Ethics of mental disorders: theory and empirical research (2023)

Mental disorders and their treatment are unusual problems in biomedical ethics. The disorders themselves call for ethical criticism, as do the attitudes of society towards them; research in the diagnosis and treatment of mental disorders also raises special ethical questions. The current high profile of the ethics of mental disorders, accentuated by recent political and legal developments, makes this an area of ​​research that is not only important, but also highly topical. For these reasons, the Wellcome Trust's Biomedical Ethics Program has convened a meeting, "Ethics and Mental Disorders Research," to discuss current research and stimulate topics and methods for future research in the field. The meeting was attended by policy makers, regulators, research funders and researchers, including social scientists, psychiatrists, psychologists, lawyers, philosophers, criminologists and others. In addition to encouraging a stronger research effort, the meeting also sought to foster a better understanding of the methods and interactions that can contribute to 'empirical ethics' in general.

This document reports on the meeting by describing the contributions of individual speakers and discussion sections of the meeting. Finally, we describe and discuss the conclusions of the meeting. As a result, the text is referenced less than would normally be expected in a review. Also, we may have created inaccuracies when summarizing the contributions of said presenters during the meeting; however, the final version of each article, cited directly by the presenter, is available athttp://www.wellcome.ac.uk/doc.WTX025116.html.

Policy background: Some sources of ethical concern

Many ethical issues related to mental disorders arise from and are reflected in government policy. Chris Heginbotham (Executive Director, Mental Health Law Commission) argued that mental health policy and care is undergoing transformation as new treatments become available, new service models are developed and new policy frameworks are written. He summarized that the National Service Framework⁶ushered in a new era for mental health care, but many of its promises have yet to be fulfilled. He added that the political approach to patients with mental disorders has consistently suffered from a paternalistic attitude, with little respect for 'autonomy'.

Two recently passed or proposed laws directly related to mental disorders are based on contradictory philosophical foundations and are confusing in themselves and in their operation. Therefore, the Mental Capacity Act 2005 takes an 'autonomous' approach to the treatment of physical illness; while the Draft Law on Mental Health has a largely paternalistic and "public protection" approach. There remains great concern among service users, service providers, clinicians and advocates about the extremely broad definition of mental disorder adopted in this bill, the conditions for coercion, the misuse of such preventive detention legislation and the (in)availability of appropriate treatment.⁷Overall, the proposed law is likely to lower the threshold for coercion for people with less clearly "medically valid" conditions.^8,9How can this be ethically justified? Even within the Mental Capacity Act there are concerns about protecting patients' civil rights under the law.

Ethics and the difference between mental and physical disorders

Observing the differences between legal provisions concerning the treatment of physical and mental illness naturally led to a presentation by a philosopher here, Eric Matthews (Emeritus Research Professor of Medical Ethics and Philosophy of Psychiatry, University of Aberdeen). This stands alongside Fulford's writings on value-based diagnosis in the domains of mental and physical health, and Fraser's later suggestion of the meeting of "convolutional" facts and values ​​(see below).

Matthews argued that much of the policy and legislation relating to mental disorders is not only discriminatory, but also assumes that the distinction between mental and physical disorders, and between treatments for those disorders, is rigid. Is that a reasonable working assumption?

In contemporary culture, there are conflicting views on mental disorders, which creates uncertainty, which then affects the ethics of psychiatric treatment. Philosophical confusion about the concept of mind is also a primary source of uncertainty; so a philosophical resolution of this confusion can help clarify ethical issues in mental health research.

In short, it is difficult to draw a sharp distinction between physical and mental disorders, instead there is a continuous spectrum of conditions.

In the biomedical model of disease, disease results from an externally induced biological disorder; however, this model does not apply as well to mental disorders. Many such conditions deviate from human norms rather than from normal biological function. Accepting a biomedical model for mental disorders in general means trying to locate and remove the underlying biopathology, even if the individual does not identify as ill. This then commits the practitioner to wide-scale medical paternalism, which is at odds with individual autonomy.

The philosophical basis of the biomedical model is Cartesian, and therein lies the root of the problem. Cartesian dualism leads to the idea of ​​the mind as a substance separate from the body: but the mind is not a machine, like the body. It works in terms of reason, so it cannot be sick as the body can. Mental illness is therefore contradictory to itself.Anti-dualists claim da umispurely physical ("the mind is the brain"). However, both sides are making a fundamental mistakeoneas a 'thing'.

