In lieu of an abstract, here is a brief excerpt of the content:Commentary on“Psychopathy, Other-Regarding Moral Beliefs, and Responsibility”Gwen Adshead (bio)AbstractIn this commentary, I address two points raised by Fields: the origin of other-regarding beliefs, and the management of psychopaths, if they are not criminally responsible (as Fields suggests). I argue that the capacity to form affective bonds is necessary in order to hold other-regarding beliefs, and that a psychological developmental perspective may be helpful in understanding the moral (...) understanding of the psychopath. In response to Fields’s view that psychopaths should receive “treatment,” I suggest that most forensic psychiatrists do not agree.Keywordspersonality disorder, empathy, development, remorse, attachment theoryInsufficient attention has been paid to the problem posed by so-called “psychopaths.” Lloyd Fields’s paper is therefore welcome. Here I shall focus on two issues: the nature and acquisition of other-regarding beliefs, and the implications for managing those who do not have them.Fields argues that there is a subgroup of psychopaths, unable to form “other-regarding beliefs”; that such beliefs provide a motivation for acting in a particular way, and result in a “[disposition] to experience certain emotions and to have certain attitudes.”But it is arguable that the disposition to experience certain emotions and have certain attitudes towards others could be critical to acquiring the capacity to have other-regarding beliefs. If one asks what stops people from hurting others, a common answer is that it makes people feel bad. To quote Mencius (Legge, 1960): “All men have a mind which cannot bear to see the suffering of others.”The question then is, how does anyone acquire a notion of “the other,” such that failing to endorse other-regarding principles/beliefs has an adverse effect on the subject?Mencius’ “mind” implied “reciprocity,” and involved four components:i. The recognition of another’s distressii. Being moved by that distress (empathy)iii. Wishing to reduce that distress (sympathy)iv. Altruism (the sense of obligation to reduce distress, and guilt if one fails).By these criteria, (iv) resembles Fields’s “other-regarding” belief, in that the sense of obligation provides a reason for acting. I would argue that (iv) is a virtue, which requires (i), (ii) and (iii) as capacities—not necessarily separate, but different aspects of a broader “affective” capacity. It is this affective capacity which is arguably lacking in the psychopath.Some of these capacities have already been discussed in the literature of psychopathy. It is the [End Page 279] failure to recognize another’s distress which Cleckley describes in many of his cases (Cleckley 1964), and which he describes as a type of “agnosia.” This term implies some neuropathological deficit, and there is some evidence for such deficits in psychopaths, mainly in the autonomic nervous system. Blair (1995) has also suggested that psychopaths lack a (postulated) violence inhibitory mechanism (VIM).It could be argued, however, that such neuropathological hypotheses lead to circular arguments about psychopathy, as described by Barbara Wootton 1(Wootton 1959). A more fruitful account is offered by theories (such as attachment theory) which offer a developmental account which includes both psychological and neuropathological perspectives. Described and developed by Bowlby (1969), attachment theory draws on experimental work with non-human primates and emphasises the importance of relationships with significant others in infancy for the development of later social relationships (Harlow 1975; Ruppenthal et al 1976). Such attachment relationships are also important for the development of cortical neural networks, and the modulation of stress, which can itself be neurotoxic (Sapolsky 1994).How could attachment theory be relevant to acquiring an affective capacity? The earliest work on attachment behaviors showed that monkeys failing to make early attachments behaved recklessly with other monkeys, and could not make relationships (for example, to mate). Of particular relevance was the finding that such monkeys launched suicidal attacks on monkeys higher in the hierarchy; not dissimilar to those “self-defeating” behaviors which Cleckley described in human psychopaths.So much for possibly psychopathic monkeys; do humans with failed attachments lack affective capacity? There is evidence that substantial proportions of “psychopaths” have histories of failed attachments in childhood. The more severe the failure, the more severe the disturbance in adulthood, which might explain why there... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 185-187 [Access article in PDF] Measuring Moral Identities:Psychopaths and Responsibility Gwen Adshead Doctor Ciocchetti examines the responsibility of psychopaths as a function of psychological capacities operating within relationships. He then argues against the punishment of psychopaths. I have some sympathy with both views, but perhaps argued in different ways, and from different standpoints, based on my clinical experience.Doctor Ciocchetti's offers an (...) unusual account of responsibility as a concept that involves at least two people, and perhaps many more than two; and this I would entirely support. In this sense, responsibility is a transitive and dynamic process that involves not only the personal sense of ownership of an action or thought, but also the attribution of responsibility by others. Moral, when applied to intentions, seems to me to suggest that they are intentions that involve another person and that they are held by an active agent who can make choices about those intentions. Responsibility implies not only causal responsibility, but also that the actor owns his own intentions about his behaviors toward others.Responsibility, either as experienced by the actor or attributed by others, is a type of moral judgment; an exercise in moral reasoning. Following Gilligan (1987), I am persuaded that moral reasoning, or the discourse of ought-and-should is relational in nature and must be seen in the context of relationships. I think much of the early work on moral reasoning in offenders is flawed because it assumes that moral reasoning was a capacity like