Grant Gillett

Delusions, a key feature of psychosis, are usually thought of as a type of belief, as in the definition of the American Psychiatric Association: A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (e.g. it is not an article of religious faith). This characterization is often criticized, but other definitions typically comprise similar elements. For some, delusions are only loosely considered as beliefs (Jaspers 1963; Moor and Tucker ..

The embodied human subject is dynamically connected to his or her historico-sociocultural context, the soil from which a person’s psyche is nourished as multiplex meanings are absorbed and enable personal development. In each culture certain towering artistic works embody this perspective. The Dream of the Red Chamber introduces Jia Bao-yu—a scion of the prestigious Jia family—and his relationships with a large cast of characters. Bao-yu is controversial but, at the time of the family’s tragic collapse, he can be seen as embodying a spiritual struggle in which his instinct, nature, sensitivity, and creativity are grounded in his transcendent relationship with a fragment of the world stone, an eternal source of energy and creativity. We are invited to draw on a metaphysical level of thought to consider his struggles with man-made hierarchies and a situated historico-sociocultural order in such a way as to live out his spiritual being. As such, the novel is closely relevant to questions of spirituality in bioethics. Through personal experiences, passions, creativity, and relationships with others, the body is inscribed, forming the soul, which may be misconstrued (for instance, through a medical or Cartesian reformulation of events) but which can be seen as the site of ethical and spiritual thought

The human brain is subjective and reflects the life of a being-in-the-world-with-others whose identity reflects that complex engaged reality. Human subjectivity is shaped and in-formed (formed by inner processes) that are adapted to the human life-world and embody meaning and the relatedness of a human being. Questions of identity relate to this complex and dynamic reality to reflect the fact that biology, human ecology, culture, and one's historic-political situation are inscribed in one's neural network and have configured its architecture so that it is a unique and irreplaceable phenomenon. So much is a human individual a relational being whose own understanding and ownership of his or her life is both situated and distinctive that neurophilosophical conceptions of identity and human activity that neglect these features of our being are quite inadequate to ground a robust neuroethics

ABSTRACTThere are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions available that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro‐euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism

Informed consent is the practical expression of the doctrine of autonomy. But the very idea of autonomy and conscious free choice is undercut by the view that human beings react as their unconscious brain centres dictate, depending on factors that may or may not be under rational control and reflection. This worry is, however, based on a faulty model of human autonomy and consciousness and needs close neurophilosophical scrutiny. A critique of the ethics implied by the model takes us towards a 'care of the self' view of autonomy and the subject's attunement to the truth as the crux of reasoning rather than the inner mental/neural state views of autonomy and human choice on offer at present.

The first edition of The Mind and its Discontents was a powerful analysis of how, as a society, we view mental illness. In the ten years since the first edition, there has been growing interest in the philosophy of psychiatry, and a new edition of this text is more timely and important than ever. In The Mind and its Discontents, Grant Gillett argues that an understanding of mental illness requires more than just a study of biological models of mental processes and pathologies. As intensely social animals, he argues, we need to look for the causes of human mental disorders in our interactions with others; in social rule-following and its role in the organization of mental content; in the power relations embedded within social structures and cultural norms; in the way that our mental life is inscribed by a cumulative life of encounters with others. Drawing upon work from within the philosophy of mind, epistemology, post-modern continental philosophy, and philosophy of language, he tries to elucidate the nature of psychiatric phenomena involving disorders of thought, perception, emotion, moral sense, and action. Within this framework, a series of chapters analyse important psychiatric disorders such as depression, attention deficiency, autism, schizophrenia, and anorexia. Along the way, Gillett explores the nature of memory and identity; of hysteria and what constitutes rational behaviour; and of what causes us to label someone a psychopath or deviant. Updated, available in paperback, and more accessible than before, the new edition of this fascinating book will provide readers with important insights into the causes and nature of psychosis. In addition, Gillett's arguments have considerable implications for the way in which we understand and treat people suffering from psychiatric disorders. The Mind and its Discontents will be read by researchers and postgraduate students in a range of academic areas, including psychiatry, bioethics, philosophy of mind, social theory, and clinical psychology. It will also be of considerable interest to practising psychiatrists.

The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or ‘rescue’ procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other ‘rescue situations’, the utility of the procedure cannot be rationalised on a mere cost–benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation

This open access book is a systematic update of the philosophical and scientific foundations of the biopsychosocial model of health, disease and healthcare. First proposed by George Engel 40 years ago, the Biopsychosocial Model is much cited in healthcare settings worldwide, but has been increasingly criticised for being vague, lacking in content, and in need of reworking in the light of recent developments. The book confronts the rapid changes to psychological science, neuroscience, healthcare, and philosophy that have occurred since the model was first proposed and addresses key issues such as the model’s scientific basis, clinical utility, and philosophical coherence. The authors conceptualise biology and the psychosocial as in the same ontological space, interlinked by systems of communication-based regulatory control which constitute a new kind of causation. These are distinguished from physical and chemical laws, most clearly because they can break down, thus providing the basis for difference between health and disease. This work offers an urgent update to the model’s scientific and philosophical foundations, providing a new and coherent account of causal interactions between the biological, the psychological and social.