Gilbert Ryle argued that the discussion of dualism is a category error. We know how to use the word "spirit" in plain language. However, in theorizing about it, we have been misled by the fact that the word "spirit" is a noun, into the assumption that it must denote a thing, a substance. One possible way to solve this problem is to return to the common meaning and use of terms. So we reveal our minds to each other in many ways (voices, facial expressions, etc.), which then leads to meaningful interactions. Ghost talk, then, talks about people by focusing on their significant interactions. This changes the terms in which we should see mental disorders. If the mind is shorthand for a whole range of meaningful interactions with other people, then a mental disorder should be seen as a deficit in those interactions. So, a mental disorder is a disorder of the entire relationship towards the world and others. And the treatment of mental disorders should be aimed at re-establishing a full range of meaningful interaction with the individual. Namely, autonomy. However, since autonomy is viewed as beinglostin the case of a mental disorder, his recovery through psychiatric treatment does not mean only following the currently expressed wishes of the patient. So we can act to restore autonomy, even overriding the patient's refusal to do so.

Ethics, research and legal framework

Bringing together legal distinctions and theoretical ethics related to the physical and mental, Genevra Richardson (Professor of Public Law, University of London) explored the relationship between ethics, mental health and the law. She asked three questions. First,legal frameworkethical management of mental health care? It's anothertrainingthis branch of medicine ethically? The third is behaviorResearchin terms of this branch of medicine ethically?

When answering the first and second questions, it is necessary (again) to pay attention to the Draft Law on Mental Health Protection and the Law on Mental Health Protection, which differ from each other in a number of points. Some certaintiesAre theyit is evident from the application of each frame: if treatment is needed for a physical disorder and there is no capacity, the Social Assistance Act must be applied; if it concerns the treatment of a mental disorder, and there is capacity and refusal, the GGZ Act can be applied. However, what happens to the treatment of mental disorders in the absence of capacity, both where the individual gives in and where he resists? If used in such situations, the Mental Health Act probably provides better protection; however, it may increase patient stigma and does not explicitly address patient 'interests' and 'advance decisions'. In addition, the WGG does not elaborate any underlying principles for its application, regarding the distinction between mental and physical disorders or the appropriate conditions for treatment without consent. Therefore, perhaps the only way to avoid discrimination in mental health care is not to treat mental disorders as legally and clinically special. Answering the third question, we can ask whether the research is focused on mental disorderseverethical. Is it ethical to conduct research within a branch of medicine that is itself governed by an unethical framework? Does such research satisfy the usual ethical requirements; or does the regulation of research ethics stifle relevant research in this area? Despite these concerns, there is a role for philosophers, lawyers and social scientists in exploring what an ethical legal framework for mental health care might look like, particularly with regard to issues of autonomy and capacity. Addressing such issues could ultimately lead to a more thoughtful legal framework for mental health care.

Mental disorders: medical conditions or social labels?

This session, introduced by Gwen Adshead (Consultant Forensic Psychotherapist, Broadmoor Hospital), began with a discussion of a question raised by Matthews, namely: Can we make a valid distinction between physical and mental illness?

The group emphasized that most physical states are at the top of the fact:value spectrum, but emphasized that even a "fact" can have its own evaluative basis. And hybrid disorders, including but not limited to mental disorders, are more open to interpretation as disorders because they clearly contain value judgments.

Values ​​were seen as part of a 'sense of self'. With some mental disorders, this can be negatively affected, but it can also be the other way around - for example, people with a personality disorder often do not feel that they have a disorder and/or do not always feel that their condition is bad. thing. Alternatively, acceptance of one's own values ​​and sense of self may invalidate any diagnosis of the disorder, as Tan suggested in another group (see below).

Some participants suggested that there is an inherent moral hierarchy to mental disorders; consequently, mental disorders have their ownownsocial tags. Personality disorder - for example, is such a stigmatizing label that patients may ask to be reclassified as 'schizophrenic', because schizophrenia is a diseaseUbecause it is a condition that is often considered medically treatable (compared to a personality disorder).

It was felt that researchers could productively explore the boundary between medical diagnosis and social label. However, the dichotomy has the most meaning and real meaning for service users who live within and across borders. Therefore, the group agreed that future research should include direct involvement of service users, particularly in relation to associated risk assessment and stigma (see also below).

Treatment and curability of mental disorders: ethics and objectivity

Mariam Fraser (Senior Lecturer in Sociology, Goldsmith's College) opened this discussion by describing her research into the first lawsuit to appear in US courts over the safety of Prozac. The case involved a certain Joseph Wesbecker who was prescribed an anti-depressant in 1989, shortly before he shot 20 of his colleagues and then killed himself. The lawsuit involved a debate over whether the makers of Prozac acted ethically and legally in the way they determined the drug's safety and effectiveness.