serum bilirubin: normally distributed out there in the population, and able to be measured by an objective observer, in a process independent of the findings. Unsurprisingly, these studies found either that offenders had immature moral reasoning capacities (which we might have guessed already), or they had normal moral reasoning capacity, which was disturbing and puzzling.What we want to understand is how people come to let themselves do horrible things to others. Cioccchetti argues that psychopaths can do these things because they lack the affective capacities needed to respond to others' distress. Ordinary people care about harm to others (including the physical self/body and sentient animals) and demand explanations for the deliberate infliction of suffering on others. It is not only the lack of participant attitudes in the psychopath that bother us; it is our own responses, expressive of our participant attitudes, that tell us something about what this person is, and what is wrong. In my view, this is what punishment is all about for us, the larger social group [End Page 185] forced to respond to the distressing and disturbing actions of others.As Ciocchetti suggests, it is the perceived guilt of the offender that justifies the punishment; it is also the experienced distress of those affected that drives the need for punishment. The distress is part of the relationship between the victim and the offender; the victim is often just as active as the offender.The issue becomes most clear in relation to capital punishment and its supporters, especially those who wish not only to view executions, but also to broadcast them. In considering this, there are two useful sources of information: first, studies of the reactions of those who witness executions, and second, studies of the impact of murder on those related to the murder victim, so-called secondary victims. In those states that have capital punishment in the United States, it is often the secondary victims who witness the execution. They often have testified to the appalling impact of the offender's crime on them; most states give them a right to be present at the execution, even if they do not exercise it. It is hard not to think that it is the enormity of the feelings caused by the offender's wrongdoing that the death sentence is designed to address; the death of the offender changes the relationship between victim and offender, as much as the death of the original victim changes the relationship with their relatives. One might then wonder about the impact of his or her execution on the relatives... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 15-18 [Access article in PDF] Through a Glass, Darkly:Commentary on Ward Gwen Adshead Keywords: psychopathy, moral reasoning. Now we see, as through a glass darkly.... (St Paul's first letter to the Corinthians, Chapter 13) JIM DID AN EVIL THING. He deliberately caused another person's suffering in a way that was humiliating, cruel, and persistent. He very nearly killed another man. He (...) knew what he was doing; he knew it was wrong, but somehow, that did not matter to him. After he was caught, he came to a forensic psychiatric facility where he was offered therapy. (What the purpose of therapy is could be the subject of a paper in its own right, although I will say a little more about this at the end of the paper). Several years on, Jim has had many thoughts about his behavior. First, he has no doubt that he was responsible insofar as he chose to do what he did, and he feels guilty on that count. Second, he is also aware that he had consciously carried out such acts many times in his mind before, but had not previously acted out his fantasy; and that therefore the process of crossing the line between fantasy and reality is a crucial one for him to think about further. This metaphor of a line that has to be crossed from one place to another suggests two worlds: one of internal reality and the other of external reality. Jim used the metaphor thus: "I came up to the line, but I drew back." He also said of this moment (when he nearly killed his first victim): "I said to myself... 'This is mad... I can't justify this.'... " I have emphasized these words of Jim's because I want to use his experience to explore some of the arguments raised in David Ward's most interesting paper. I found much to agree with, and some claims that sat less easily. I should say that the context of my response is my work as a psychotherapist with mentally disordered offenders in Broadmoor Hospital, and also a current research project with Jonathan Glover and Christine Brown on moral reasoning in antisocial men. Kant and Won't I have no doubt that most if not all of the men (and women) that I work with do operate according to universalizable principles. As the author suggests, however, these principles are incoherent and contain what Cleckley (1976) called a type of agnosia, or distorted vision. It seems to me that Kant's two forms of principle are really two different levels of intention or choice-making process. Kant's hypothetical level of intention is very much about making choices in the external world: I experience the world as cold, I want to be warm because I need to be warm, I will do what I need to do to make that need happen for me. It is not universalizable because [End Page 15] others may not feel the cold as I do. Notice that this level of intention may be very closely linked to the next level, which Kant calls categorical: I would like the world to be such that everyone who is needy will get their needs met, and I would like to be the sort of person who makes that happen. The categorical level of intention is Kant's take on the Golden Rule: that you should want everyone to be treated as you yourself would wish to be treated. It is an intentional process that is interpersonal, which implies a second order of thinking—thinking about one's thoughts and wishes, and thinking about the sort of person one would wish to be in relation to others.At this point, I think it may be helpful to bring in the other aspect of Kant's vision of moral intentions, which is the injunction to treat others as ends in themselves and not merely as means to ends. Thus every individual is a unique person or self, who claims respect as a person and not... (shrink)

