Camillia Kong

Human rights have recently impacted on current conceptualisations of the rights and obligations owed to individuals with impairments, culminating in the UN Convention for the Rights of Persons with Disabilities. Particularly significant is Article 12, where interpretations have heralded a “will and preferences” paradigm which rejects substituted decision-making mechanisms, even in situations where an individual should make personally harmful or unwise decisions about their treatment, care, or relationships. This paper explores problems with “strict” and “flexible” interpretations of Article 12, focusing specifically on safeguarding issues in cases of relational abuse, exploitation, and coercion. Drawing analogies with feminist arguments opposing violence against women in the domestic sphere, I challenge the private/public and individualistic account of autonomy which is implicit in interpretations of the “will and preferences” paradigm, and suggest that proponents of Article 12 should consider the possible justifiability of expanded protectionist measures in cases of abuse involving individuals with impairments.

Anne was sexually and physically abused as a child and adolescent. Since an adolescent, she has had episodes of engaging in self-injurious behavior, where she repetitively cuts her arms with a knife or scissors, sometimes so seriously that she has had to go to the emergency room. She is relatively high functioning as an individual, where her academic cleverness has enabled her to study for a philosophy degree at a top university. Owing to her history of deliberate self-injury, psychiatrists have diagnosed her with borderline personality disorder. In moments of anger and emotional upset, like when her psychiatrist has seemed cold toward her or her session has stopped early, she reverts to cutting her arms.Borderline...

This paper offers a critique of Christine Korsgaard’s interpretation of Kantian instrumental reason. Korsgaard understands Kantian hypothetical imperatives to share a common normative source with the categorical imperative – namely self-legislating, human rational agency. However, her reading of Kantian hypothetical imperatives is problematic for three reasons. Firstly, Korsgaard’s agent-centred approach renders incoherent Kant’s analytic-synthetic division. Secondly, by minimising the dualistic framework of Kant’s practical philosophy the dialectical character of practical rationality is lost: norms of instrumental reasoning therefore become confused with those of moral reasoning. Thirdly, this in turn curtails the distinct critical authority of pure practical rationality over instrumental choice. The paper argues that we need to understand the normativity of instrumental rationality through the lens of Kant’s dualisms. An alternative interpretation is offered which highlights how the norms of hypothetical imperatives appeal to standards of theoretical cognition and practical efficiency rather than the self-legislative demands of pure practical reason.

Realizing the benefits of translating psychiatric genomics research into mental health care is not straightforward. The translation process gives rise to ethical challenges that are distinctive from challenges posed within psychiatric genomics research itself, or that form part of the delivery of clinical psychiatric genetics services. This article outlines and considers three distinct ethical concerns posed by the process of translating genomic research into frontline psychiatric practice and policy making. First, the genetic essentialism that is commonly associated with the genomics revolution in health care might inadvertently exacerbate stigma towards people with mental disorders. Secondly, the promises of genomic medicine advance a narrative of individual empowerment. This narrative could promote a fatalism towards patients' biology in ways that function in practice to undermine patients' agency and autonomy, or, alternatively, a heightened sense of subjective genetic responsibility could become embedded within mental health services that leads to psychosocial therapeutic approaches and the clinician-patient therapeutic alliance being undermined. Finally, adopting a genomics-focused approach to public mental health risks shifting attention away from the complex causal relationships between inequitable socio-economic, political, and cultural structures and negative mental health outcomes. The article concludes by outlining a number of potential pathways for future ethics research that emphasizes the importance of examining appropriate translation mechanisms, the complementarity between genetic and psychosocial models of mental disorder, the implications of genomic information for the clinician-patient relationship, and funding priorities and resource allocation decision making in mental health.

