Abstract
Traditionally, philosophy has been regarded as operating at a level above practical application. However, the discipline can offer mental health policy and practice some valuable aid. First, its logical rigour can help to clarify concepts and expose inconsistency and prejudice; second, its wealth of theory about morality can enrich the concepts that guide mental health practice. By avoiding simplistic solutions (such as reliance on the ‘four principles’ of biomedical ethics) those who turn to the discipline of philosophy may learn how to be more critical of accepted policies and practices.
The idea that philosophy can help in any practical sense is heresy in some philosophical quarters. On this view, the moment you seek to use philosophy to get solutions to practical problems you corrupt its essential nature; for, philosophy is essentially analytical, critical and inconclusive. Its task is to open up new and unexpected questions, to question unexamined assumptions – above all to debate and to allow diversity of view. Such a discipline cannot genuinely provide guidance to legislators, policy-makers or practitioners. Although I have some sympathy with this view, I think it oversimplifies the task of philosophy and underrates its value to practical life and social policy. In this brief paper, I shall consider two aspects of the usefulness of philosophy: first, its rigorous commitment to logical argument; second, its offering of fresh insights through conceptual and theoretical richness and diversity.
Philosophical method
Philosophical argument depends on some basic rules of valid reasoning: coherence, consistency and clarity in the use of terms. These are exceedingly useful in a practical sense. They are defences against prejudice, bigotry and sophistry. They demand of any person promoting a point of view that she is honest about the assumptions upon which it is based, consistent in her application of her assumptions across a range of issues, open to alternative viewpoints and willing to justify or change her assumptions if challenged. All thismakes philosophy very useful to mental health policy making and practice, not because it offers solutions to some of its dilemmas, but because it demands coherence and honesty in the arguments used to defend specific policies and procedures.
I shall now try to show how philosophy can be helpful by applying these rules of reasoning to some concepts and controversies in mental health. I shall look at dangerousness, responsibility and treatability.
Dangerousness
The criterion of harm to self or others is central to legislation justifying intervention in the life of another on the grounds of mental illness. In the public mind the notion of the ‘dangerous lunatic’ seems a fixed idea, fuelled by sensationalist reports in the press, when a person with some kind of psychiatric disorder commits a violent crime. But so far as harm to others is concerned the statistics show that only a tiny minority of such crimes is committed by people with clear mental illness. The vast majority occur in domestic situations in which mental illness is not an issue or in the course of criminal offences, in which the offenders appear perfectly sane. Harm to self is far more commonly associated with mental illness, but again there are many examples of self-harm and suicide in which we cannot identify a specific illness (unless we take attempted suicide as itself the definition of mental illness). Eating disorders add still more conceptual difficulties, because they are potentially lethal, yet do not fit easily into the notion of mental illness.
So far as harm to others is concerned, there seems to be an urgent need for further conceptual work on the concept of dangerousness, especially as this relates to attempts to diagnose personality disorders, which predispose a person to violence. The huge debate over the idea of preventative detention provoked by recent UK proposals for legislative reform shows how far removed political response to public pressure and prejudice is from professional assessment of what constitutes a reason for detention (for the text of the Bill, see http://www.dh.gov.uk/Home/fs/en). Issues of consistency arise here: for example, we know that most fatal road accidents are caused by young men – so in order to prevent harm, should we refuse to issue licences to this group, say until the age of 25? Another example would be the sorry statistic that most child abusers have themselves been abused in childhood, so should we seek to prevent such people caring for children, whether their own or others? Such examples of inconsistency in social policy illustrate the point that public prejudice rather than reasoned justificationmay lie behind some moves for mental health policy change.
In the case of self-harm, the ghost of John Stuart Mill still haunts us! Mill's robust defence of liberty led him to want to restrict the freedom of individuals to act only to those actions that threatened others [1]. But, it may be argued, people in the grip of a depressive illness are not genuinely choosing self-harm – their actions are determined by their illness, not by their own free choice. This is no doubt often true, but what are the limits to this judgement that the person is not free? What if the illness itself proves to be untreatable, or treatable only by the most extreme measures – is it not competent for a person to choose death rather than the recurrence of such misery? We already accept such choices in the case of refusal of treatment in extreme physical situations, so why refuse the same choice to a person with mental illness, if that choice is made at times of mental lucidity? No answers to this question come from philosophy, but its method of analysis seeks coherence of conclusions derived from assumptions about the human right to self-determination.
Responsibility
This leads me to the next tricky area in conceptual analysis of responsibility in mental illness. Philosophy has struggled for centuries over the paradoxes of free will and determinism, and medical ethics more recently over questions of mental competence or incompetence. We need to accept that when it comes to ‘mental causation’ we are always going to be talking about degrees of freedom and responsibility, never about some on/off distinction. This has been acknowledged in the courts in the case of the psychiatric patient who refused a potentially life saving amputation [2]. The judge held that the mere fact that he was diagnosed as mentally ill did not in itself invalidate his competence to decide in this case and he allowed the refusal, even though the reasons given were related to his delusional beliefs. This illustrates a broad matter of principle when we are talking about who should take responsibility for decisions or actions. This principle is that the burden of proof must lie in proving a person incompetent. Moreover, competence/incompetence must not be judged globally, but rather should be always judged in relation to specific decisions in specific situations. Thus, the question of whether ‘the balance of his mind was disturbed’ is always case specific.
