilemma. This paper aims to do away with the responsibility problem through arguing for a functional approach to mental illness, a blameless responsibility ascription to the person with mental illness, as well as a nuanced understanding of SDM as part of an emancipation-oriented PCC model.
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Affiliation(s)
- Leila El-Alti
- School of Health and Social Care, Edinburgh Napier University, Sighthill Court, EH11 4BN, Edinburgh, UK.
- Department of Philosophy, Linguistics, and Theory of Science, University of Gothenburg, Box 200, 405 30, Gothenburg, Sweden.
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Vyshka G, Simoni S. Magic and forensic psychiatry: A case study and review of the literature. World J Meta-Anal 2021; 9:45-50. [DOI: 10.13105/wjma.v9.i1.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 01/24/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
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Ingerslev LR. Inhibited Intentionality: On Possible Self-Understanding in Cases of Weak Agency. Front Psychol 2020; 11:558709. [PMID: 33101130 PMCID: PMC7545107 DOI: 10.3389/fpsyg.2020.558709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/28/2020] [Indexed: 12/01/2022] Open
Abstract
The paper addresses the question of how to approach consciousness in unreflective actions. Unreflective actions differ from reflective, conscious actions in that the intentional description under which the agent knows what she is doing is not available or present to the agent at the moment of acting. Yet, unreflective actions belong to the field in which an agent experiences herself as capable of acting. Some unreflective actions, however, narrow this field and can be characterized by intentionality being inhibited. By studying inhibited intentionality in unreflective actions, the aim of the paper is to show how weaker forms of action urge us to expand our overall understanding of action. If we expand the field of actions such that it encompasses also some of the involuntary aspects of action, we are able to understand how unreflective actions can remain actions and do not fall under the scope of automatic behavior. With the notion of weak agency, the paper thus addresses one aspect of unreflective action, namely, “inhibited intentionality” in which an agent feels a diminished sense of authorship in relation to her possibility for self-understanding. The notion of weak agency clarifies how agency itself remains intact but can involve a process of appropriation of one’s actions as one’s own. With a diachronic account of consciousness in unreflective action, the paper accounts for possible self-understanding in cases where none seems available at the moment of action.
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Affiliation(s)
- Line Ryberg Ingerslev
- Department of Philosophy, Faculty of Humanities, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
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Santoro TN, Santoro JD. Racial Bias in the US Opioid Epidemic: A Review of the History of Systemic Bias and Implications for Care. Cureus 2018; 10:e3733. [PMID: 30800543 PMCID: PMC6384031 DOI: 10.7759/cureus.3733] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The opioid epidemic has been declared a US national public health emergency. Discrepancies in the rates of abuse and access to treatment exist among non-white minorities. A narrative literature review evaluated the minority racial disparities in opioid use, abuse, and care in the US. Racial disparities in the prescription of opioid-containing compounds are dramatic with the non-white individuals being prescribed at half the rate. Historical and cognitive biases may have insulated the non-white minorities, while the minorities have limited access to treatment. Physician bias, media portrayal of opioid abuse disorders, and governmental regulation are a polyfactorial root of racial inequity in the opioid epidemic. As part of the national response, addressing these issues will be an important factor in curbing this epidemic.
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Nurturing Our Better Nature: A Proposal for Cognitive Integrity as a Foundation for Autonomous Living. Behav Genet 2018; 49:154-167. [PMID: 30101395 DOI: 10.1007/s10519-018-9919-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
As we account for the genetic and environmental influences on morally-relevant character traits like intellectual honesty, industriousness, and self-control, do we risk becoming ever less accountable to ourselves? Behavioral genetic research suggests that about half the variance in such character traits is likely attributable to heredity, and a small fraction to the shared family environment. The remaining 40-60% is explained by neither genes nor family upbringing. This raises the question: how active a role can individuals play in shaping their own character? What, if anything, can and should one do to take responsibility for the kind of person one becomes? This paper sketches a novel theoretical proposal for addressing these questions, by drawing on several previously disparate lines of research within behavior genetics, philosophy, and experimental psychology. Our core proposal concerns the metacognitive capacity to engage in active, reality-based cognition, as opposed to passive, stimulus-driven processing or an active pretense at cognition (i.e., self-deception). We review arguments and evidence indicating that human beings both can and should exercise this capacity, which we have termed "cognitive integrity." We argue that doing so can in a certain sense "set us free" of our genetic and environmental influences-not by rendering them irrelevant, but by giving us the awareness and motivation to manage them more responsibly. This perspective has important implications for guiding the development of psychosocial interventions, and for informing how we direct ourselves more generally, both as individuals and as a society.