Chapter 9 describes and evaluates the relatively recent mental health models of the impact of trauma, and discusses the ways that traumatic events affect people, the political and cultural effects of understanding these consequences as ‘disorder’, particularly as Post-traumatic Stress Disorder (PTSD), and concludes by looking at the relevance of the concept of PTSD to forensic populations.

In lieu of an abstract, here is a brief excerpt of the content:Vice and ViciousnessGwen Adshead (bio)Keywordspsychiatric diagnosis, antisocial behaviorI am Grateful to Professor Sadler for such a clear and helpful account of how human misconduct (or vice) has been confounded diagnostically with human disease (as defined by the Diagnostic and Statistical Manual of Mental Disorders [DSM] classificatory system); and even more grateful for the chance to offer comment. Professor Sadler’s paper raises questions about the DSM enterprise as a (...) whole; and this is a field in which I have no particular experience to offer for additional discussion. But his other main point is that psychiatrists are constantly invited to distinguish between vice and disease, and he gives three examples, one of which is a clinical case from my own research. I entirely agree with him that this is a good example, and in this commentary, I will explain why.The argument is about how to distinguish between human behaviors that reflect chosen deviance from prosocial norms and behaviors that reflect a diseased state of mind. Arguments are both legal and political: Aristotle, in the Nichomachean Ethics sets out conditions in which a man should not be blamed for his behaviors, and to some extent these conditions still hold good in the criminal court; ignorance of the meaning of one’s actions, or being forced to act under duress, are good legal defenses. Politically, as Professor Sadler makes clear, the arguments were set out first by Foucault and then Szasz; it is possible for the state to use medical discourse to turn what might be a legitimate social grievance into individual pathology—the ultimate ad hominem argument.These arguments have not gone away, despite the best efforts of a materialist wing of neuropsychiatry, aided and abetted by pharmaceutical companies, who have a great interest in reductionist arguments in the biosciences. This is particularly so in relation to antisocial behaviors, especially crime. I want to focus on one particular type of antisocial behaviors, namely, the wish to hurt another person. I focus on this because it is my clinical bread and butter: My work as a forensic psychiatrist and psychotherapist requires me to try and understand how and why people want to hurt others. But I think it also makes sense to focus on this because it is the most problematic wish socially and demands understanding. All three of Professor Sadler’s examples involve hurt and harm to others, and it is noteworthy that neuroreductionist or medicalized explanations are rarely sought for theft or tax evasion. This must be in part because socially we think it is normal to try and profit yourself, even illegally, if you can get away with it. (I actually think that such behavior is not all that normal, but that is an argument for another day).Let us take the clinical example from my own work, cited by Professor Sadler. It is an example of what is called in the DSM “Factitious Disorder by Proxy” (FDP), although it also has an unhelpful eponym of “Munchausen’s Syndrome by Proxy.” As a practicing forensic psychiatrist, it is one of the best examples I know of what has been crudely dichotomized as a “mad or bad?” debate. A [End Page 23] mother quite deliberately makes her child ill, and then presents the child to medical services as in need of hospital treatment. In the case I described with Dr. Bluglass, the mother smothered her baby girl and then presented her as having “breathing difficulties” (which was, of course, quite true in one sense). There are two examples of vice here: deliberately hurting your child and lying to others about it; the lies also have the indirect result of potentially causing more harm to the baby. Harming your child, and then lying about it, in a not-for-profit way, are criteria for FDP.Quite how these actions ever made it into the DSM is puzzling, when they are quite straightforwardly antisocial. If a man in the street were to smother another man to the point of asphyxia, and then lie about it, we might well ask many questions about why he had done it, but we would not say that no offence had occurred. We... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What’s His Story?Gwen Adshead (bio)Keywordsnarrative, violence, identityIn this commentary, I discuss three issues raised by Cartwright: whether and to what extent explanations from the past can adequately explain or excuse present actions, the nature of moral identity, and the notion of the moral community.I have often thought that psychiatrists and psychotherapists working with offenders have to be like writers of detective fiction. To make the story convincing, (...) the writer of detective fiction has to convey to the reader an understanding of the killer's motives. The successful writer enables the reader to appreciate the killer's reasons for killing; and these reasons offer to readers a tantalizing glimpse of what it might actually be like to be a violent and dangerous person; or more particularly, one who acts on their cruel and violent thoughts.Psychiatrists want to understand the reasons for their patient's violence, for several reasons (which probably include the voyeuristic pleasure that all humans seem to have at other people's disasters). However, the main reason is to do with prevention of future harm; if we understand the reasons that this happened, then we can take steps to make sure that it does not happen again. This view has been called the just world theory (Janoff Bulman 1989), which implies a world of predictable causes and reasons, where disasters occur because of an identifiable fault or omission that can be rectified with good result. The payoff of this view is that it gives the believer a sense of control, which after a disaster is important for maintaining confidence and self-esteem.The problem with this theory is that it presupposes that the world of human actions is essentially rational, and that people do things for reasons that make sense to them. However, much human cruelty has an irrational and unreasonable aspect to it; one that literally makes no sense. Cartwright's paper begins with a narrative about real people doing really dreadful things for no reasons that would ever satisfy the average detective story reader. Forensic mental health work is full of histories that are actually much stranger than any detective fiction.But it seems that humans are not happy with stories that do not make sense, even if senselessness is part of the natural world around them. As Cartwright indicates (see p. 150), when we hear about people like Robert Harris, we immediately move the field of inquiry from "Why did he do that?" to "Why is he like that?" With the rise of developmental psychology over the last 150 years, it has become natural to look at people's histories to see if this explains the person's present identity. In this sense, therefore, we seem to be natural Aristotelians, assuming that a man's character is revealed by his current actions: we also seem to be assuming that a man's character is an expression of past actions and events. [End Page 157]His-Story: Explaining the PresentIs this in fact the case? To what extent is it true that our identities are shaped by our past experiences? Even if this were the case, shaping is not the same as determining. There has always been a risk that developmental psychology will take up a similar position to genetics, with regard to explaining behavior; namely, that there are those who will try to argue that the presence of this, that, or the other gene, or this, that, or the other experience, both determines and "explains" the behavior. The moral point here is that when it comes to violent and antisocial behaviors, a person's past history is said to simultaneously explain the behavior, determine the behavior, and excuse it, by implying that the actor had no choice about what he did, given his past. This has been taken to an extreme in the US criminal courts, with what Dershowitz (1994) has called "the abuse excuse" (used most notably in the trial of the Menendez brothers, who killed their parents and claimed at the trial that their parents had abused them).Trials are about evidence, and it is worth considering the evidence about the effect of early childhood adversity... (shrink)

Freely given informed consent to participation is the ethical cornerstone of research in health care. However, in mental health settings, there are many patients who lack the capacity to give such consent to participate in research. There is an abundance of guidance now available on how researchers might think about this issue and the Royal College of Psychiatrists has also recently reviewed its guidance to members about the ethics of research. In this piece, I will discuss some of the issues (...) that were raised during the revision process, and add some reflections of my own. (shrink)