Psychopaths are often regarded as a scourge of contemporary society and, as such, are the focus of much public vilification and outrage. But, arguably, psychopaths are both sinned against as well as sinners. If that is true, then their status as the victims of abusive subcultures partially mitigates their moral responsibility for the harms they cause. We argue, from the neuroethics of psychopathy and antisocial personality disorder (ASPD), that communities have a moral obligation to psychopaths as well as a case against them. A reflection on the genesis and developmental epidemiology of psychopathy reveals an individualist, attribution-type error evident in much Western psychological and legal thinking—an error that obscures important moral truths about psychopaths. The resulting analysis makes us reconsider the distinction between disorders and moral failings and the ethical significance of the biological or neurocognitive mechanisms underpinning psychopathy. We claim that casting aside the deficit model (based on the presupposition that psychopaths are intrinsically unlike the rest of us) in favor of a relational and holistic view of personality potentiates a more informed and inclusive set of ethical, forensic, and therapeutic attitudes.

The diagnosis of bipolar disorder has been linked to giftedness of various sorts and this raises a special problem in that it is likely that the condition has a genetic basis. Therefore it seems possible that in the near future we will be able to detect and eliminate the gene predisposing to the disorder. This may mean, however, that, as a society, we lose the associated gifts. We might then face a difficult decision either way in that it is unclear that we are preventing an unalloyed bad when we diagnose and eliminate bipolar disorder through prenatal genetic testing and yet if we allow the individual to be born we are condemning that person to being an unwitting sacrifice in that they might well suffer considerable net distress as a result of our need to keep our gene pool enriched in the relevant way.

Abstract The phenomenology of Multiple Personality (MP) syndrome is used to derive an Aristotelian explanation of the failure to achieve rational integration of mental content. An MP subject is best understood as having failed to master the techniques of integrating conative and cognitive aspects of her mental life. This suggests that in irrationality the subject may lack similar skills basic to the proper articulation and use of mental content in belief formation and control of action. The view that emerges centres mind on the activity of a subject rather than a structured causal nexus

Cara sui (care of the self) is a guiding thread in Foucault's later writings on ethics. Following Foucault in that inquiry, we are urged beyond our fairly superficial conceptions of consequences, harms, benefits, and the rights of persons, and led to examine ourselves and try to articulate the sense of life that animates ethical reasoning. The result is a nuanced understanding with links to virtue ethics and post-modern approaches to ethics and subjectivity. The approach I have articulated draws on the phenomenology of Levinas and Heidegger, the Virtue ethics of Baier, and the post-structuralist writing of Michel Foucault. The subject is seen as negotiable, embodied, provisional and able to be transformed in a way that denies essentialism about human beings, their moral status, and the idea of the good. The human being emerges as responsible because, properly, responsive to the context of discourse in which morality becomes articulated. When we import this style of thinking into bioethics we find that it reaches beyond issues of policy or right conduct and allows us to use the biomedical sciences and the clinical world to revise and interrogate our understanding of ourselves and the theoretical foundations of health care ethics.

Consciousness and its relation to the unconscious mind have long been debated in philosophy. I develop the thesis that consciousness and its contents reflect the highest elaboration of a set of abilities to respond to the environment realized in more primitive organisms and brain circuits. The contents of the states lesser than consciousness are, however, intrinsically dubious and indeterminate as it is the role of the discursive skills we use to construct conscious contents that lends articulation and clarity to the mental acts which cumulatively make up our mental lives. I lay out a tripartite structure for the formation of mind in which the ongoing interaction between brain and world, the formative effect of socio-cultural context and the self production of a relatively coherent narrative all play an important part in making a mind. The latter two influences clearly transcend biological science and suggest that human minds have features which broadly align with certain Freudian insights but do not support the reification of the causally structured unconscious that Freud envisaged.

