Jillian Craigie

Introduction. There is substantial evidence that patients with delusions exhibit a reasoning bias—known as the “jumping to conclusions” bias—which leads them to accept hypotheses as correct on the basis of less evidence than controls. We address three questions concerning the JTC bias that require clarification. Firstly, what is the best measure of the JTC bias? Second, is the JTC bias correlated specifically with delusions, or only with the symptomatology of schizophrenia? And third, is the bias enhanced by emotionally salient material? Methods. To address these questions, we conducted a series of meta-analyses of studies that used the Beads task to compare the probabilistic reasoning styles of individuals with and without delusions. Results. We found that only one of four measures of the JTC bias—“draws to decision”—reached significance. The JTC bias exhibited by delusional subjects—as measured by draws to decision—did not appear to be solely an epiphenomenal effect of schizophrenic symptomatology, and was not amplified by emotionally salient material. Conclusions. A tendency to gather less evidence in the Beads task is reliably associated with the presence of delusional symptomatology. In contrast, certainty on the task, and responses to contradictory evidence, do not discriminate well between those with and without delusions. The implications for the underlying basis of the JTC bias, and its role in the formation and maintenance of delusions, are discussed.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) is being used to argue for wider recognition of the legal capacity of people with mental disabilities. This raises a question about the implications of the Convention for attributions of criminal responsibility. The present paper works towards an answer by analysing the relationship between legal capacity in relation to personal decisions and criminal acts. Its central argument is that because moral and political considerations play an essential role in setting the relevant standards, legal capacity in the context of personal decisions and criminal acts should not be thought of as two sides of the same coin. The implications of particular moral or political norms are likely to be different in these two legal contexts, and this may justify asymmetries in the relevant standards for legal capacity. However, the analysis highlights a fundamental question about how much weight moral or political considerations should be given in setting these standards, and this is used to frame a challenge to those calling for significantly wider recognition of the legal capacity of people with mental disabilities on the basis of the Convention.

A crucial question in relation to support designed to enable the legal capacity of people with mental disabilities concerns when support constitutes undue influence. This article addresses this question in order to facilitate the development of law and policy in England and Wales, by providing a normative analysis of the different approaches to undue influence across decisions about property, contracts, health, finances, and accommodation. These are all potential contexts for supporting legal capacity, and, in doing so, the article compares approaches to undue influence that are rarely considered together. Drawing on the UN Convention on the Rights of Persons with Disabilities, third sector and public body documents, and law in England and Wales, the analysis identifies six models that conceptualise undue influence in terms of: modes of influence; an overborne will; an inference from the situation; an overborne will understood as a mental incapacity; an overborne will in connection with vulnerability; and impaired discursive control. This final approach is a novel proposal for understanding undue influence. The analysis highlights key policy-relevant issues that distinguish the models, and generates a deliberative framework for navigating them, with the ‘overborne will’, ‘inference-based’, and ‘discursive control’ models identified as potentially fitting for the support context.

This article investigates the ability of mental incapacity tests to account for problems of control, through a study of the approach to alcohol dependence and a comparison with the approach to anorexia nervosa, in England and Wales. The focus is on two areas of law where questions of legal and mental capacity arise for people who are alcohol dependent: decisions about treatment for alcohol dependence and diminished responsibility for a killing. The mental incapacity tests used in these legal contexts are importantly different—one involves a ‘cognitive’ test, while the other includes an explicit impaired-control limb—and the comparison provides insight into a longstanding debate about the virtues of one type of test over the other. It is shown that both kinds of test can take control problems into account, but also that both can be interpreted in narrow and wide ways that significantly influence the outcome of the assessment. It is therefore argued that to a large extent, it is not the kind of mental incapacity test that matters, but how the test is interpreted. It is further proposed that value judgements are playing an unrecognised and inappropriate role in shaping this interpretation. This raises concerns about the current approach to assessing the impact of alcohol dependency on the capacity to make decisions about alcohol use or treatment, as well as broader concerns about flexibility within incapacity tests.

