Jack Sadler

In the first of four parts the chapter describes the contemporary breakdown of public civil discourse in the realms of political discourse, social media use, and education for civic engagement. Second, it introduces the concept of “values literacy” as a set of epistemic skills and attitudes for recognizing, analyzing, and interpreting values. Third, the chapter then fleshes out a method of values recognition and analysis and defines values operationally as attitudes or dispositions that are action-guiding and subject to praise or blame. Finally, in the fourth part, the chapter makes the case for how educating the polity in values analysis can deepen and expand civil discourse. The sincere seeker of human flourishing can use values analysis to explode simplistic accounts into complex sets of value trade-offs and compromises, exposing the insincere while revealing potentials for common ground and shared flourishing.

The themes of the previous chapters are brought together in Chapter 7 through the introduction of a series of cases. In contrast to standard depictions of third-person case vignettes, distorted and over-simplified by the heuristic purposes they serve, a new method of case presentation is employed here that attempts to capture the inner world of the practitioner as well as the dynamic ebb and flow of the interchange between patient(s) and practitioner during particular “moments” in the therapeutic session. This demonstrates previous emphasis on the moral psychology and character of the practitioner.

The brief concluding chapter returns to the questions, first introduced in Chapter 5, of whether, and how, virtue can be taught. The preceding discussions have laid out reasons _why_ virtue should be taught to those who will practice psychiatry. There is a growing body of evidence indicating it is possible to deepen and augment the affective and moral responses making up character traits such as empathy, for example, using a range of pedagogical techniques that harness imaginative capabilities. Alongside the practice skills they learn, the virtues of the good practitioner in psychiatry should and can be habituated and deepened using such techniques, it is argued. As well as to the acquisition of more technical skills, emphasis ought to be placed on character training.

Some tensions inherent in joining the traditional concept of character to that of social roles are outlined in Chapter 6. They are illustrated through a discussion of the moral psychological dangers that attend role morality: inner compartmentalization or lack of integrity, inconstant virtues (honored in one role and neglected in another), and apparently incompatible roles (such as healer and upholder of criminal justice). Some difficulties springing from the way virtues are habituated, are also introduced, including the ethical status of virtues that are merely feigned (as when the practitioner pretends an empathic response to the patient that is not wholehearted or genuine).

The centrality of culture and particularly gender to psychiatry and to the psychiatric project are demonstrated in Chapter 4. (Factors given attention include the cultural associations linking male heterosexuality with mental health, the bias found in diagnostic categories, the differential treatment provided to women, and the implications of practicing psychiatry within traditionally male-oriented cultures.) As one implication of recent identity politics, issues of gender identity represent an inescapable ethical challenge for today's practitioner, and reflect ideas that have received little systematic attention. Moving beyond questions about misogyny, homophobia and homosexuality to explore the ethics of practice with trans-gendered identities, this chapter introduces the elements of a gender sensitive psychiatry.

Some of the virtues called for by the psychiatric setting are enumerated in Chapter 5. Several different kinds of character traits are included here: some are traits as essential in everyday as in professional life but demanded to a greater degree in practice setting than in most other settings. Others, while elsewhere merely prudential or intellectual virtues, become role-constituted virtues for the practitioner in psychiatry. Yet other traits are closely role-constituted virtues, without universally recognized moral value beyond the professional setting. Not intended to be a complete portrait of the character of the virtuous psychiatrist, Chapter 5's discussion rather serves as a template for identifying that character by appeal to particular aspects of the psychiatry setting. The virtues selected for discussion are each analyzed in an effort to demonstrate their link to demands determined by that setting.

Chapter 3 introduces the idea of psychiatric ethics understood as virtue ethics. The authors show why a virtue ethics framework suits the role morality associated with professionalism, and define role-constituted virtues - character qualities called for by the practice setting, that constitute moral reasons for the practitioner. The original contribution of this chapter lies in its explication of the character demands of the psychiatry setting and explanation of why a virtue ethics framework particularly fits psychiatric practice. Within such practice, it is demonstrated, a special part is played by virtues which elude rule-based approaches (here called “unruly virtues”) such as empathy and compassion, and those that are superogatory, such as leadership.

This chapter places psychiatric ethics within professional and biomedical ethics more generally, and introduces the “role morality” notion: that some ethical imperatives derive from particular social roles. Some differences between psychiatry and other medical practices are illustrated through three issues: questions of patient autonomy, rules governing the ‘boundaries’ around the therapeutic relationship, and concerns over psychiatric diagnostic categories. Building on previous work in biomedical ethics, the authors adopt the methodology employed in the American Psychiatric Association's _Annotations with Particular Application to Psychiatry_ (2001), which identifies the ethical implications of particular features distinctive to the practice of psychiatry. When practiced with severely ill patients, it is asserted, psychiatry makes extra ethical demands on practitioners.