What drives someone to commit an act of terrible violence? Drawing from her thirty years' experience in working with people who have committed serious offenses, Dr. Gwen Adshead provides fresh and surprising insights into violence and the mind. Through a collaboration with coauthor Eileen Horne, Dr. Adshead brings her extraordinary career to life in a series of unflinching portraits. In eleven vivid narratives based on decades of providing therapy to people in prisons and secure hospitals, an internationally (...) renowned forensic psychiatrist and psychotherapist demonstrates the remarkable human capacity for radical empathy, change, and redemption. Based on 30 years of experience working in prisons and secure psychiatric hospitals with people convicted of serious violent offenses, internationally renowned forensic psychiatrist Dr. Gwen Adshead presents an account of mental illness and the nature of evil in this compelling series of stories. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Tyranny of the BureaucratsSimon Wilson (bio) and Gwen Adshead (bio)Keywordsviolence, mental health, bureaucracyWe are grateful for the opportunity to respond to the two kind and thoughtful commentaries on our paper. Sadler suggests irrationality may be the key to distinguishing psychiatric from nonpsychiatric violence. We are not so sure that this is necessarily as helpful as it might at first seem. Who gets to decide what is (...) rational? Much “normal” violence, committed in the heat of the moment, impulsively, and drunkenly, may not appear that rational, even to the perpetrator, in the cold light of day. We are not sure one would wish to bring this sort of violence within the province of psychiatric explanations. Likewise, a point we made in our paper: Even delusionally driven violence often has its own internal coherence and rationality within an irrational framework.We found much to agree with in McCallum’s commentary, and perhaps his alternative approach is more helpful. He proposes a more sociological model of understanding what is going on in these complex cases, one that starts with societal dividing practices. Our present times have been described as the tyranny of the bureaucrats. Professional approaches are devalued. Diagnosis is only relevant in terms of its bureaucratic utility in moving people from one category to another. Since the writing of our paper, the criminal law has changed further in England and Wales. The Criminal Justice Act 2003 brought with it new sentences of indeterminate detention for public protection for those offenders categorized as “dangerous.” The presence or absence of psychiatric disorder being largely irrelevant for these purposes. This would seem to fit nicely with McCallum’s analysis, and in principle rather takes the wind out of our sails when we argued about the discrimination against psychiatric violence—now a diagnosis is not necessary for the state to intervene in a probabilistic fashion to prevent future violence. Deciding between what sort of violence counts as psychiatric and what does not, does not have quite the same drastic differential effect on the individual as perhaps it did. Its importance is now, as predicted by McCallum’s model, more to do with bureaucracy: Which government department will be paying for the individual’s preventive detention (Department of Health or Ministry of Justice)? [End Page 75]Related ArticlesFeature Article: When Violence Becomes a Psychiatric SymptomCommentary: The Contingent Object of PsychiatryCommentary: Reasons CountResponse: The Tyranny of the BureaucratsSimon Wilson Simon Wilson is a Consultant Forensic Psychiatrist at the Maudsley Hospital and an Honorary Senior Lecturer at the Institute of Psychiatry, London, UK. He qualified at Leeds University and trained in psychiatry at the Maudsley Hospital. He was previously Consultant Forensic Psychiatrist at HM Prison, Brixton, UK. He has particular interests in prisons, philosophical, and ethico-legal issues in psychiatry. He can be contacted via e-mail at:[email protected] Adshead Gwen Adshead is a Forensic Psychiatrist and Psychotherapist. She works as a psychotherapist in a high-security hospital. She is a group analyst and researcher in attachment theory as it relates to offenders. She has a Master’s degree in Medical Law and Ethics, and is a founder member of the Philosophy Special Interest Group of the Royal College of Psychiatrists. She can be contacted via e-mail at:gwen.adshead@wlmht.nhs.ukCopyright © 2009 The Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.1 (2001) 33-37 [Access article in PDF] "Impossible Things before Breakfast":A Commentary on Burman and Richmond Gwen Adshead "Why sometimes, I've believed as many as six impossible things before breakfast." --Lewis Carroll, Through the Looking GlassBoth Burman and Richmond discuss how a feminist critique or take on a body of theory helps to illuminate or confuse further theoretical development. Burman applies such a (...) critique to False Memory Syndrome (FMS); Richmond to psychoanalytic accounts of eating disorders. In this commentary, I want to discuss the application of a feminist critique to two vital concepts for psychiatry: the recording and measurement of data, and truthful accounts of experience. These concepts are of course related, and I want to explore their connections, not only with each other, but with specific areas of mental health practice, namely, mental health research, psychodynamic psychotherapy, and expert psychiatric testimony. The Recording Angel: Subjectivity and Objectivity, Measurement and Truth Most feminist critiques of measurement begin with an attack on the traditional theoretical distinction between objective and subjective worlds (for example, Fox Keller 1985). Classical accounts of Western scientific practice have assumed that it is possible to divide external physical experience in this way, and this assumption generates two further beliefs: first, that it is possible for an observer to, as it were, stand apart or outside the events observed, and second, that objective accounts of events are somehow real-er or true-er than subjective accounts. This account contains some very old ideas about natural experience: first, that a fixed reality exists that is external to those who have experienced an event, and second, that this reality is observable by others, that is, there is a space between the observer and the observed. This notion of objectivity has been thought to be crucial to valid measurement.In contrast, a feminist critique counterargues that every observer is influenced and influences what he is studying; that he is himself "positioned" in the subject of his interest, in Rom Harré's term. Further, feminist theory argues that because the objective-subjective split is artificial, subjective accounts of experience may be just as "true" as objective accounts. Overarching is the notion that all social behavior is socially constructed and affected by social context, including "science" in all its forms.Such doubts about the exact nature of science have been fueled by two sets of theory within [End Page 33] "science"--the claims of quantum theory in the 1920s and Thomas Kuhn's account of shifting scientific paradigms in the 1960s--and both of these theories have been important for feminism and feminist critique of scientific practice. Despite many odd features, quantum theory has produced research with considerable explanatory power (Hawking 1988, Barrow 1991, Smollin 1997), and some of its claims provide indirect support for the feminist position described above. For example, one claim of quantum theory is that, at the micro-level of events, what is being observed is influenced by the position of the observer. If true, then the notion of an easy divide between internal and external space, in which observer and observed are separately located, is undermined; rather, every position taken by the observer influences the observed in a dynamic relationship. There is no objectivity but rather a developing matrix of positions that are not externally fixed, but changing and uncertain. Similarly, in relation to social construction of theory, Kuhn's description of the changing nature of scientific paradigms also emphasizes the importance of social and community influences on scientific theories and how "true" accounts of events can change. Internal and External Worlds: Implications for Mental Health Research and Psychotherapy Practice Arguably, feminist claims about the social positioning of science are now unremarkable; no one involved in research (especially mental health research) could dispute that what is studied, what is funded, and what is published is hugely influenced by many social and political processes. Even if only to a limited extent, quantum theory and Kuhn do support the doubt thrown on classic notions of objectivity by feminist theory; if only by suggesting that reality... (shrink)

