Dan J Stein

The majority of the global literature in psychiatry and psychology has focused on Western, educated, industrialized, rich, and democratic (WEIRD) regions. This chapter considers the issue of cognitive enhancement in South Africa, a low-middle income country that is arguably particularly useful when thinking about issues in psychiatry and psychology. The author discusses the issue of cognitive enhancement in a country where there is significant inequity between different groups. He considers the question of well-being and whether this should be a focus of interest in a low-middle income country. And he raises the question of whether the approach of clinical neuroscience or of global mental health is more relevant in such a country. The chapter makes the argument that it is important for neuroethics to be an international field that encourages the development of a cross-cultural neuroscience and that ultimately contributes to global mental health.

A variety of mental disorders—including ASD, ADHD, major depression, and anxiety disorder, among others—may directly impact what an agent notices or fails to notice. A recent debate has emphasised the potential significance of such “impairment-derived ignorance,” and argued that failure to account for certain compelling cases would seriously undermine theories which intend to establish the conditions for blameworthy ignorance. In this comment we argue, contra a recent challenge, that Quality of Will (QW) accounts are able to explain the normative significance of impairment-derived ignorance. The plausible, ambivalent results QW accounts yield in difficult cases of impairment-derived ignorance further reveals the explanatory power of such accounts when it comes to blameworthy ignorance.

In this chapter, we focus on the experience of anxiety and attempt to link this to clinical neuroscience. Our central argument is that anxiety is a heterogeneous construct and that the different subjective experiences of anxiety may relate to different neurocircuitry. There are, for example, differences in the experience of anxiety that may reflect proximity to the fear stimulus (ranging from precautionary concerns and worries through anxiety and fear and, at close proximity, to imminent panic). There are also differences that may reflect different kinds of responses to the fear stimulus (e.g., fear versus avoidance) and that may reflect different kinds of fear stimuli (e.g., agoraphobia, generalized anxiety, specific anxiety, social anxiety, and posttraumatic anxiety). There is growing evidence that variations in phenomenology of anxiety are associated with different mediating neuronal circuitry.

Obsessive-compulsive disorder (OCD) symptoms arise when a “natural” feeling of certainty is lost. OCD patients typically attempt to regain this feeling of certainty by means of overly conscious thinking, magical rituals, and repetitive behaviors. Ironically, these OCD symptoms might provide some relief in the short term but lead to a further loss of certainty over the long term. The loss of certainty that is clinically observed in OCD patients has been made more tangible by recent neuroscientific research. It has been shown that the feeling of certainty or uncertainty is likely to be encoded by distinct firing patterns of dopaminergic neurons in the brain’s reward system. As OCD is often associated with dopamine alterations in the striatum, this might very well explain the altered subjective feeling of certainty and its phenomenology in OCD. Additionally, treatment with deep brain stimulation in OCD patients, in which specific brain targets are stimulated directly with implanted electrodes, reveals from direct clinical observations that patients experience primarily more “confidence” as a first sign of improvement. Linking the phenomenological study of the subjective experience of certainty and its implicated mechanisms is an important start toward a neurophenomenology of OCD.

A variety of mental disorders—including ASD, ADHD, major depression, and anxiety disorder, among others—may directly impact what an agent notices or fails to notice. A recent debate has emphasised the potential significance of such “impairment-derived ignorance,” and argued that failure to account for certain compelling cases would seriously undermine theories which intend to establish the conditions for blameworthy ignorance. In this comment we argue, contra a recent challenge, that Quality of Will (QW) accounts are able to explain the normative significance of impairment-derived ignorance. The plausible, ambivalent results QW accounts yield in difficult cases of impairment-derived ignorance further reveals the explanatory power of such accounts when it comes to blameworthy ignorance.