Fraser advocated a view of science and medicine that embraced complexity and contingency, rather than treating it as "noise" to be minimized by "objective" methods. Healing was a complex 'event' that could not be broken down into separate and autonomous parts. Complex medical conditions, like Wesbecker's, had to be approached on their own terms. While Fraser suggested that clinical trials should be abandoned in favor of unproven therapies, Fraser argued that scientific numerical data generated by clinical trials should be recognized in their specificity—that is, clinical trialsstatisticalinformation about the drug's efficacy and safety - and that its relevance outside the specialized field of clinical trials remains open. In other words, she argued that the relationship between biochemistry and mental health and disease should be understood as a question rather than a questionfromto ask Fraser drew on the work of Isabella Stengers, and in particular the concept of 'relevance', to explore the envelope of facts and values ​​against the scientific, and sometimes ethical, approaches that try to separate them.

Fraser's work is based on Isabella Stenger's concept of 'relevance'. This perspective emphasizes that facts and values ​​are intertwined, unlike ethical (and scientific) approaches that try to separate them.

The group recognized that interdisciplinary approaches may not be appropriate for the full range of ethics and mental health research questions and that, insomeareas, would have the advantage of investigating the question through a number of different empirical approaches and theoretical perspectives. Such problems may include the possibility of treatmentfrom; plus specifying various treatment goals, including bringing about physiological change, modifying attitudes, and even inducing "repentance" in the offender. These studies couldIform the basis for later interdisciplinary cooperation.

Risk assessment and management of mental disorders: techniques and ethics

George Szmukler (Dean, Institute of Psychiatry) gave a presentation on the application of risk assessment techniques in mental health, highlighting the tension between individual and public rights by referring to the mathematics of prediction.

He argued that it is difficult to predict rare events, including serious acts of violence by the mentally disturbed, while research tools for predicting such acts are highly imprecise and produce a large number of "false positives" for violence. In terms of values, the key questions are: what level of false positives in risk assessment is acceptable and who should make that decision? Ultimately, a cost-effectiveness assessment is made: the benefit is that society is supposedly protected, and the cost is that patients with mental disorders, who are already a socially excluded group, are further discriminated against.

Hence, argues Szmukler, the policies that mental health practitioners should followalreadythe patient risk assessment is both flawed and profoundly illiberal because it accepts that many will need to be detained to prevent a serious act of violence.

The question arises why they arethis onethe risk of 'dangerous persons', given that within the Venn diagram of total social violence, persons with mental disorders represent an extremely small share of the total number, so such discrimination is not only mathematically unjustified, but also ineffective as a means of risking the public.

It was generally agreed that the current practice of asking first whether someone has a mental disorder and then whether he or she poses a danger to others is the wrong approach. Instead, the primary question is: Is this person dangerous? After that, the intervention is considered and in what way,powerit depends on the state of their mental health.

Risk assessment is routinely used outside of healthcare, for example in the aviation industry. In these settings, mistakes are assumed and human vulnerability is acknowledged. Risk management systems are therefore designed to take into account the inevitability of human error. INpsychiatry, is the constant pursuit of "perfect decision making" while ignoring the benefits of risk management systems that accommodate human error and planning.¹⁰The model is therefore both potentially unethical and practically ineffective.

The group decided that justice was the most important principle in this debate; and, while therepowerin order to justify discrimination against the mentally ill, such discrimination is necessarybe justified.

Can intellectual disability be researched and if so, how?

General hospital psychiatrists and senior psychiatrists are often asked to assess whether patients with physical illness have the mental capacity to make decisions about medical treatment. Matthew Hotopf (Professor of General Hospital Psychiatry, Institute of Psychiatry) presented research using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T),¹¹showing that it is a valid measure of capacity in the UK. The study also found that disability occursoftenin the general medical context and originates from physical rather than functional mental illnesses, and that clinicians overlook many cases of disability.¹²

In another presentation, Jacinta Tan (Honorary Consultant in Child and Adolescent Psychiatry, University of Oxford) described the findings of a study examining the attitudes, values ​​and beliefs about the treatment of adolescent patients with anorexia nervosa, their parents and consultant psychiatrists. .¹³Using the MacCAT-T again, patients did well on the capacitance measure. However, most still talked about itdifficultieswhen making decisions. This disparity reflects the difference between cognitive and evaluative difficulties that contribute to disability. Tan found that some patients have the ability to think about thought processes, but that these processes themselves appear to be evidence of incapacity. This picture was in sharp contrast to Hotopf's overall hospital study, in which patients who lacked capacity did so mainly because of cognitive deficits, which again stemmed from physical rather than functional mental health problems. Tan hopes her research will contribute to a more subtle and interactive understanding of capacity.