Philosophy says that life must be understood backwards. But . . . it must be lived forward. . , , It is more and more evident that life can never be really understood in Time. It was a pleasure to read Jason Thompson’s serious and thought-provoking piece, and I am grateful to the editors for giving me a chance to comment. The idea that the self is revealed in narrative is a popular one among different schools of psychotherapy, both in (...) terms of technique and theory; and my response addresses both these issues in turn. As a clinician, I have always liked people’s stories. As a junior psychiatrist, I used to love the moment when I first met someone and could say to them, ‘You were born; and then what .. (shrink)

Feminist analyses address the way differences between the sexes are conceptualized and operationalized in society. In this paper, I discuss how violence by men and women is conceptualized as different in the psychological scientific discourses of forensic mental health. I suggest that these empirical discourses perpetuate assumptions of difference and discourage examination of similarities. Specifically, I will argue that neutralization techniques are frequently used that reduce women’s agency and responsibility for violence compared to their male counterparts, and compared to nonoffending (...) women. I discuss the implications for violence research and interventions for violence perpetrators. (shrink)

I am grateful to the editor for asking me to comment on this interesting article about interdisciplinary work between a philosopher and a psychiatrist, with which I found much to agree. As a medical student, I had no exposure to bioethical reasoning in medicine, and even now, I think it is the case that junior doctors in the UK have variable exposure to good quality ethical reasoning in clinical practice. I also agree that lectures are a poor way to learn (...) about ethical reasoning, especially in psychiatric practice; and I have been part of a special interest group at the Royal College of Psychiatrists that has tried to develop and enhance bioethical awareness in mental health. We do this by a) ensuring that ethical... (shrink)