Chapter 2 puts forward a systematic and developed rationale for the view introduced previously that psychiatry requires its own ethics. Few aspects of psychiatric practice are medically unique, yet taken together a set of elements differentiates psychiatry as a unique healing practice. These elements include patient vulnerability, attitudes towards psychiatric symptoms, stigma and controversy over mental disorder in our culture, and the nature of the therapeutic project in psychiatry. These are analyzed, together with more recent factors influencing practice, in particular, managed care delivery systems, and the advent of consumer movements made up of mental health service users.

BackgroundCase reports are valuable tools that illustrate and analyze practical scenarios, novel problems, and the effectiveness of interventions. In psychiatry they often explore unique and potentially stigmatizing aspects of mental health, underscoring the importance of confidentiality and informed consent. However, journals’ guidance on consent and confidentiality for case reports varies. In 2013, an international expert group developed the CAse REports (CARE) Guidelines for best practices in case reports, which include guidelines for informed consent and de-identification. In 2016, the Committee on Publication Ethics (COPE) issued ethical standards for publishing case reports, calling for written informed consent from featured patients.MethodsUsing a cross-sectional approach, we assessed the instructions for authors of 253 indexed psychiatry journals, of which 129 had published English-language case reports in the prior five years. Our research identified and evaluated journals’ use of COPE and CARE guidelines on informed consent and de-identification in case reports.ResultsAmong these 129 journals, 84 (65%) referred to COPE guidelines, and 59 (46%) referenced CARE guidelines. Furthermore, 46 (36%) required informed consent without de-identification, 7 (5%) required only de-identification, and 21 (16%) required both, specifying consent for identifying information. Notably, 40 (31%) lacked informed consent instructions. Of the 82 journals that required informed consent, 69 (85%) required documentation of consent.ConclusionA decade after the publication of expert guidance, psychiatry journals remain inconsistent in their adherence to ethical guidelines for informed consent in case reports. More attention to clear instructions from journals on informed consent—a notable topic across different fields—would provide an important educational message about both publication ethics and fundamental respect for patients’ confidentiality.

Back in 2011, I wrote a paper for the Journal of Bioethical Inquiry, an Australian journal, for a special issue dedicated to ethical issues associated with psychiatric genetics research. The editor was particularly excited by the recent findings of the 5-HTT allele in psychiatric illness. I had different ideas about what I wanted to write about, and the editor, Michael Robertson, graciously considered them and ultimately published the paper. At the time I was interested in the colossal investment of National Institutes of Mental Health (NIMH) research dollars in psychiatric genetic research; at the time I was troubled at the lack of on-the-ground clinical implications of this research investment, and figured an... Read More.

In lieu of an abstract, here is a brief excerpt of the content:Crushing Pressures and Radical IdeasJohn Z. Sadler, MD (bio)Back in 2011, I wrote a paper for the Journal of Bioethical Inquiry, an Australian journal, for a special issue dedicated to ethical issues associated with psychiatric genetics research. The editor was particularly excited by the recent findings of the 5-HTT allele in psychiatric illness. I had different ideas about what I wanted to write about, and the editor, Michael Robertson, graciously considered them and ultimately published the paper. At the time I was interested in the colossal investment of National Institutes of Mental Health (NIMH) research dollars in psychiatric genetic research; at the time I was troubled at the lack of on-the-ground clinical implications of this research investment, and figured an Australian journal and referees would be more generous to a critical paper on U.S. funding priorities. I dug into the National Institutes of Health (NIH), NIMH, and National Science Foundation websites and found some crude dollar evidence of respective expenditures for research funding in various disorders and focus areas, and compared these investments to psychiatric genetic research funding commitments. I will not go into details (Sadler, 2011), but the gist was that the psychiatric genetics research enterprise was and had been an extraordinarily expensive enterprise, when other research questions that could be immediately implementable into clinical care improvements remained marginally funded at best. The paper was not read widely and other than a couple of annoyed responses from psychiatric genetic researchers, not much came of it.This concern about funding priorities was one of the reasons why I was pleased to see this paper by Turkheimer and Greer which explores the long term results of the Spit for Science (S4S) initiative, which was launched grandly the same year as my paper’s whisper from down under. I hope this Philosophical Case Conference explores the many dimensions of interest for this paper, which is extraordinarily careful and even handed in its attitude, while at the same time being incisive in its analysis.My focus here is not in the science per se, which is beyond my competence. I’m interested in Turkheimer and Greer’s (T&G) conceptual overview of this research program. More specifically, I focus on T&G’s highlighting of the extraordinary willingness of the S4S authors to interpret prevailingly negative results in the most generous, even misleading, degree possible. I try to provide some possible ways of understanding this kind of research rhetoric exhibited by a cohort of highly respected, very successful scientists.I acknowledge the well-described varieties of interpretive bias that all of us are subject to. First on the list must be confirmation bias, our tendency to interpret situations in terms consistent [End Page 447] with our preconceived notions—in this case, the idea that genetics has something important to do with addictive disorders. Another might be epistemic overconfidence—the tendency to fail at interpretive skepticism in favor of one’s preferred conclusion. Related to this may also be interpretive momentum, the tendency to maintain a conviction about the correctness of one’s expectations and disregard inconsistent findings over the course of a research program—in this case, the multiple S4S studies (O’Sullivan & Schofeld, 2018). However, these kinds of biases tend to “blame” the individual authors’ thinking styles. I opine, though, that other vectors shaping the declaring-success rhetoric are more important.These sources have to do with the state of practice in doing biomedical science research in universities and particularly academic medical centers (AMCs) today. I identify several causal vectors that compel, however subtly, researchers to declare success in the face of failure. I have only picked three, and in no order of importance: 1) funding caps for NIH grants, 2) the overleveraging of university budgets and ballooning dependence on soft money, and 3) the incentivizing of intellectual property development within AMCs.Funding Caps for NIH GrantsIf you are a university or AMC, one way you hold onto your most productive scientists (e.g., grants, publications, discoveries, and status) is by paying them well. Single NIH grants today commonly amount to millions of dollars, and often tens of millions. These bring...