In the discussion, some wanted to emphasize the use of the element of 'regard' (the person's situation), included in the MacCAT-T, to address the evaluative deficit in patients represented by the mismatch between the externally perceived 'fact' and the 'self'display. Others have emphasized the importance of assessing volitional disorders in patients who exhibit, for example, anorexia nervosa, substance abuse, substance dependence, and intentional self-injury.

Presumably, the research of both presenters implies that the legally required clarity in terms of clinical-ethical competence is not yet available. Tools such as the MacCAT-T can help increase the legitimacy of decisions, but these tools are limited in relation to evaluative incompetence—that is, incompetence that occurs as a result of disordered evaluation of oneself or others, as opposed to cognitive incompetence; other more value-based schemes are needed.

Overall, this research aims to clarify the concept of incompetent treatment refusal, help resolve the clinical-ethical dilemmas involving patients who often resist or refuse treatment, and provide policy solutions to address the problem of treatment refusal, given the current wide range of experts' responses to such patients.

How can empirical research reflect and inform theoretical ethics?

Another main purpose of the meeting was to focus on methodological issues as such, and in particular on the interrelationships between empiricism and theory. Tony Hope (Professor of Medical Ethics, University of Oxford) has proposed a way of looking at the relationship between theoretical and empirical ethical work, within the term 'empirical ethics'. He highlighted the uncertainty and confusion within "biomedical ethics" about the relative contributions of each. Therefore, some theorists might argue that ethics is actually philosophy and that knowledge of the real world has nothing to offer normative analysis; while some empiricists operate in ways separate from ethical theory, although they may conduct research in domains that are deeply "ethical" in nature or in their implications.

The classical model of biomedical ethics assumes a linear relationship between theory and data, within which a clinical dilemma gives rise to a real concern for medical ethics, which then results in application. However, Hope argued that a more useful view of empirical ethics would rely on a cyclical model in which ethical analysis, empirical questions, new data, and empirical studies inform each other on a continuum.

Empirical ethics must therefore be normativesometime. It should include systematic collection of empirical data, and ethical analysis should influence empirical design and vice versa.

In an accompanying presentation, Alastair Campbell (Professor of Medical Ethics, University of Bristol) refuted the idea that philosophy is irrelevant to mental health policy and practice. On the contrary, the application of rigorous moral thinking, beyond simply stated principles, and the richness of moral theory can enrich the field and add critical value.¹⁴

Big or small questions?

Some participants of the meeting believed that many of the issues discussed reflected well-known dilemmas, or "big questions", and that they remained unsolvable. It has been suggested that the focus should be on smaller frontier areas in development, such as confidentiality, screening, behavioral genetics, enhancement and direct change in brain function. Others, however, expressed concern that known problems should not or even be ignoredAre theypassed exactlybecausethey are inevitable, and often arereflectedin smaller and more specifically defined questions. The 'big questions' are also probably the most pressing concerns for patients and subjects, and new methodologies must be applied to known problems.

Policy-related research

The meeting emphasized that mental health policy is a rich source for ethical research, as illustrated by the frequent tension within policy between the pursuit of paternalism and autonomy.

However, the question of policy as such does not necessarily lead to the question of ethical research; and policy-driven ethical research can move away from the conceptual. Therefore, policy research should focus on an "ethical dilemma", for example, an ethical issue not yet addressed in legislation or an approach taken by a piece of legislationdirectionan ethical issue. Ideally, a research portfolio in this area would also include projects that are directly relevant to policyUprojects that investigate fundamental key questions, including research conducted over time and in different policy contexts. Finally, conceptual work should be linked to empirical research, if only because confronting a problem may reveal that the "problem" is often one of meaning. Therefore, communication and language research is central to this research area.

Many policies are enacted in law, and several ethical-legal topics for future research have emerged:

• exploring the interaction between the law and various legislative and ethical codes

• how, ethically, practitioners implement the Mental Health Act¹⁵

• implications of scrapping separate mental health legislation and relying on a single 'disability bill'¹⁶

• how one set of values ​​can 'outperform' another

• impact of legislation on people with mental disorders

• using public and user opinion on coercion to achieve relevant mental health law reform

• expressing values ​​in defining mental disorders in different ways through the legal system.