Psychiatrists are increasingly expected to be involved in violence assessment, prediction, and prevention. For some psychiatrists this sits uncomfortably with their conception of themselves as doctors. Is violence (ever) a medical/psychiatric symptom? If so, what is the role of medicine/psychiatry in preventing violence? What are the consequences of an interventionist stance? We attempt to explore some of these questions in this paper.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.1 (2001) 39-40 [Access article in PDF] Remembering Feminisms:A Response to the Commentary Erica Burman I am grateful to Gwen Adshead for outlining the broader arguments surrounding feminist critiques of science and their relevance for mental health, particularly in forensic contexts. As she highlights, the debates about the status of accounts of memory hinge upon contested concepts of objectivity and the problem of (...) discursive and provisional (but also necessary) claims to external reality, these being debates to which feminists have actively contributed. There are four additional points I would like to make in response to her comments.Firstly, while I am in general agreement with her presentation of feminist positions in relation to scientific theory and method--and this does largely reflect a current consensus within feminist approaches--it is important not to overstate this consensus. Feminist debates about science, method, and claims to truth are precisely debates. There is no unitary feminist approach. Key arguments between feminists concern, for example, whether to lay claim to (forms of "strong") subjectivity rather than objectivity (see Harding 1986, Hollway 1989, Griffin et al. 1998) or whether to re-work criteria for objectivity to takeaccount of well-known gender biases (Eichler 1988).In my analysis of feminist approaches to "false memory syndrome" (FMS), I wanted to highlight the diversity of feminist positions in order to indicate something of the interconnections between feminist and other political, theoretical, and cultural analyses--ranging from the modernist and empiricist to the postmodernist and constructionist. Hence, while I agree with Adshead that much feminist analysis seems unremarkable since its impact on cultural practice has been so great, I would argue that her account glosses over the many different feminist positions mobilized within the debate around "false/recovered memories." There are widely different views, for example, about the status of evidence/science. Another key area of debate is the role of psychiatric diagnosis between those who subscribe to and those who reject the "terms of art" of psychiatric diagnostic categories.This may sound like a mere effort to attest to the rigor and rationality of feminist scholarship, including feminist re-workings of these terms. However, to come to my second point, there is a material consequence of this closer attention to the conditions for, and reception of, specific feminist analyses. For the debate about "false" or "recovered" memories goes beyond questions about the circulation of the roles of victim versus perpetrator that surround claims of credibility, legitimacy, manipulation, or gullibility. [End Page 39]Thus, Laura Brown and I (1997) and Jan Haaken (1998) have suggested that in order to understand how the current debates surrounding (women's) reported memories could have come about, we need to analyze what has happened through, and what the stakes have been in, the (limited) institutionalization of feminism within models and practices of therapy. This involves attending to the particular forms of feminism that have been included and excluded: For example, how far do therapeutic models accept, and how far do they problematize, the forms and functioning of families? We also need to consider the broader societal response (or backlash?) to a feminized/therapeutic culture, including consequences of the confounding of the therapeutic with the feminized. In particular, Haaken draws attention to the gender essentialism that pervaded second wave (1960s and 1970s) U.S. feminist therapies. This essentialism, she argues, has fueled a failure to interrogate power dynamics (including therapeutic dynamics) between women that make possible displacements of transferential dynamics to an outside party, whether past or present.My third point concerns the ever closer relationship between the therapeutic and legal arenas reflected within the career of FMS. Adshead's reference to a film narrative to highlight competing versions of legal knowledge puts me in mind of how FMS--as a potent cocktail of psychiatric labeling, familial conflict and abuse, and litigation--is the U.S. television courtroom drama writ large. It may be the case that, as Adshead argues, I fail adequately to address the complexity of legal process, with its assumptions about what makes certain accounts more credible or legitimate than others... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Cause, Fault, NormJohn Z. Sadler (bio)Keywordscriminality, mental disorder, responsibilityThanks to the commentators for their fine work. In my brief comments I cannot address all that is raised, but can touch upon everyone’s discussion briefly.In her commentary, Gwen Adshead reflects on her experience as a forensic psychiatrist and therapist for violent offenders. Although Adshead discusses a number of important points, I found her insight into why some (...) vices find their way into psychiatric classification particularly compelling and thought provoking. I will here interpret these in my own terms. Dr. Adshead implies that a (perhaps) assumed folk psychology underlies our motivation to classify (as disorder) some, but not all vices. The contribution of this folk psychology does not depend on particular details, but rather, the folk psychology concerns the degree to which the vice–actor’s actions are amenable to explanation, or are transparently understandable or interpretable. We (think we) understand why prostitutes sell themselves and why tax evaders cheat; their folk psychologies are variously constituted by moralistic constructs like desperation, oppression, licentiousness, greed, opportunism, and indignation. In contrast, some offenses step outside our empathic realm: the pedophile, or the serial killer, or even the persistently acting-out child provoke onlookers to wonder, “There has to be something wrong with a person who does that!” “Loud” symptoms in themselves do not qualify; seemingly incomprehensible loud symptoms fit better into the “sick” category. Indeed, in a recent translation of Foucault’s lectures at the College de France, Foucault describes the “monster” as combining “the impossible and the forbidden.” (Foucault 1999, 56) When confronted with the impossible and forbidden, the lust for classification is irresistible.Adshead’s wonderment about the use of “really” to question the explanation of wrongful conduct (what’s “really” going on) leads naturally to Michael First’s discussion. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV really tries to make a firm distinction between vice and mental disorder, and First describes the DSM approach.Drawing on his experience as the DSM-IV Text Editor, Dr. First provides a particularly lucid presentation of the distinction between what I call “vice” and mental disorder. He supplies vivid examples to illustrate his points. The DSM key for distinguishing disorder from vice is whether “the deviance or conflict is a symptom of a dysfunction in the individual.” As other commentators point out later, First notes that the “vice action” (a term coined by Morse in his own commentary following) may disguise a number of possible explanations: the car thief may simply be seeking thrills and profit, or may be motivated by a delusion—leading to alternative explanations for the behavior. Sometimes the explanation for vice actions are transparent—as in the red Mustang example, but other times they are not so clear. The DSM approach requires the clinician to [End Page 51] make an explanatory claim in order to distinguish the appearance of vice versus the appearance of disorder. I think everyone would agree that an explanation of the phenomenon is required in distinguishing vice from disorder, so that much can be accepted.In my view, the problems with the DSM account are three: (1) The requirement for an internal psychological dysfunction is an easy claim to make for virtually any vice condition. The prostitute’s vice may be attributable to childhood trauma, deviant social learning, pathological desire to sexually control others, and so on. The tax evader may in turn have a pathological resentment of authority combined with a desperate financial situation and a pathological denial and avoidance of paying taxes. Every misbehavior has its psychology, and if we proclaim this psychology is abnormal or deviant, then we have an “internal dysfunction.” Indeed, it is easy to proclaim a psychology as abnormal if it is less than an ideal response to circumstances, or even an adequate response to circumstances; after all, not everyone who is exposed to sexual trauma becomes a prostitute nor does every financially desperate individual cheat on taxes. The DSM’s overinclusiveness on this account defaults to an arbitrariness about what counts as a legitimate (or not) internal dysfunction. Here there will be great argument.(2) First (and later, Wells) admits there... (shrink)

A response to two commentaries by Gwen Adshead and Shaun Gallagher on my feature article "Internalism, Emotionism, and the Psychopathy Challenge".