Informed consent is required for any medical procedure although the situations in which it is given are beset by uncertainties and indeterminacies. These make medicolegal scrutiny of such situations very difficult. Although some people find the decision in the Sidaway case incomprehensible because of its continuing regard for a 'professional practice standard' in informed consent, I will argue that an important fact in many cases is the moral integrity of the doctor concerned and the pattern of his practice. This may provide the only morally principled and legally accessible evidence enabling a correct decision to be made in a difficult case. Although the epistemological significance of a professional practice standard is thereby defended the 'prudent patient standard' for what counts as consent is left intact

Lacan, despite being largely ignored and misunderstood in Anglo-American analytic philosophy, brings psychoanalytic theory into close contact with the philosophy of mind and psychiatry as illuminated by the continental tradition. He draws on Freud, phenomenology, existentialism, and structuralism to construct a subtle theoretical approach to the psyche according to which our engagement in discourse and our existence in the world combine to generate a many layered structure of meanings and influences that forms us. This allows him to focus on the nature and role of language and our discursively constructed self-conceptions both in the therapeutic encounter and in the maladies of the psyche. The relevance of Lacan's thought for analytic philosophy of psychiatry can be explored by pursuing his links to Freud, his complex treatment of issues in the philosophy of language, and a subtle blend of existentialism and continentally inspired naturalism that paints the contours of the unconscious mind in operationally compelling terms.

ABSTRACT AIDS raises the moral problem of confidentiality because those in sexual contact with the patient may contract a life‐threatening and incurable disease. Medicine has a tradition in which a patient's condition is regarded as confidential information held by the doctor alone. In this case there is a clear moral inclination to inform those at risk from the disease. In most cases no problem will arise but when it does the moral justification for a violation of confidentiality comes into question. Confidentiality is important because of our respect for certain human values and their importance to our patient. Where that patient acts so as to disregard the welfare of others with whom they are in close relationship, those values are lacking. This lack warrants a departure from our normal canons and provokes a suspension of normal moral privileges. The contention that any transgression, however slight, could be held to justify such a response posits a slope down which we, in fact, have no tendency to slide.

Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient–physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust – a crucial matter in healthcare especially because there are numerous ethical implications – has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources. In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework.

The relationship between "causal" and "meaningful" (Jaspers) influences on behavior is explored. The nature of meaning essentially involves rules and the human practices in which they are imparted to a person and have a formative influence on that person's thinking. The meanings that come to be discerned in life experience are then important in influencing the shape of that person's conduct. The reasoning and motivational structures that develop on this basis are realized by the shape of the neural processing networks that constitute the mature human brain. This implies that meaning is not only realized by brain micro-structure but, in part, explains its workings. This in turn entails that in psychiatry we must continue to avail ourselves both of neuropsychology/neurobiology and of dynamic/meaningful explanation. Keywords: brain and mind, causality and meaning, cognitive models, meaning, mind and brain, neuropsychology and meaning CiteULike Connotea Del.icio.us What's this?

'Representation' is a concept which occurs both in cognitive science and philosophy. It has common features in both settings in that it concerns the explanation of behaviour in terms of the way the subject categorizes and systematizes responses to its environment. The prevailing model sees representations as causally structured entities correlated on the one hand with elements in a natural language and on the other with clearly identifiable items in the world. This leads to an analysis of representation and cognition in terms of formal symbols and their relations. But human perception and cognition use multiple informational constraints and deal with unsystematic and messy input in a way best explained by Parallel Distributed Processing models. This undermines the claim that a formal representational theory of mind is 'the only game in town.' In particular it suggests a radically different model of brain function and its relation to epistemology from that found in current representational theories

The idea of freedom of the will seems to conflict with the principle of causal efficacy implicit in many theories of mind. The conflict is normally resolved within a compatibilist view whereby the desires and beliefs of the agent, replete with a respectable if yet to be elucidated causal pedigree, are taken to be the basis of individual freedom. The present view is an alternative which erects mental content on a framework of rule following and then argues that rule‐following is conceptually distinct from causally produced activity. The normative aspect of rule‐following defies reduction to descriptive or dispositional terms. According to this view we cannot get beyond the agent as a self‐determining rational individual in formulating a theory of mind and action. The theory is neo‐Kantian in that it identifies rules or conceptions of laws as central in human thought. It, follows Wittgenstein's treatment of rule‐following and generates a plausible (but non‐causal) account of mental explanation and weakness of the will.

In all fields of clinical medicine, there is an increasing awareness that outcome must be assessed in terms of quality of life and cost effectiveness, rather than merely length of survival. This is especially the case when considering decompressive craniectomy for severe traumatic brain injury. The procedure itself is technically straightforward and involves temporarily removing a large section of the skull vault in order to provide extra space into which the injured brain can expand. A number of studies have demonstrated many patients going on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation. In an attempt to address these issues, we have used the analytical framework proposed by Jonsen, that requires systematic consideration of medical indications, patient preferences, quality of life and contextual features