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Ahmed SH. Individual decision-making in the causal pathway to addiction: contributions and limitations of rodent models. Pharmacol Biochem Behav 2018; 164:22-31. [DOI: 10.1016/j.pbb.2017.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 12/23/2022]
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Pârvan A. Changing Internal Representations of Self and Other: Philosophical Tools for the Attachment-Informed Psychotherapy with Perpetrators and Victims of Violence. PHILOSOPHY, PSYCHIATRY, & PSYCHOLOGY : PPP 2017; 24:241-255. [PMID: 28936108 PMCID: PMC5604738 DOI: 10.1353/ppp.2017.0034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Attachment research shows that the formation of unconscious, insecure representations of the self, the other, and the self-other relations is linked to perpetration and receipt of violence. Attachment-focused therapy aims to change these internal schemata to more secure, adaptive representations by therapeutic work addressed to senses, emotions, and behavior. The paper proposes a new approach to altering the self and other representations in offenders and victims: it involves intellectual reflection on self, will, action and responsibility informed by Augustine's views, facilitated by actual relational experience, and translated into a distinct self-soothing strategy. The reflective-experiential approach can complement existing methods of working with violent or traumatized individuals both within and outside an attachment theory framework. It consists in: identifying that a non-reflective nondistinction between self and behavior supports damaging self- and other- representations and interactions; proposing ways for clients to comprehend and consciously operate with the distinction between self and action.
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Affiliation(s)
- Alexandra Pârvan
- Contact information: Department of Psychology and Communication Sciences, University of Pitesti, Str. Târgu din Vale 1, 110040 Pitesti, Romania;
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Snoek A. How to Recover from a Brain Disease: Is Addiction a Disease, or Is there a Disease-like Stage in Addiction? NEUROETHICS-NETH 2017; 10:185-194. [PMID: 28725287 PMCID: PMC5486512 DOI: 10.1007/s12152-017-9312-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/23/2017] [Indexed: 11/24/2022]
Abstract
People struggling with addiction are neither powerless over their addiction, nor are they fully in control. Lewis vigorously objects to the brain disease model of addiction (BDMA), because it makes people lose belief in their self-efficacy, and hence hinders their recovery. Although he acknowledges that there is a compulsive state in addiction, he objects to the claim that this compulsion is carved in stone. Lewis argues that the BDMA underestimates the agency of addicted people, and hence hinder their recovery. Lewis's work offers us a very much to be welcomed neurobiology of recovery. It offers addicted people a hopeful and respectful narrative for their recovery that treats them as agents rather than as damaged brains. However, I argue that overestimating people's agency can also result in people losing belief in their self-efficacy. Lewis's strong focus on the agency of addicted people might not match their experiences of struggle, hence reinforcing their feelings of guilt when they fail to control their use. I propose to replace the notion of addiction as a disease with a notion of a disease-like stage in addiction. I call this stage the duress stage in addiction, in which the addictive behaviour is largely impervious to the agent's values and to available techniques of self-control. However, the agent can overcome this stage by developing new techniques of self-control, by building on their self-concept and belief in self-efficacy, by changing their environments and habits, and by engaging in projects that are meaningful to the agent.
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Affiliation(s)
- Anke Snoek
- Faculty of Health, Medicine & Life Sciences, Maastricht University, Peter Debyeplein 1, 6229 HA Maastricht, The Netherlands
- Faculty of Arts, Philosophy Department, Macquarie University, Sydney, NSW 2109 Australia
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Abstract
Drug use and drug addiction are severely stigmatised around the world. Marc Lewis does not frame his learning model of addiction as a choice model out of concern that to do so further encourages stigma and blame. Yet the evidence in support of a choice model is increasingly strong as well as consonant with core elements of his learning model. I offer a responsibility without blame framework that derives from reflection on forms of clinical practice that support change and recovery in patients who cause harm to themselves and others. This framework can be used to interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and instead maintaining care and compassion alongside a commitment to working for social justice and good.
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Affiliation(s)
- Hanna Pickard
- Department of Philosophy, ERI Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
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Pickard H. Choice, deliberation, violence: Mental capacity and criminal responsibility in personality disorder. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2015; 40:15-24. [PMID: 25997380 PMCID: PMC4503821 DOI: 10.1016/j.ijlp.2015.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Personality disorder is associated with self-harm and suicide, as well as criminal offending and violence towards others. These behaviours overlap when the means chosen to self-harm or attempt suicide put others at risk. In such circumstances, an individual's mental state at one and the same time may be deemed to meet the conditions for criminal responsibility, and to warrant involuntary hospital admission. I explore this tension in how people with personality disorder are treated at the hands of the criminal and civil law respectively in England and Wales: they may be deemed sufficiently mentally well to be punished for their crimes, but not deemed sufficiently mentally well to retain the right to make their own decisions about matters of serious importance to their own lives, including whether or not to continue them. The article divides into four sections. After introducing this tension, Section 2 sketches the nature of personality disorder and the psychology underlying self-directed and other-directed violence. Section 3 addresses the questions of whether people with personality disorder who are violent, whether towards self or others, typically meet the conditions for criminal responsibility and mental capacity respectively, considering in particular whether their underlying desires and values, or their emotional distress, affect their mental capacity to make treatment decisions. Section 4 then considers what we might do to address the tension, within the confines of current legislation. Drawing on The Review of the Mental Health Act 1983, I argue that we are ethically justified in involuntarily admitting to hospital people with personality disorder who pose a serious risk to themselves only if we simultaneously undertake to offer genuine help for their future, in the form of appropriate treatment, social support, and better life opportunities - a provision which, as things stand in England and Wales, is sorely lacking.
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Affiliation(s)
- Hanna Pickard
- Department of Philosophy, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
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