The Convention on the Rights of Persons with Disabilities is increasingly seen as driving a paradigm shift in mental health law, particularly in relation to the understanding that it requires a shift from substituted to supported decisions. This article identifies two competing moral commitments implied by this shift, both of which appeal to the notion of autonomy. It is argued that because of these commitments the Convention is in tension with more general calls in the medical ethics literature for preserving patient autonomy through support. The competing commitments within the Convention also present a particular challenge in putting the support it requires into practice. A discursive control account of freedom is used to develop some practical guidelines for navigating this new moral territory

Empirical research in the field of moral cognition is increasingly being used to draw conclusions in philosophical moral psychology, in particular regarding sentimentalist and rationalist accounts of moral judgment. This paper calls for a reassessment of both the empirical and philosophical conclusions being drawn from the moral cognition research. It is proposed that moral decision making is best understood as a species of Kahneman and Frederick's dual-process model of decision making. According to this model, emotional intuition-generating processes and reflective processes operate in an integrated way in moral deliberation, and metacognition is assigned an essential role in the monitoring and shaping of moral intuitions. In combination with observations from philosophical moral psychology, this proposal cautions against endorsing simple sentimentalism or rejecting rationalist accounts on the basis of the moral cognition research.

According to the principle of patient autonomy, patients have the right to be self-determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions.In this paper I examine this claim in light of theories of practical rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision-making, and that this same criterion can be applied to a patient's decision-guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case

In light of the recent focus in bioethics on questions of deliberate moral enhancement through the use of psychoactive drugs, Levy et al. (2014) argue that the more pressing issue may be the incidental effect that prescription drugs could already be having on moral agency. Although concerns have focused on the possibility of altering moral psychology through direct effects on brain function, the authors point out that this may already be a reality, albeit an unintentional one. They conclude from their survey of prescription drugs already in use, that we should urgently investigate the ways they may be “influencing the shape of our societies” (2014, 123). The question of how we ought to respond to this possibility, I believe, must be considered in the broader context of existing attitudes and policy in response to substances with similar effects; and the relative significance of these drug effects compared with other factors, in particular social factors that shape society through their developmental influence on moral psychology. First, it is important to consider the drugs described by the authors alongside widely used drugs with known, comparable effects. For example, alcohol has profound effects on features of cognition that seem relevant to moral agency, in altering risk assessment and increasing aggression (Bushman and Cooper 1990; George et al. 2005). Its impairing of inhibitory control arguably undermines the reflective processes that are often considered central to moral agency (Craigie 2011; Field et al. 2010). However, by and large the current policy adopted in liberal democratic societies is to educate people about these dangers but leave it up to adults to choose whether they use alcohol. Exceptions to this position are grounded in reasons of public protection, for example, in the case of blood alcohol limits for drivers in order to protect people against injury or death as a result of drunk driving. Restrictions are also sometimes placed on inebriation in the context of particular public roles, for example, serving on a jury, although the issue remains controversial (Law Reform Commission 2010, s. 8.21, 8.26, 8.27). This approach to alcohol regulation offers an established model for responding to the kinds of drugs in question. Broadly, it suggests that concerns about the effect of a drug on moral agency are only considered serious enough to warrant restricting its use when this puts others at risk of serious harms, or when a person is fulfilling a public role where sound decision making is of great importance (e.g., in maintaining trust in institutions such as the criminal justice system). Although at first it may be an alarming thought that pharmaceuticals [End Page 127] could be influencing individual moral psychology, the example of alcohol suggests that this this is a familiar experience, and something for which states already have a policy framework. Caffeine is another commonly used drug with psychoactive properties that seem likely to affect moral agency. Along with potentially morally relevant effects on attention and aggression (Einöther and Giesbrecht 2013; Kuhns et al. 2010), research suggests a connection between cortisol—a hormone that is elevated by caffeine—and the processing of social cues relating to threat (Montoya et al. 2012; Putman et al. 2007). There are little in the way of restrictions on the use of caffeine. Nonetheless, one might be concerned about the possible effects of caffeine on moral agency and society, particularly if the effects are less obvious than in the case of alcohol (Kuhns et al. 2010). The same concern might apply to the pharmaceuticals in question. Perhaps there is a need to investigate these effects on thought and behavior because they are not easy to detect. The greater danger might be in the fact that people do not recognize how these drugs change their appraisals and decisions, rather than in the effects themselves. It seems a reasonable suggestion that if a drug has significant enough effects on interpersonal relationships, then this information should be made available as a part of an informed consent procedure.

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an alternative justification. However, this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis.