Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders.

PURPOSE OF REVIEW: Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT). RECENT FINDINGS: Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.

Communication in youth mental health clinical encounters: Introducing the agential stance.

When young people seek support from mental health care practitioners, the encounters may affect the young people's sense of self, and in particular undermine their sense of agency. For this study, an interdisciplinary team of academics and young people collaboratively analysed video-recorded encounters between young people and mental healthcare practitioners in emergency services. They identified five communication techniques that practitioners can use to avoid undermining the young person's sense of agency in the clinical encounter. They conceptualise the use of those techniques as the adoption of an agential stance towards the young person. The agential stance consists of: (a) validating the young person's experiences, (b) legitimising the young person's choice to seek help, (c) refraining from objectifying the young person, (d) affirming the young person's capacity to contribute to positive change, and (e) involving the young person in the decision-making process.

Do delusions have and give meaning?

Delusions are often portrayed as paradigmatic instances of incomprehensibility and meaninglessness. Here we investigate the relationship between delusions and meaning from a philosophical perspective, integrating arguments and evidence from cognitive psychology and phenomenological psychopathology. We review some of the empirical and philosophical literature relevant to two claims about delusions and meaning: (1) delusions are meaningful, despite being described as irrational and implausible beliefs; (2) some delusions can also enhance the sense that one's life is meaningful, supporting agency and creativity in some circumstances. Delusions are not incomprehensible representations of reality. Rather, they can help make sense of one's unusual experiences and in some circumstances even support one's endeavours, albeit temporarily and imperfectly. Acknowledging that delusions have meaning and can also give meaning to people's lives has implications for our understanding of psychotic symptoms and for addressing the stigma associated with psychiatric conditions.

Threats to epistemic agency in young people with unusual experiences and beliefs.

A good therapeutic relationship in mental health services is a predictor of positive clinical outcomes for people who seek help for distressing experiences, such as voice hearing and paranoia. One factor that may affect the quality of the therapeutic relationship and raises further ethical issues is the impact of the clinical encounter on users' sense of self, and in particular on their sense of agency. In the paper, we discuss some of the reasons why the sense of epistemic agency may be especially fragile in young people with unusual experiences and beliefs. We argue that it is important to identify and avoid behaviours that can undermine young people's contributions as epistemic agents in the clinical encounter.

Instrumental rationality and suicide in schizophrenia: a case for rational suicide?

It is estimated that up to 7500 people develop schizophrenia each year in the UK. Schizophrenia has significant consequences, with 28% of the excess mortality in schizophrenia being attributed to suicide. Previous research suggests that suicide in schizophrenia may be more related to affective factors such as depression and hopelessness, rather than psychotic symptoms themselves. Considering suicide in schizophrenia within this framework enables us to develop a novel philosophical approach, in which suicide may not be related to loss of self-consciousness, thought processing dysfunctions or perception disturbances. The action of suicide may be due neither to persistent hallucinations nor other psychotic symptoms, such as delusional beliefs, but to other underexamined, perhaps rational reasons, such as extreme social isolation, severe depression or emotional withdrawal. This paper does not examine the moral character of suicide. Instead, it argues that we should conceive the action of suicide in schizophrenia as an act that is not necessarily irrational. People with schizophrenia might end their life based on reasons if suicide is the best means to achieve their ends. However, the paper does not support assisted suicide. It aims to provide a better understanding of the reasons why people take their own lives and suggests that understanding can inform effective interventions to reduce high rates of suicide.

What is unrealistic optimism?

Here we consider the nature of unrealistic optimism and other related positive illusions. We are interested in whether cognitive states that are unrealistically optimistic are belief states, whether they are false, and whether they are epistemically irrational. We also ask to what extent unrealistically optimistic cognitive states are fixed. Based on the classic and recent empirical literature on unrealistic optimism, we offer some preliminary answers to these questions, thereby laying the foundations for answering further questions about unrealistic optimism, such as whether it has biological, psychological, or epistemic benefits.

Moral Preferences.

In this brief response to Etzioni's paper we argue that satisfying one's preferences and seeking to live up to one's moral standards are not incompatible ways of living one's life, and that choosing to act morally need not involve self-sacrifice.

The epistemic innocence of motivated delusions.

Delusions are defined as irrational beliefs that compromise good functioning. However, in the empirical literature, delusions have been found to have some psychological benefits. One proposal is that some delusions defuse negative emotions and protect one from low self-esteem by allowing motivational influences on belief formation. In this paper I focus on delusions that have been construed as playing a defensive function (motivated delusions) and argue that some of their psychological benefits can convert into epistemic ones. Notwithstanding their epistemic costs, motivated delusions also have potential epistemic benefits for agents who have faced adversities, undergone physical or psychological trauma, or are subject to negative emotions and low self-esteem. To account for the epistemic status of motivated delusions, costly and beneficial at the same time, I introduce the notion of epistemic innocence. A delusion is epistemically innocent when adopting it delivers a significant epistemic benefit, and the benefit could not be attained if the delusion were not adopted. The analysis leads to a novel account of the status of delusions by inviting a reflection on the relationship between psychological and epistemic benefits.

The relative importance of undesirable truths.

The right not to know is often defended on the basis of the principle of respect for personal autonomy. If I choose not to acquire personal information that impacts on my future prospects, such a choice should be respected, because I should be able to decide whether to access information about myself and how to use it. But, according to the incoherence objection to the right not to know in the context of genetic testing, the choice not to acquire genetic information undermines the capacity for autonomous decision making. The claim is that it is incoherent to defend a choice that is inimical to autonomy by appealing to autonomy. In this paper, I suggest that the choice not to know in the context of genetic testing does not undermine self-authorship, which is a key aspect of autonomous decision making. In the light of this, the incoherence objection to the right not to know seems less compelling.

Is it pathological to believe conspiracy theories?

According to a naturalist conception of what counts as a disorder, conspiracy beliefs are pathological beliefs if they are the outcome of a cognitive dysfunction. In this article, I take issue with the view that it is pathological to believe a conspiracy theory. After reviewing several approaches to the aetiology of conspiracy beliefs, I find that no approach compels us to view conspiracy beliefs as the outcome of a dysfunction: a speaker's conspiracy beliefs can appear as implausible and unshakeable to an interpreter, but in a naturalist framework it is not pathological for the speaker to adopt and maintain such beliefs.

Implying implausibility and undermining versus accepting peoples' experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments.

Background: Patients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples' experiences of self-harm and suicidality are believed or not. We use an empirical method -conversation analysis - to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person's story to contest and recharacterize their accounts. Aims: To investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples' experiences of suicidal ideation and self-harm. Methods: Using conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants' medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated. Results: When peoples' experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person's account; asked questions that implied inconsistency or implausibility ("Didn't you tell your GP that you were coping okay?"); juxtaposed contrasting information to undermine the person's account ("You said you were coping okay before, and now you're saying you feel suicidal"); asked questions asserting that, e.g., asking for help implied they were not intending to end their life ("So when you called 111 what were you expecting them to do"); and resistinged or directly questioned the person's account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person's decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn't take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person's control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples' experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients' accounts. Conclusion: These findings advance our understanding of how peoples' experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples' experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.

The right not to know: the case of psychiatric disorders.

This paper will consider the right not to know in the context of psychiatric disorders. It will outline the arguments for and against acquiring knowledge about the results of genetic testing for conditions such as breast cancer and Huntington's disease, and examine whether similar considerations apply to disclosing to clients the results of genetic testing for psychiatric disorders such as depression and Alzheimer's disease. The right not to know will also be examined in the context of the diagnosis of psychiatric disorders that are associated with stigma or for which there is no effective treatment.

Reproductive and parental autonomy: an argument for compulsory parental education.

In this paper we argue that comprehensive and systematic parental education has the potential to equip young adults with the necessary information for the responsible exercise of their autonomy in choices about reproduction and parenting. Education can allow young adults to acquire largely accurate beliefs about reproduction and parenting and about the implications of their reproductive and parental choices. Far from being a limitation of individual freedom, the acquisition of relevant information about reproduction and parenting and the acquisition of self-knowledge with respect to reproductive and parenting choices can help give shape to individual life plans. We make a case for compulsory parental education on the basis of the need to respect and enhance individual reproductive and parental autonomy within a culture that presents contradictory attitudes towards reproduction and where decisions about whether to become a parent are subject to significant pressure and scrutiny.

'Faultless' ignorance: strengths and limitations of epistemic definitions of confabulation.

There is no satisfactory account for the general phenomenon of confabulation, for the following reasons: (1) confabulation occurs in a number of pathological and non-pathological conditions; (2) impairments giving rise to confabulation are likely to have different neural bases; and (3) there is no unique theory explaining the aetiology of confabulations. An epistemic approach to defining confabulation could solve all of these issues, by focusing on the surface features of the phenomenon. However, existing epistemic accounts are unable to offer sufficient conditions for confabulation and tend to emphasise only its epistemic disadvantages. In this paper, we argue that a satisfactory epistemic account of confabulation should also acknowledge those features which are (potentially) epistemically advantageous. For example, confabulation may allow subjects to exercise some control over their own cognitive life which is instrumental to the construction or preservation of their sense of self.

Are clinical delusions adaptive?

Delusions are symptoms of psychiatric disorders such as schizophrenia and dementia. By and large, delusions are characterized by their behavioral manifestations and defined as irrational beliefs that compromise good functioning. In this overview paper, we ask whether delusions can be adaptive notwithstanding their negative features. Can they be a response to a crisis rather than the source of the crisis? Can they be the beginning of a solution rather than the problem? Some of the psychological, psychiatric, and philosophical literature has recently suggested that they can. We consider different types of delusions and different ways in which they can be considered as adaptive: psychologically (e.g., by increasing wellbeing, purpose in life, intrapsychic coherence, or good functioning) and biologically (e.g., by enhancing genetic fitness). Although further research is needed to map the costs and benefits of adopting and maintaining delusional beliefs, a more nuanced picture of the role of delusions in people's lives has started to emerge. This article is categorized under: Philosophy > Representation Philosophy > Knowledge and Belief Neuroscience > Cognition.

Stranger than Fiction: Costs and Benefits of Everyday Confabulation.

In this paper I discuss the costs and benefits of confabulation, focusing on the type of confabulation people engage in when they offer explanations for their attitudes and choices. What makes confabulation costly? In the philosophical literature confabulation is thought to undermine claims to self-knowledge. I argue that when people confabulate they do not necessarily fail at mental-state self-attributions, but offer ill-grounded explanations which often lead to the adoption of other ill-grounded beliefs. What, if anything, makes confabulation beneficial? As people are unaware of the information that would make their explanations accurate, they are not typically in a position to acknowledge their ignorance or provide better-grounded explanations for their attitudes and choices. In such cases, confabulating can have some advantages over offering no explanation because it makes a distinctive contribution to people's sense of themselves as competent and largely coherent agents. This role of ill-grounded explanations could not be as easily played by better-grounded explanations should these be available. In the end, I speculate about the implications of this conclusion for attempting to eliminate or reduce confabulation.