We routinely take diminished capacity as diminishing moral responsibility (as in the case of immaturity, senility, or particular mental impairments). The prospect of enhanced capacity therefore poses immediate questions with regard to moral responsibility. Of particular interest are those capacities that might allow us to better avoid serious harms or wrongdoing. We can consider questions of responsibility with regards to enhancement at various removes. In the first instance: where such (safe and effective) interventions exist, do we have an obligation to undergo such enhancement? Secondly: once enhanced, would the ambit of our responsibility therefore increase? Some philosophers have argued that enhanced capacities potentially generate “hyperresponsibility.” Hyperresponsible people would be held to a different and higher moral standard than those of us with more ordinary human capacities, and are liable to be more blameworthy for wrongdoing than ordinary agents. This chapter discusses the implications of enhancement for three central views of responsibility, namely: capacity-based, control-based and revelation-based views. Debates around moral responsibility have primarily concerned diminished capacities; as such the prospect of enhancement introduces new terrain—and potentially new fault-lines and complexities—in which to interrogate our theoretical conceptions of the foundations (and limits) of moral responsibility.

Despite growing understanding of the addictive qualities of the internet, and rising concerns about the effects of excessive internet use on personal wellbeing and mental health, the corresponding ethical debate is still in its infancy, and many of the relevant philosophical and conceptual frameworks are underdeveloped. Our goal in this chapter is to explore some of this evolving terrain. While there are unique ethical considerations that pertain to the formalisation of a disorder related to excessive internet use, our ethical concerns (and indeed our mental health concerns) about whether certain technologies undermine wellbeing can and should be far broader than the debates about the appropriateness of particular diagnostic categories. In this chapter we introduce some of these wider debates with regards to persuasive digital technologies— particularly those which aim to maximise use, or even to encourage compulsive engagement—as well as the difficulty in articulating the harms involved in excessive internet use, especially where such use has not led to functional impairment. Following these conversations we briefly consider some more practical ethical implications, including regulation of certain design features, concerns about growing socioeconomic inequality in online services, and whether there should be a “right to disconnect.”

Exemption from blameworthiness is often bound to implicit or explicit claims of diminished agency, or even non-agency. This poses a dilemma in navigating moral relationships affected by mental illness. While it is crucial for assessments of responsibility to be responsive to the significance of mental illness, must this responsiveness come at a cost to symmetrical moral relations? In this paper we argue, contra recent critiques, that Strawsonian accounts of responsibility are able to navigate this dilemma, and can accommodate significant exculpation on the basis of mental illness while maintaining symmetrical relations. We understand this to be part of the larger recognition that while we have certain fundamental entitlements within our moral relationships, it is also possible to be over-entitled, and to expect too much of others. Our account draws, in particular, on the moral significance of difficulty. Difficulty is inherently scalar, and in drawing on this explanatory framework we explicate a theory of both excuse and exemption by degree. We argue for a significant realm of excuse on the basis of mental illness that is fully compatible with symmetrical relations. However, we also acknowledge the limits of this accommodation on Strawsonian grounds, and argue that these limits are justified and appropriate.

The notion of uncommandability has been central to how we perceive our emotional lives, and particularly romantic love. According to this notion, while we can control how we treat people, we have little control over how we feel about them. The argument from uncommandability is often evoked as a way of sidestepping moral obligations regarding our romantic emotions. One challenge to uncommandability is the potential to manipulate our emotions through psychopharmaceuticals. Much of the debate on so-called ‘love drugs’ has concerned the permissibility and worth of these interventions. By comparison, there has been less exploration of their implications for moral obligation and responsibility. How might the emergence of these interventions change what can be emotionally demanded of us? We ultimately suggest that it is necessary to view the complex morality of our emotional lives through different evaluative paradigms: one concerning moral duty and obligation, where we have no claim to each other's romantic love irrespective of its commandability, and the other concerning the appropriateness of our reactive attitudes, where we are at times justified in feeling morally injured by another person on account of their failure to love us, regardless of whether they had control in the matter.