In recent human rights and legal instruments, individuals with impairments are increasingly recognised as agents who are worthy of respect for their inherent dignity and capacity to make autonomous decisions regarding treatment and care provisions. These legal developments could be understood using Stephen Darwall’s normative framework of the second person standpoint. However, this paper draws upon phenomena – both in legal developments and recent court cases – to illustrate theoretical difficulties with the contractualist underpinnings of Darwall’s account if applied to questions of what is owed to individuals with disabilities. I argue that, under Darwall’s framework, whether the threshold for second-personal competence has been met will determine whether respect or rational care is owed to them. This fact distorts our understanding of what we owe to persons with mental impairments—in part because it limits respect to relations that are symmetrical and reciprocal. In light of these challenges the paper offers an account of hermeneutic competency, which can be applied to non-reciprocal and asymmetrical relationships. This alternative account will be of practical import to judicial determinations of best interests under the Mental Capacity Act 2005 in England and Wales. It will also be of broader theoretical interest to any legal system that deals with people with mental disabilities

In May 2012, in A Local Authority v E and Others,' a best interests ruling was made under the Mental Capacity Act 2005 to coercively treat a severely anorexic woman, E, against her will. The best interests decision was purportedly reached through a process of judicialbalancing; however there is something deeply unsatisfactory about this account. This commentary delves beyond the expressed balancing method and applies the tools of philosophical hermeneutics to both understand and challenge the best interests ruling in A Local Authority v E and Others. First, the hermeneutic concept of 'prejudice' makes explicit the implicit judgments determining the best interests decision in this case. Secondly the commentary challenges the best interests decision in two ways: the hermeneutic emphasis on dialogical understanding provides grounds for questioning the judge's failure to integrate the views of E and her wider decision community ; the ruling could be deemed invalid due to the implicit application of a status-based rather than statutory functional test to assess E's current and retrospective capacity.

It has become increasingly common to interpret Hume as a `sceptic' of practical reason. This means that Hume supposedly contests, not only the ability of reason to provide demonstrable truths, in the conventional rationalist sense, but also reason's ability to guide our practical action. Proponents of this reading include Jean Hampton, Elijah Millgram and Christine Korsgaard. If this `sceptical reading' of Hume is correct, he would lack the philosophical resources to justify his account of political justice. However, if examined further, this sceptical reading begins with deep-seated Kantian presuppositions about the role and function of practical reason. The paper critiques these presuppositions, arguing that they must be set aside in order to appreciate more fully how Hume does indeed have a proper theory of practical reason. Specifically, Hume believes practical reason encompasses the discursive articulation and evaluation of human character traits and moral values within the social context. These articulatory and intersubjective dimensions of practical reasoning emphasized in the Humean account could provide further theoretical inspiration for communitarian critiques of contemporary liberalism

Informed consent procedures for participation in psychiatric genomics research among individuals with mental disorder and intellectual disability can often be unclear, particularly because the underlying ethos guiding consent tools reflects a core ethical tension between safeguarding and inclusion. This tension reflects important debates around the function of consent tools, as well as the contested legitimacy of decision-making capacity thresholds to screen potentially vulnerable participants. Drawing on human rights, person-centred psychiatry and supported decision-making, this paper problematises the use of consent procedures as screening tools in psychiatric genomics studies, particularly as increasing normative emphasis has shifted towards the empowerment and participation of those with mental disorder and intellectual disabilities. We expound on core aspects of supported decision-making, such as relational autonomy and hermeneutic competence, to orient consent procedures towards a more educative, participatory framework that is better aligned with developments in disability studies. The paper concludes with an acknowledgement of the pragmatic and substantive challenges in adopting this framework in psychiatric genomics studies if this participatory ethos towards persons with mental disorder and intellectual disability is to be fully realised.