In lieu of an abstract, here is a brief excerpt of the content:Editorial changes at PPPWelcomes and ThanksJohn Z. Sadler, MDAfter 30 years of co-editing (with Bill Fulford) and editing Philosophy, Psychiatry, & Psychology, I thought it was time for me to step down, and last fall the Association for the Advancement of Philosophy and Psychiatry Executive Council assembled an international search team to select a new Editor-in-Chief. This thoughtful and efficient group, led by Robyn Bluhm, completed the search and selection in a matter of a few months! All of us in the field are grateful to the search committee members for their congenial, disciplined, and fruitful work: Derek Bolton, David Crepaz-Keay, Anthony Fernandez, Brent Kious, Guilherme Messas, and Michael Wong. We are excited about the future of the journal with our new Editor-in-Chief, Professor Werdie van Staden. Briefly, Werdie is the Nelson Mandela Professor of Philosophy and Psychiatry and Director of the Centre for Ethics and Philosophy of the Health Sciences, the University of Pretoria, South Africa.Students, trainees, and early career scholars in our field often ask about how senior scholars found their way to, and through, the field of philosophy/psychiatry. The reading of Werdie's biography, in chronological order, would befuddle a reader trying to predict where he would end up by 2024. In the youth of his adulthood, Werdie was heading toward a career in music, collecting several degrees in music theory, composition, and performance. Indeed, music would occupy a big piece of his life over the decades. Dr. van Staden has continued his musical career as a composer of two symphonies, a concerto, as well as multiple choral and chamber works. He has performed as a flautist for the Pretoria Symphony Orchestra since 2006, and was the Principal for 8 years.However, he was also an individual directed toward service to his fellow human beings. He completed his MBChB medical degree in 1990 and went on to several degree qualifications in medicine, psychiatry, and philosophy. Most significant for us was his early experience with Bill Fulford's master's degree program in the Philosophy of Mental Health at the University of Warwick, later completing a doctoral degree. His Mandela Professorship at Pretoria was the first endowed Professorship in our philosophy/psychiatry multidisciplinary field. Since then his intellectual work has ranged over clinical and research ethics, philosophy of language and psychopathology, Ubuntu virtue theory, person-centered medicine, medical education, and many more areas, making him a most versatile scholar. Over the past three [End Page 91] decades he has functioned as a practicing clinician, a department chair, a clinical trialist, a partner to Bill Fulford in developing and disseminating the Values-Based Practice approach to clinical medicine, a leader in many professional organizations, an editor of the South African Journal of Psychiatry, not to overlook serving as an author, reviewer, and Senior Editor at PPP at various points since the journal's inception. His professional and intellectual activities and accomplishments are too numerous to recount; suffice to say we are delighted to have him bring his vision, creativity, and vigor to us by adding PPP to his to-do list!We congratulate and thank Professor Nancy Potter on her retirement from academia as well as one of our first Senior Editors of PPP. Nancy's path to philosophy/psychiatry was by way of work in the correctional system in her youth, followed by philosophical field work in the emergency psychiatry department at the University of Louisville Hospital, with her psychiatrist colleague Rafi El-Mallakh, MD. However, philosophy has been her first priority, with work in feminist theory, philosophy of peace, virtue theory, and standpoint/social epistemology over her career. Never satisfied with armchair philosophy, Dr. Potter has immersed herself in settings, traditions, and practices to understand them from inside as well as out. As a PPP Senior Editor, Nancy was instrumental in developing the service-user voice, as well as diversifying our authorship in many other ways. I will miss her even-tempered, yet rigorous editorial voice in the journal.My last appointment of a Senior Editor turned out to be one of Dr. van Staden's students. I welcome Dr. Mohammed Abouelleil Rashed as our newest...