The focus of debates about conversational AIs (CAIs) has largely been on social and ethical concerns that arise when we speak to machines. What is gained and what is lost when we replace our human interlocutors—including our human therapists— with AIs? Here, we focus instead on a distinct and growing phenomenon: letting machines speak for us. What is at stake when we replace our own efforts at interpersonal engagement with CAIs? The purpose of these technologies is, in part, to remove effort. But effort also has enormous value, and in some cases even intrinsic value. This is true in many realms, but especially in interpersonal relationships. To make an effort for someone, irrespective of what that effort amounts to, often conveys value and meaning in itself. We elaborate on the meaning, worth and significance that may be lost when we relinquish effort in our interpersonal engagements, and also on the opportunities for self-understanding and growth that we may forsake.

Recent years have seen growing public concern about the effects of persuasive digital technologies on public mental health and well-being. As the draws on our attention reach such staggering scales and as our ability to focus our attention on our own considered ends erodes ever further, the need to understand and articulate what is at stake has become pressing. In this ethical viewpoint, we explore the concept of attentional harms and emphasize their potential seriousness. We further argue that the acknowledgment of these harms has relevance for evolving debates on digital inequalities. An underdiscussed aspect of web-based inequality concerns the persuasions, and even the manipulations, that help to generate sustained attentional loss. These inequalities are poised to grow, and as they do, so will concerns about justice with regard to the psychological and self-regulatory burdens of web-based participation for different internet users. In line with calls for multidimensional approaches to digital inequalities, it is important to recognize these potential harms as well as to empower internet users against them even while expanding high-quality access.

Background The rise in genomic and biobanking research worldwide has led to the development of different informed consent models for use in such research. This study analyses consent documents used by investigators in the H3Africa (Human Heredity and Health in Africa) Consortium. Methods A qualitative method for text analysis was used to analyse consent documents used in the collection of samples and data in H3Africa projects. Thematic domains included type of consent model, explanations of genetics/genomics, data sharing and feedback of test results. Results Informed consent documents for 13 of the 19 H3Africa projects were analysed. Seven projects used broad consent, five projects used tiered consent and one used specific consent. Genetics was mostly explained in terms of inherited characteristics, heredity and health, genes and disease causation, or disease susceptibility. Only one project made provisions for the feedback of individual genetic results. Conclusion H3Africa research makes use of three consent models—specific, tiered and broad consent. We outlined different strategies used by H3Africa investigators to explain concepts in genomics to potential research participants. To further ensure that the decision to participate in genomic research is informed and meaningful, we recommend that innovative approaches to the informed consent process be developed, preferably in consultation with research participants, research ethics committees and researchers in Africa.

Tilmes concludes his interesting and informative piece with the sentence that “analysis of psychiatric vagueness merits further consideration.” I agree with this point, as well as with his earlier assertion that how one understands psychiatric vagueness may implicate the diagnostic model that one adopts, and the research that one pursues. Fortunately, there has been recent attention to vagueness in psychiatry, addressing both degree-vagueness and combinatorial vagueness. Vagueness in psychiatry is related to a range of nosological debates, including about the...

This study investigated the applicability of a novel instrument to assess parent–child attunement in free play interactions, in dyads with an infant with and without visual impairments. We here report the findings on the reliability and applicability of the newly developed Attune & Stimulate Mother–Infant 56-items Instrument in two separate samples: one with infants with VI and one with typically sighted infants. In addition, we assessed the contribution of parental sensitivity to attunement in dyadic interactions. The A&S M-I is an observational comprehensive instrument of behaviors that captures different body parts and their motility, and different senses. The appropriate responding of a parent to the child’s signal reflects the ability to attune in the dyad as well as parent’s ability to stimulate the child to become engaged in the contact or activity. Consistency assessments revealed good reliability for maternal and infant behaviors, acceptable internal consistency and good test–retest reliability. Furthermore, both samples scored significantly above chance level on attunement, suggesting that the instrument captures parent–infant behavioral coordination, and VI was not related to parent–infant attunement. Lastly, a relation between parental sensitivity and attunement was found only in the TS sample. Altogether, these findings provide promising initial evidence of the applicability of the A&S M-I instrument for assessing dyadic attunement across different populations and ages. Having assessed the applicability of this observational instrument, future work should corroborate these findings in larger samples.