A second very important consideration is that the removal of responsibility or self-determination can itself have a detrimental effect on the person's capacity for autonomous decision-making. (This is the well-researched phenomenon of institutionalization [3].) The opposite is also true – that the interaction between agents itself enhances autonomy and self-determination. In the memorable language of Martin Buber, treating a person as a ‘thou’ rather than an ‘it’, itself develops personhood [4]. These considerations have profound implications for the nature of psychiatric treatment and for the tension between custody and therapy.
Treatability
And so we come to my final problematic concept – treatability. What do we mean when we say there is a ‘treatment’ or ‘cure’ for mental illness? This is no idle question, for, if we insist on incarceration but can offer no therapy, we are in effect delivering a life sentence to some individuals. Perhaps, this is justifiable in some cases – this could be debated – but our uncertainty demonstrates how central the notion of treatability has to be in any discussion of mental health policy. The problem is that conceptual debate rages over how we define health, illness and disease (I am thinking of the valuable work of Lennart Nordenfelt and Bill Fulford on this topic [5], [6].) To what extent, if any, is the concept of disease an objective concept? In the mental health field especially, how do we define ‘normal’? Faced with these puzzles, the usual thing is to resort to practical criteria, related both to prevention of harm (as discussed earlier) and to functionality. So, treatment would restore a range of normal functions – lieben und arbeiten, as Freud put it.
This does not solve all the puzzles, however. What of the eccentric person who lives unconventionally – I am thinking of the lady who lived in a car in a suburban street for many years (tolerated it seems by the residents). Was she mentally ill, if this is how she preferred to live and she caused no real harm to anybody? A more serious case, I believe, is that of cyclothymic disorder (manic– depressive illness). Those with this illness feel more truly ‘themselves’ when they are slightly manic, and so many have great difficulty complying with the treatment regimen, because it flattens out the highs and lows. To add to the problem, people with this disorder are often highly creative in their high periods. So, what is cure? What is the right treatment? Can, should, a person choose to avoid treatment on the grounds that his true identity rests in what is perceived as a diseased state? Interestingly, we have begun to accept the relativity of disease or disability categorizations in the cases of physical disability, for example, the notion of the deaf world as a reality of equal value to the hearing world. Should we also recognize some ‘mad worlds’ as alternative realities?
Philosophical theory
More briefly, I want to discuss the place of theory in philosophical ethics. Here, the term ‘meta-ethics’ is sometimes used for the attempt to analyse the range of what we recognize as moral beliefs and judgements in order to systematize them in a normative theory of ethics. Classical forms of such meta-ethical theory are virtue ethics, consequentialism and various types of duty-based theory (sometimes referred to as deontological theory).
The essential thing, if we want to respect the true nature of philosophy, is to recognize that there is no single ‘knockdown’ theory, nor is there ever likely to be. Instead we have a lively debate between theories, which has gone on for centuries, and no doubt will continue. In Biomedical Ethics there has been an attempt by Beauchamp and Childress [7] to provide some kind of overarching framework, in the form of four principles, by means of which we can structure ethical discussion. In itself, this proposal is relatively harmless – it may serve to provide a common area for debate. But the four-principles approach has been widely misunderstood as providing a formula by which ethical dilemmas inmedicine can be ‘solved’. This is far from the authors' intention, but it is a hardly surprising misunderstanding, when most of medical education consists of readily memorized formulae for dealing with clinical uncertainty. (The four-principles approach can be seen as a kind of aid to differential diagnosis in the ethical field!)
As an antidote to this kind of oversimplification of theory, we need to remember that philosophy is not a descriptive science, and that it does not offer straightforward solutions. Rather, it opens up new ways of thinking. So, it is the diversity of ethical theory that gives the discipline its strength. The process is one of trying a range of theoretical analyses – for example, contrasting a utilitarian analysis of justified detention and treatment with a human rights approach – and then finding them both challenged by communitarian or virtue ethics approaches. This fresh air of philosophical debate is what gives philosophy its value.
Conclusion
My aim in this short paper has been to stimulate debate about the usefulness of philosophical analysis. I have claimed that its utility for psychiatric practice is twofold: (i) it insists on reasoned discussion; and (ii) it widens, through theoretical debate, the horizons of our conceptualization. This may seem like thin gruel indeed, but, if we are honest, it is all that is on offer from a discipline, which has its own integrity to maintain, in the face of demands for relevance and practical application. The view espoused by Socrates that the unexamined life is not worth living [8] must remain the only defence that philosophy really has to offer.