Walter Freeman, the self styled neurosurgeon, became famous (or infamous) for psychosurgery. The operation of frontal leucotomy swept through the world (with Freeman himself performing something like 18,000 cases) but it has tainted the whole idea of psychosurgery down to the present era. Modes of psychosurgery such as Deep Brain Stimulation and other highly selective neurosurgical procedures for neurological and psychiatric conditions are in ever-increasing use in current practice. The new, more exciting techniques are based in a widely held philosophical position on the relationship between the mind, brain and soul, which is the key to ethical debates in this area. Psychosurgery has always posed questions of responsibility, personality, character, identity, spirit, relationship, integrity, and human flourishing and they do not go away when we enter the brave new world of neuroethics and Deep Brain Stimulation

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.1 (2005) 83-85 [Access article in PDF] Lacan, Science, and Determinism Douglas McConnell Grant Gillett Keywords Lacan, the unconscious, free will Van Staden And Hinshelwood's commen-taries raise a number of issues, but there are two particular themes common to both that we pick up in this response.The first theme concerns the reconcilability of Lacanian theory to the disciplines of analytic philosophy and "Anglo-American positivist psychiatry." This is closely related to the relationship between the unconscious and the empirical sciences discussed in the editorial (McConnell and Pickering 2005). The second theme concerns the relevance of Lacanian theory to our understanding of free will and the structure of the mind. Lacan, Analytic Philosophy, and Scientific Psychiatry First, psychoanalysis or psychotherapy generally should not try to reunite with neuroscience because of the fundamental difference in their approaches to the patient, which is likely to mean that even if a theoretical rapprochement can be found, a working relationship is unlikely.Although there are many facets of Lacan's theory that were not addressed in our paper and even if many of those are totally irreconcilable to analytic philosophy, we believe that we have addressed the most ontologically fundamental issues and that these can genuinely contribute to and challenge analytic philosophy of mind.As Hinshelwood points out, psychiatry does operate with a philosophical basis, critical (or sometimes relatively uncritical) scientific realism (even though it may not be acknowledged), and it as such it can legitimately be contributed to or challenged by the philosophical aspects of Lacanian theory outlined in our paper.In fact, the theoretical basis is evinced in van Staden's commentary when he remarks on the relation between Lacanian theory and psychiatry: "... the unconscious is not only structured like a language but actually reflects and is produced by linguistic interaction between the subject and others. This is a difficult claim to verify, no doubt, but it prompts further related questions... whether the conscious mind is structured like a language" (van Staden 2005, 78). And one must ask whether this is the kind of claim that can be verified or whether it is a hermeneutic claim (in somewhat the way suggested by Jaspers), serving more as a framing belief to allow people to make sense of what has influenced them in their life histories and is currently played out in their relationships with others. We would lean toward this interpretation of the unconscious, explicitly distancing ourselves from any overreaching, quasi-scientific realism about unconscious contents and mental structures, but clinging to the thought that dealing with such contents is an essential part of the therapeutic encounter. [End Page 83]Looked at in this way, both the Lacanian unconscious and conscious mental life bear the imprint of language due to the subject's immersion and participation in the symbolic realm. This may seem a "difficult claim to verify," but because verification is linked to the scientific framework of inquiry rather than the hybrid that is clinical knowledge, we would better regard it as being difficult to establish as an axiom of therapy. The linguistic structure of the conscious and unconscious mind is, on this account, a conceptual implication of the role of the symbolic register in thought and not a thesis that requires verification (a Wittgensteinian thesis espoused by a number of contemporary philosophers, including Dummett and Davidson).As it happens, cognitive science has found linguistic structure to be important in operations of the cognitive unconscious (arguably different from the dynamic unconscious due to the former's dependence on scientific experiment and the latter's connections to life history rather than mere psychological or cognitive traits [see Gillett and McConnell 2005]). Given that language and problem solving are so closely intertwined, it would suggest that cognitive science was overlooking something important rather than damaging Lacanian theory if linguistic structure did not appear on cognitive science's "radar." So, how does language logically (in the sense defended by Husserl and Frege, that is, to do with the sense or content of thoughts not merely the processes underpinning one's contingently evolving stream...

Abstract The language of consciousness and that of brain function seem vastly different and incommensurable ways of approaching human mental life. If we look at what we mean by consciousness we find that it has a great deal to do with the sensitivity and responsiveness shown by a subject toward things that happen. Philosophically, we can understnd ascriptions of consciousness best by looking at the conditions which make it true for thinkers who share the concept to say that one of them is conscious. This depends on consciousness being manifest. When we also note that manifest, flexible and exploratory responses to one's environment are the basis of concept use, an a priori link between concepts and consciousness is forged. The brain structures subserving such responses are complex but crucially involve the multi?tracked and cross?linked information processing to be found in the neocortex. This function draws on the motivational and orienting activity arising in lower brain systems but orchestrates that into an articulated structure of behaviour control. The conclusion is that human consciousness is an umbrella term for complex and animated mental activity which makes extensive use of many different perceptual systems and also of the social milieu within which human cognition develops