Defining mental disorders

Potential future areas and questions for research in this area have been identified:

• public, professional and patient constructions of mental disorders;

• patients' experiences with diagnostic and social labels;

• whether new drugs cause new diseases;

• how diagnoses change, including social and official reasons;

• approaches to defining mental disorders in different professional, social and political contexts;

• the role of personal identity in defining and diagnosing psychological disorders;

• ethical issues of diagnosis and personality posed by new technologies, for example through different forms of brain imaging;

• ways of conceptualizing mental difficulties and their impact on patients and psychiatric practice, and

• resource allocation policy in mental health care in relation to diagnosis.

Treatment of mental disorders

Research suggestions here include:

• explore what concepts of treatment and care are used by different professionals in different contexts;

• determining different goals or definitions of treatment, including effect on physiological changes, postural adaptation, and risk reduction;

• how to measure 'normal' brain function, ito changefunctions, effects on concepts of 'self' and 'improvement', compared to recovery from disability, and

• a reversal of the medical paradigm.

Risk evaluation

Suggested research topics included:

• impact of risk assessment on patients;

• costs of risk assessment for persons other than the patient;

• impact of risk assessment culture on patient consent to treatment or research;

• the impact of the 'high risk' assessment on the patient;

• how risk is embedded in policy and practice;

• possible ethical justifications for discriminatory policies and practices that benefit society at the expense of a small number of the mentally disturbed;

• alternative ways of balancing the protection of society and individual rights;

• whether policies in different policy areas reveal differences in core values;

• description of the language of risk and the social basis of risk aversion;

• is assertive behavior in the community ethical and

• the role and methods of risk assessment experts targeting legal decision-making by criminal and mental health courts.

Capacity

Much research on the ethics of mental disorders currently focuses on the definition and operation of capacity. However, the results of this study appear to translate poorly into policy and practice, and many clinicians are still unsure how to use the concept in different settings. Even in the US, where statutes are often appliedbasedin the field of capacity assessment, such statutes have arguably had little impact, as patients with mental disorders continue to experience greater violations of their human rights than patients with physical disorders. Valuable research could therefore focus on how often and how people with mental disorders are coerced into treatment compared to people with physical disorders. Also developing is the field of research dealing with 'coercion' in mental health care.^17,18,19

Other possible research topics included:

• autonomy and self-concepts;

• disability assessment as a supplement to the MacCAT-T;

• the concept and understanding of 'evaluation' within MacCAT-T;

• increase capacity;

• longitudinal studies that examine capacity and importance over time, and

• fluctuating capacity studies.

method

The meeting emphasized that biomedical ethics research is not necessarily limited to one discipline and that it is likely to benefit from aunderdisciplinary approach within the increasingly better understood relationship between theoretical and empirical methods.

The group examined how different disciplines understand 'ethics' as a subject of research. It became clear that mutual misunderstanding between disciplines is common and that for interdisciplinarity to really work, understanding of each discipline by the others must precede collaboration—that is, interdisciplinarity is not additive, but interactive.

Much discussion has focused on ethical analysis, its limitations, and its relationship to empirical research. Some have argued that theoretical analysis is diverse and that empirical studies can sometimes be inconsistent with a particular ethical analysis, raising further questions for empirical study and/or theoretical analysis. However, rather than being seen as in conflict with Hope's model, such diversity can be incorporated into the cycle of empirical ethical research, and if the empirical data are inconsistent with ethical analysis, this in turn can stimulate further productive research.

A comparison has emerged between 'bottom-up' and 'top-down' approaches to empirical ethics. This reflected the natural tendency of conflict between theorists and empiricists. Thus, philosophers were mainly researchers of ethical theory looking for an example; while empirical scientists were inclined to take examples from "empirical domains" and conduct research based on their own conception of ethics and special methodology. However, the beginnings of a resolution of this conflict emerged as participants agreed that whatever research method was used, whether theoretical or empirical, ethical research should focus on the 'itch' (that is, there should be a normative question that 'burdens' Explorer); and that scratching can work within different methodological frameworks. Theabsencehowever, the "itch" of a particular research project implied that it amounted to descriptive research, althoughrelevantto the ethical consideration of a certain 'itch'.

Competing interests: NE chairs the Wellcome Trust's Biomedical Ethics Funding Committee. BS is an employee of the Wellcome Trust.

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