In lieu of an abstract, here is a brief excerpt of the content:Underplayed Ethics and the Dilemmas of Psychiatric CareChong Siow Ann and Tamra LysaghtThe practice of psychiatry is fraught with uncertainty. The exact causes and the biological substrates underlying mental disorders remain to be elucidated; even the diagnosis of these disorders is descriptive and not based on an etiological understanding and no biological diagnostic markers have been validated. The manifestation of almost all mental disorders results from a complex interaction (...) of biological and environmental factors which encompasses the patient’s unique life history, experiences and relationship with others and the community. In the face of such uncertainties — at times extending to the types of treatment (psychiatry is generally acknowledged not be an exact science) — it has been argued that adopting a pragmatic approach is necessary.1 Accordingly, this approach necessitates high ethical standards among mental health practitioners.Some mental illnesses are associated with varying degrees and types of cognitive impairments. Others have certain symptoms like auditory hallucinations and delusions that might severely compromise the patients’ autonomy, distort their sense of reality, increase the risk of harm to themselves or others and render them incapable of making informed decisions in their treatment and participation in research.Consequently, there are issues that are particular to the provision of mental healthcare. These include the need for enforced involuntary treatment with the corollary of depriving a patient of his personal liberty even [End Page 173] though it is often justified on the grounds that it is in the patient’s best interests. However, at times, it is the legal and societal obligation of mental health practitioners to protect those who might be harmed from the patient’s action that might seem to be more pressing. In this situation of double agency, lies the tension of providing confidential care for patients and acting as “an agent of the state” where that patient’s confidentiality might be breached and his liberty infringed upon. This situation is further aggravated by the stigma that clings ever so tenaciously to those who suffer from mental disorders and where it is the norm to stereotype them as dangerous and unpredictable.Consideration of a patient’s autonomy is also challenged by characteristics that are unique to the practice of psychiatry. The prescription of certain psychotropic medications can alter how people think and feel, while psychotherapy works towards changing the patient’s views and values. The philosopher, Jennifer Radden, describes this process as “re-forming the patient’s whole self or character … akin to the responsibilities of raising children”.2 The psychotherapeutic relationship is thus particularly personal and intimate because patients are asked to provide information that often reveals their innermost feelings, fears and fantasies. This information is provided on the basis of trust and assurance of confidentiality, and with expectation of being helped.Jeremy Holmes and Gwen Adshead have elaborated on the vulnerability of patients seeking psychotherapy: they might be particularly susceptible to exploitation because their past experiences of being exploited have led to their distress and help seeking — their dependency and the extreme privacy of the therapeutic relationship make any transgression difficult to be uncovered.3 There is a calamitous combination of the “unconscious wish in the patient to be used” with the complicity of an unethical therapist seeking to fulfil his own interests.4As in any other doctor-patient relationship, the relationship between the mental healthcare practitioner and the patient is one of unequal power where the former is ascendant. While that power should be exercised to heal and to relieve suffering, it also gives the practitioner tremendous power “to harm, reject, misunderstand, or exploit patients who struggle with the experience of mental illness, which itself may generate helplessness, despair, distress, and exceptional dependence on the clinician”.5 Given the potential of doing good and harm coupled with the likelihood of being so significant in the life of the patient,6 providing care for those with mental disorders and distress is necessarily ethically exacting — arguably more so than in other medical practice settings. [End Page 174]This precariousness has led to the suggestion that ethics in psychiatry should have a special status and that the more general principles of biomedical ethics are too limited in scope to... (shrink)

Gwen Bradford presents the first systematic account of what achievements are, and why they are worth the effort. She argues that more things count as achievements than we might have thought, and offers a new perfectionist theory of value in which difficulty, perhaps surprisingly, plays a central part in characterizing achievements.

Using a 2×2×2 experimental design, the effects of situational and individual variables on individuals' intentions to act unethically were investigated. Specifically examined were three situational variables: (1) quality of the work experience (good versus poor), (2) peer influences (unethical versus ethical), and (3) managerial influences (unethical versus ethical), and three individual variables: (4) locus of control, (5) Machiavellianism, and (6) gender, on individuals' behavioral intentions in an ethically ambiguous dilemma in an work setting. Experiment 1 revealed main effects for quality (...) of work experience, Machiavellianism, locus of control, and an interaction effect for peer influences and managerial influences. Experiment 2 showed main effects for all three situational variables and Machiavellianism. Neither experiment supported gender differences. Limitations, future research, and implications for management are discussed. (shrink)

This article gives an account of what makes achievements valuable. Although the natural thought is that achievements are valuable because of the product, such as a cure for cancer or a work of art, I argue that the value of the product of an achievement is not sufficient to account for its overall value. Rather, I argue that achievements are valuable in virtue of their difficulty. I propose a new perfectionist theory of value that acknowledges the will as a characteristic (...) human capacity, and thus holds that the exercise of the will, and therefore difficulty, is intrinsically valuable. (shrink)

Perfectionism, broadly speaking, is the view that the development of certain characteristically human capacities is good. The view gains motivation in part from the intuitive pull of an objective approach to wellbeing, but dissatisfaction with objective list theory. According to objective list theory, goods such as knowledge, achievement, and friendship constitute good in a life. The objective list has terrific intuitive appeal – after all, it’s a list generated by reflecting on the good life. But as a theory, some find (...) it unsatisfying. What justifies presence on the list? On the traditional conception it is just a list and not much of a theory at all. Perfectionism captures the intuitive pull of the objective list and provides a unifying justification: the entries on the list share in common a special relationship to human nature. This essay gives an overview of perfectionism. (shrink)

In light of arguments that citizen science has the potential to make environmental knowledge and policy more robust and democratic, this article inquires into the factors that shape the ability of citizen science to actually influence scientists and decision makers. Using the case of community-based air toxics monitoring with ‘‘buckets,’’ it argues that citizen science’s effectiveness is significantly influenced by standards and standardized practices. It demonstrates that, on one hand, standards serve a boundary-bridging function that affords bucket monitoring data a (...) crucial measure of legitimacy among experts. On the other hand, standards simultaneously serve a boundary-policing function, allowing experts to dismiss bucket data as irrelevant to the central project of air quality assessment. The article thus calls attention to standard setting as an important site of intervention for citizen science-based efforts to democratize science and policy. (shrink)