Psychiatric genomics research protocols are increasingly incorporating tools of deep phenotyping to observe and examine phenotypic abnormalities among individuals with neurodevelopmental disorders. In particular, photography and the use of two-dimensional and three-dimensional facial analysis is thought to shed further light on the phenotypic expression of the genes underlying neurodevelopmental disorders, as well as provide potential diagnostic tools for clinicians. In this paper, I argue that the research use of photography to aid facial phenotyping raises deeply fraught issues from an ethical point of view. First, the process of objectification through photographic imagery and facial analysis could potentially worsen the stigmatisation of persons with neurodevelopmental disorders. Second, the use of photography for facial phenotyping has worrying parallels with the historical misuse of photography to advance positive and negative eugenics around race, ethnicity and intellectual disability. The paper recommends ethical caution in the use of photography and facial phenotyping in psychiatric genomics studies exploring neurodevelopmental disorders, outlining certain necessary safeguards, such as a critical awareness of the history of anthropometric photography use among scientists, as well as the exploration of photographic methodologies that could potentially empower individuals with disabilities.

Bioethics is gradually becoming an important part of the drive to increase quality healthcare delivery in sub‐Saharan African countries. Yet many healthcare service‐users in Africa are familiar with incidences of questionable health policies and poor healthcare delivery, leading to severe consequences for patients. We argue that the overarching rights‐based ethical administrative framework recently employed by healthcare authorities contributes to the poor uptake and enforcement of current normative tools. Taking Ghana as a case study, we focus on the cultural ethical context and we tease out the concepts of the good and the ethical among the Akan and Bulsa ethnic groups. We point out three tenets towards building a normative framework that can resonate with service‐users and practitioners: ontological communitarianism; empathic humanism; and virtuous character. Finally, we indicate how these core tenets can be dovetailed into building an effective normative framework and into the training of healthcare providers.

Recent legal developments challenge how valid the concept of mental capacity is in determining whether individuals with impairments can make decisions about their care and treatment. Kong defends a concept of mental capacity but argues that such assessments must consider how relationships and dialogue can enable or disable the decision-making abilities of these individuals. This is thoroughly investigated using an interdisciplinary approach that combines philosophy and legal analysis of the law in England and Wales, the European Court of Human Rights, and the United Nations Convention on the Rights of Persons with Disabilities. By exploring key concepts underlying mental capacity, the investigation concludes that both primary relationships and capacity assessments themselves must display key competencies to ensure that autonomy skills are promoted and encouraged. This ultimately provides scope for justifiable interventions into disabling relationships and articulates the dialogical practices that help better situate, interpret, and understand the choices and actions of individuals with impairments.

Psychiatric genomics research with African populations comes with a range of practical challenges around translation of psychiatric genomics research concepts, procedures, and nosology. These challenges raise deep ethical issues particularly around legitimacy of informed consent, a core foundation of research ethics. Through a consideration of the constitutive function of language, the paper problematises like‐for‐like, designative translations which often involve the ‘indigenization’ of English terms or use of metaphors which misrepresent the risks and benefits of research. This paper argues that effective translation of psychiatric genomics research terminology in African contexts demands substantive engagement with African conceptual schemas and values. In developing attenuated forms of translational thinking, researchers may recognise the deeper motivational reasons behind participation in research, highlighting the possibility that such reasons may depart from the original meaning implied within informed consent forms. These translational issues might be ameliorated with a critical re‐examination of how researchers develop and present protocols to institutional ethics review boards.

Under the Mental Capacity Act 2005 (MCA) in England and Wales, the liberal commitments to subjective freedom guide obligations towards persons who do not lack capacity. For the subject of proceedings who might lack capacity (P), it is less clear as to what obligations orient best interests decision-making on their behalf. The UK Supreme Court has emphasised the centrality of ‘P-centricity’ in best interests decision-making, where there is the legal obligation to consider P’s subjective views and wishes in a holistic consideration of best interests. Unclarity nonetheless persists as to what is owed to P in the best interests standard, leading to the tendency to interpret obligations of P-centricity through the normative prism of subjective autonomy. This paper argues that such moves reduce the complex moral phenomenology of what a P-centric ethos entails. Instead, the phenomenological and ethical stance of moral considerability and recognition respect can best capture the enriched normative grounding for P-centric decision-making in mental capacity law.