The question of 'what is a mental disorder?' is central to the philosophy of psychiatry, and has crucial practical implications for psychiatric nosology. Rather than approaching the problem in terms of abstractions, we review a series of exemplars - real-world examples of problematic cases that emerged during work on and immediately after DSM-5, with the aim of developing practical guidelines for addressing future proposals. We consider cases where (1) there is harm but no clear dysfunction, (2) there is dysfunction but no clear harm, and (3) there is possible dysfunction and/or harm, but this is controversial for various reasons. We found no specific criteria to determine whether future proposals for new entities should be accepted or rejected; any such proposal will need to be assessed on its particular merits, using practical judgment. Nevertheless, several suggestions for the field emerged. First, while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation. Second, while dysfunction is useful for defining mental disorder, the field would benefit from more sharply defined indicators of dysfunction. Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments.

Problems of Living: Perspectives from Philosophy, Psychiatry, and Cognitive-Affective Science addresses philosophical questions related to problems of living, including questions about the nature of the brain-mind, reason and emotion, happiness and suffering, goodness and truth, and the meaning of life. It draws on critical, pragmatic, and embodied realism as well as moral naturalism, and brings arguments from metaphysics, epistemology, and ethics together with data from cognitive-affective science. This multidisciplinary integrated approach provides a novel framework for considering not only the nature of mental disorders, but also broader issues in mental health, such as finding pleasure and purpose in life. Draws on the strongest aspects of polar positions in philosophy and psychiatry to help resolve important perennial debates in these fields Explores continuities between early philosophical work and current cognitive-affective sciences, including neuroscience and psychology Employs findings from modern cognitive-affective science to rethink key long-standing debates in philosophy and psychiatry Builds on work showing how mind is embodied in the brain, and embedded in society, to provide an integrated conceptual framework Assesses both the insights and the limitations of cognitive-affective science for addressing the big questions and hard problems of living.

Glas's article is one of several in an interesting special issue focused on applying concepts from enactivism to psychiatry; his focuses on anxiety in particular. Given ongoing developments in work on enactivism, and ongoing debates about how to progress psychiatry, this application is timely. Here, I make three general points about the application of enactivism to psychiatry; I exemplify these with occasional comments on social anxiety disorder.First, as de Haan notes in her introduction, the term enactivism encompasses a number of authors and ideas. Wilson and Foglia note that enactivism falls within a broader literature on "embodied cognition." This literature is partly conceptual, but also relies on...

Global Mental Health and Neuroethics explores conceptual, ethical and clinical issues that have emerged with the expansion of clinical neuroscience into middle- and low-income countries. Conceptual issues covered include avoiding scientism and skepticism in global mental health, integrating evidence-based and value-based global medicine, and developing a welfarist approach to the practice of global psychiatry. Ethical issues addressed include those raised by developments in neurogenetics, cosmetic psychopharmacology and deep brain stimulation. Perspectives drawing on global mental health and neuroethics are used to explore a number of different clinical disorders and developmental stages, ranging from childhood through to old age. Synthesizes existing work at the intersection of global mental health and neuroethics Presents the work of leading practitioners of global mental health and neuroethics who address clinical issues Looks at clinical decision-making in settings with non-Western values and customs Covers patient empowerment, human rights, cognitive enhancement, and more.

Psychiatric genetic research investigates the genetic basis of psychiatric disorders with the aim of more effectively understanding, treating, or, ultimately, preventing such disorders. Given the challenges of recruiting research participants into such studies, the potential for long‐term benefits of such research, and seemingly minimal risk, a strong claim could be made that all non‐acute psychiatric inpatients, including forensic and involuntary patients, should be included in such research, provided they have capacity to consent. There are tensions, however, regarding the ethics of recruiting psychiatric inpatients into such studies. In this paper our intention is to elucidate the source of these tensions from the perspective of research ethics committee interests and decision‐making. We begin by defining inpatient status and outline some of the assumptions surrounding the structures of inpatient care. We then introduce contemporary conceptions of vulnerability, including Florencia Luna’s account of vulnerability which we use as a framework for our analysis. While psychiatric inpatients could be subject to consent‐related vulnerabilities, we suggest that a particular kind of exploitation‐related vulnerability comes to the fore in the context of our case study. Moreover, a subset of these ethical concerns takes on particular weight in the context of genetic research in low‐ and middle‐income countries. At the same time, the automatic exclusion of inpatients from research elicits justice‐related vulnerabilities.