Scientific instruments can help to shape and re-shape epistemic boundaries, especially those between communities of scienti?c researchers. But how do they function at boundaries between scienti?c communities and communities of non-experts? This paper examines the use of air monitoring instruments at the boundary between petrochemical facilities and nearby residential communities, asking whether a new generation of fenceline monitors shared by industry (and regulatory agency) experts and community members alter the epistemic boundary between the two groups. Arguing that epistemic communities organized (...) around instruments are characterized, in part, by a common understanding of the evidential contexts for instrumental data, the paper shows how the evidential contexts in which experts and residents interpret monitoring data diverge. Instead of the new, shared fenceline monitors helping to reconcile differences over evidential contexts, those pre-existing contexts shape the interpretation of data from the new instruments–perpetuating epistemic boundaries between industry experts and community members. (shrink)

Mobilizing Hope asks that we take the eradication of poverty as morally mandatory, that we pursue technological development, and that we act on the belief that it is possible to do both of those things at once. It resolutely does not ask that we redefine prosperity in other-than-economic terms, reconsider the binary between “human” and “nature,” question financialization, colonialism, or other root causes of global poverty, accept qualitatively different lifestyles, or endure painful transitions. While this may seem strategic, I argue (...) that bigger asks could be effective in inspiring action. (shrink)

"Margaret Cavendish's philosophical work is at last taking its rightful place in the history of seventeenth-century thought, but her writings are so voluminous and wide-ranging that introducing her work to students has been difficult—at least until this volume came along. This carefully edited abridgment of _Observations upon Experimental Philosophy_ will be indispensable for making Cavendish's fascinating ideas accessible to students. Marshall's Introduction provides a helpful overview of themes in Cavendish's natural philosophy, and the footnotes contain useful background information about some (...) of the texts and philosophers that Cavendish mentions. The additional selections from Descartes, Hobbes, Boyle, and Hooke also help contextualize Cavendish's views." —Deborah Boyle, _College of Charleston_. (shrink)

In this paper, we discuss challenges associated with implementing a policy for Ancillary Care (AC) for related and unrelated (serious) adverse events during an Ebola vaccine trial conducted in a remote area of the Democratic Republic of the Congo. Conducting clinical trials in resourceconstrained settings can raise context-related challenges that have implications for study participants’ health and wellbeing. During the Ebola vaccine study, three participants were injured in road traffic accidents, but there were unexpected difficulties when trying to apply the (...) AC policy. First, because of the nature of the adverse events, the insurer refused to cover the costs. Second, the AC policy did not address treatments by traditional medicine, even though traditional medicines are frequently used and highly trusted in the study community. This highlighted a contrast between the researchers’ well-intentioned AC approach and the participants’ legitimate preferences. The way in which researchers should address their responsibility to provide AC is not straightforward; it requires contextualization. Our experience highlights the importance of involving community representatives and the local ethics committee to ensure development of an AC policy that is culturally and ethically appropriate. Additionally, the insurance contract should clearly stipulate which adverse events are linked to the trial participation, and thus eligible for coverage, to avoid controversies when claims are made. (shrink)

This paper provides a novel response to Vlastos’s challenge that Platonic erōs in the Symposium, since it is for the form of beauty rather than any particular person, is impersonal and egotistical. Vlastos, in addition to generations of his readers and critics, badly misunderstands Diotima’s reproductive theory of love. In particular, it has been widely overlooked or diminished that the ideal erotic relationship set out in the ladder of love mirrors the reproductive labor of ancient Greek mothers and caregivers. The (...) lover of the highest mysteries undertakes the psychic equivalent of motherly care to rear virtuous ideas in the next generation. Thus, properly understanding Diotima’s gendered vision of psychic reproduction reveals that Platonic love is anything but impersonal and egotistical. (shrink)

Szasz argues that the threat of harm to self or others cannot be understood as a symptom of mental illness, and that there is an irresolvable tension between the traditional medical ethical duty to heal, and any notion of a medical duty to protect the public.1 I think these are two distinct arguments which could each be the subject of extended analysis, and this commentary is of necessity limited.Professor Szasz has consistently raised concerns about the political abuse of psychiatry as (...) a way of controlling dissidence. Many of his arguments remain as cogent and unanswered as when they were first put 30 years ago. But as sympathetic as I am to some of his criticisms, it seems to me that many are too sweeping; especially the first claim that there is no such thing as mental illness, but only persons whose expressed intentions involve taking a stance which is contrary to certain social rules.I do not propose here to discuss the so called “hard” problem of consciousness—that is, exactly how brain states give rise to intentional psychological experience, or indeed, the extent to which “brain” and “mental” can be used synonymously. If we accept that mental states give rise to intentions, then different mental states will give rise to different intentions, and there is no reason not to think that there might be abnormal mental states that might give rise to abnormal intentions. The question then is what we mean by the word “abnormal”. Clearly it is possible for abnormal to be defined as “socially inappropriate”, which is Szasz’s concern. In that case, political and social dissidence is then turned into a symptom by the language of medicine, and thus becomes not a social matter, but an individual’s personal problem.But “abnormal” could be defined with reference …. (shrink)

Neither evolutionary theory nor behavioral evidence is consistent with Rachlin's view of altruism as a learned, domain-general learned habit displayed because of its intrinsic value. But human beings can be psychologically motivated by altruism while still reaping a genetic benefit from their altruistic actions.