The philosophy of medicine and psychiatry has considered the defining of disease, illness, and disorder an important project for over three decades. Within this literature, accounts based on adaptive "functions" have been prominent, particularly in the DSM nosology. In response to this trend, Jerome Wakefield has presented a view of mental disorder as "harmful dysfunction." In this view, "harm" contributes the value-element to disorder concepts, while "dysfunction" implies a value-free foundation as long as the latter is grounded in evolutionary biology. In a critical review of Wakefield's and others' functionalist arguments for disorder concepts, we make four major points. We recommend a shift away from the definition of value-free disorder concepts, instead emphasizing the analysis of the logical features and the value commitments in nosological categories.

Values are action-guiding dispositions that are subject to praise or blame, and as such are fundamental in making choices and taking action in any human context, including clinical practice and research. The first half of the chapter reviews the contemporary role of philosophical value theory in understanding the clinical process of diagnosis and the development of formal classifications of psychopathology. The second half of the chapter discusses the kinds of values evident in these areas and raises unanswered questions for the field. Despite two decades of progress in understanding the key role of values in clinical and classificatory work, the open disclosure and negotiation of values in psychiatry remains a novel idea for many, and psychiatric and philosophical research into the area of values and diagnosis/classification is only in its infancy.

In this introduction to Section VI, the thrust of the component chapters is described. The classification and diagnosis of mental disorders collects a number of philosophical challenges to the field that call for responses from a variety of philosophical resources: hermeneutics, phenomenology, philosophy of mind, narrative theory, philosophy of science, epistemology-to name a few. The authors in this section address the general challenges in the classification of psychopathology, as well as address particular kinds of mental disorders, including autism, dementia, mania, psychotic disorders, and personality disorders.

This chapter introduces the edited volume, The Oxford Handbook of Philosophy and Psychiatry. Published in 2013, the centenary of Karl Jaspers' General Psychopathology, the chapter draws lessons from the last hundred years for the coming century. No predictions are made. Instead, five 'conditions for flourishing' are set out: 1) Particular Problems - the importance of focussing on well-defined particular problems rather than general theory building, 2) Product- orientation - remaining always responsibly product oriented in the specific sense that both sides put in the work necessary to 'go deep' with each other's fields, 3) Partnership - working in partnerships of one kind or another, 4) Process - constant reflection on process based on peer review but leaving scope for the occasional rogue voice to cut innovatively against the grain, and 5) Q - a condition of a different kind, Q is an empirically derived measure of the balance between in-group cohesion and out-group openness required to support creativity. Illustrations are given of how these five conditions for flourishing have underpinned the rapid expansion of philosophy and psychiatry in the closing decades of the twentieth century, and, correspondingly, are also reflected in the Handbook as a whole. Overviews and commentaries on individual contributions to the Handbook are given in extended editorial introductions to each of its eight sections.

Following on from Section IV on summoning concepts, this section of the Handbook presents theoretically informed descriptions of psychopathologies. The topics of the chapters range from anxiety, depression, and body image disorders, through emotion and affective disorders, to delusion, thought insertion, and the fragmentation of consciousness. These phenomena call, not only for assessment and diagnosis, but also for understanding on the part of both the engaged clinician and the philosophical commentator. They also provide case studies for general philosophical questions about different levels of description and conceptualisation and the relationships between them, and about the contributions to psychological understanding that are made by phenomenology, clinical expert knowledge, and the sciences of the mind.

This section concerns the question of how best to understand the scientific status of mental health care in general and psychiatry in particular. On the assumption that psychiatry is based, in part at least, on natural science, what is the nature or the general shape of that science? Some of the chapters aim at shedding light on component parts of a scientific world view: causation, explanation, natural kinds, models of medicine, etc. Others concern potentially fruitful scientific approaches to mental health care, drawing on brain imaging results, phenomenology, enactivism and what can be learnt from debate of the status of psychoanalysis. One overall lesson is that twenty-first-century psychiatry needs twenty-first-century philosophy of science.

In this introduction to the Section II, the thrust of the component chapters is described. An important strand in the philosophy of psychiatry since its beginnings has been sociopolitical critiques: criticism which aims to improve and humanize psychiatric practice and mental health systems. From this standpoint, the introduction provides an overview of this tradition, including considerations of "postpsychiatry," value commitments in psychiatry, the recovery movement, racism and sexism in the field, and technology.