Psychiatric disorders present distinct clinical challenges which are partly attributable to their multifactorial aetiology and the absence of laboratory tests that can be used to confirm diagnosis or predict risk. Psychiatric disorders are highly heritable, but also polygenic, with genetic risk conferred by interactions between thousands of variants of small effect that can be summarized in a polygenic risk score. We discuss four areas in which the use of polygenic risk scores in psychiatric research and clinical contexts could have ethical implications. First, there is concern that clinical use of polygenic risk scores may exacerbate existing health inequities. Second, research findings regarding polygenic risk could be misinterpreted in stigmatising or discriminatory ways. Third, there are concerns associated with testing minors as well as eugenics concerns elicited by prenatal polygenic risk testing. Fourth, potential challenges that could arise with the feedback and interpretation of high polygenic risk for a psychiatric disorder would require consideration. While there would be extensive overlap with the challenges of feeding back genetic findings in general, the potential clinical use of polygenic risk scoring warrants discussion in its own right, given the recency of this possibility. To this end, we discuss how lay interpretations of risk and genetic information could intersect. Consideration of these factors would be necessary for ensuring effective and constructive communication and interpretation of polygenic risk information which, in turn, could have implications for the uptake of any therapeutic recommendations. Recent advances in polygenic risk scoring have major implications for its clinical potential, however, care should be taken to ensure that communication of polygenic risk does not feed into problematic assumptions regarding mental disorders or support reductive interpretations.

Cell line immortalisation is a growing component of African genomics research and biobanking. However, little is known about the factors influencing consent to cell line creation and immortalisation in African research settings. We contribute to addressing this gap by exploring three questions in a sample of Xhosa participants recruited for a South African psychiatric genomics study: First, what proportion of participants consented to cell line storage? Second, what were predictors of this consent? Third, what questions were raised by participants during this consent process? 760 Xhose people with schizophrenia and 760 controls were matched to sex, age, level of education and recruitment region. We used descriptive statistics to determine the proportion of participants who consented to cell line creation and immortalization. Logistic regression methods were used to examine the predictors of consent. Reflections from study recruiters were elicited and discussed to identify key questions raised by participants about consent. Approximately 40% of participants consented to cell line storage. The recruiter who sought consent was a strong predictor of participant’s consent. Participants recruited from the South African Eastern Cape, and older participants, were more likely to consent; both these groups were more likely to hold traditional Xhosa values. Neither illness nor education were significant predictors of consent. Key questions raised by participants included two broad themes: clarification of what cell immortalisation means, and issues around individual and community benefit. These findings provide guidance on the proportion of participants likely to consent to cell line immortalisation in genomics research in Africa, and reinforce the important and influential role that study recruiters play during seeking of this consent. Our results reinforce the cultural and contextual factors underpinning consent choices, particularly around sharing and reciprocity. Finally, these results provide support for the growing literature challenging the stigmatizing perception that people with severe mental illness are overly vulnerable as a target group for heath research and specifically genomics studies.

The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical concepts of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values

Despite the effort on DSM-5 and ICD-11, few appear satisfied with these classification systems. We suggest that the core reason for dissatisfaction is expecting too much from them; they do not provide discrete categories that map to specific causes of disease, they describe clinical syndromes intended to guide treatment choices. Here we review work on anxiety and anxiety disorders to argue that while clinicians draw a pragmatic distinction between normal and abnormal emotions based on considerations such as severity and duration, understanding the evolutionary origins and utility of the emotions, including the adaptive value of adverse emotions, is key for formulating comprehensive assessments of an individual patient’s symptoms and for providing a conceptual foundation for pharmacotherapy, psychotherapy, and public health.