Care and the self: biotechnology,reproduction, and the good life

This paper explores a novel philosophy of ethical care in the face of burgeoning biomedical technologies. I respond to a serious challenge facing traditional bioethics with its roots in analytic philosophy. The hallmarks of these traditional approaches are reason and autonomy, founded on a belief in the liberal humanist subject. In recent years, however, there have been mounting challenges to this view of human subjectivity, emerging from poststructuralist critiques, such as Michel Foucault's, but increasingly also as a result of advances in biotechnology itself. In the face of these developments, I argue that the theoretical relevance and practical application of mainstream bioethics is increasingly under strain. Traditionalists will undoubtedly resist. Together, professional philosopher-bioethicists, public health policymakers, and the global commercial healthcare industry tend to respond conservatively by shoring up the liberal humanist subject as the foundation for medical ethics and consumer decision-making, appealing to the familiar tropes of reason, autonomy, and freedom.     

Theories of Practical Reason

Leading theories of practical reason can be grouped into one of four families: psychologism, realism, compatibilism, and Aristotelianism. Although there are many differences among the theories within each family, I ignore these in order to ask which family is most likely to deliver a satisfactory philosophical account of reasons for action. I articulate three requirements we should expect any adequate theory of practical reason to meet: it should account for (1) how reasons explain action, (2) how reasons justify action, and (3) how an agent can act for the reason that justifies her action. Only the Aristotelian theory, however, can meet all three requirements. It avoids the problems that plague the other theories by grounding reasons neither in psychological states nor in facts totally independent of the agent in question, but in the nature of the kind of creature the agent is. Our explanations of action need descend to the biographical only when explaining why a human being does not act in ways characteristic of her kind. The Aristotelian view of practical reason, then, appears to be the most promising program for future work.     

A social relational critique of the biomedical definition and treatment of ADHD; ethical practical and political implications

Attention deficit hyperactivity disorder (ADHD), its existence and treatment, is a contentious matter. The dominant view in medicine considers that ADHD is a psychiatric disorder. My position is to challenge this from a social relational orientation. I explore here a critique of the psychiatric disease model of causation and treatment, particularly the use of medication. A series of prejudices based on a political and social constructionist orientation are offered to address the ethics, politics and practice implications of the practitioner critical of the biomedical model of diagnosis and treatment especially the use of medication. This device is employed in order to invite critical reflection and further debate in a field dominated by the medical and genetic arguments in support of ADHD as a psychiatric disease. The implications of more open debate are explored, together with directions for more politically and ethically informed practice with children and their families.     

Ambulante Psychotherapie in Deutschland aus Sicht der Patienten

This study analyzed the provision of outpatient psychotherapy services in Germany in typical practice settings. In a representative survey (from June 2008 to September 2009) 1,212 subjects who received outpatient psychotherapy during the past 6 years were questioned about their experiences with outpatient psychotherapy via telephone interviews. Socio-economic data, reasons for seeking treatment, access paths, financial resources and psychosocial support data were collected. Therapeutic settings and modalities and concomitant medication treatment are described. The findings illustrate the problem of multiple psychiatric morbidity in the clinical practice and confirm the urgent need for patient access to professional psychotherapeutic services. Improving access to these services requires close cooperation between care providers.     

Motivation as an epistemic ground

In several papers, Mark Wrathall argued that French phenomenologist, Maurice Merleau-Ponty, identifies a sui generis type of grounding, one not reducible to reason or natural causality. Following the Phenomenological tradition, Merleau-Ponty called this form of grounding “motivation,” and described it as the way in which one phenomenon spontaneously gives rise to another through its sense. While Wrathall’s suggestion has been taken up in the practical domain, its epistemic import has still not been fully explored. I would like to take up the epistemic dimension of Wrathall’s thought in this paper. Following Wrathall, I explain how motivation can help us understand the manner in which perceptions ground singular, experiential judgments. But I extend this work in two ways. First, I suggest some additional considerations that support Wrathall’s view. Second, I argue that motivation can also help account for the way perceptions ground general judgments. My aim here will not be so much to rule out other answers to these longstanding epistemological questions, as to show that motivation carves out an attractive epistemological space.

     

Systemische Therapien bei Menschen mit psychotischen Verhaltens- und Erlebnisweisen

Systemic therapy for persons who have been diagnosed as having schizophrenic or schizoaffective psychosis has been practiced since the 1950s, not everywhere and routinely but in many psychiatric hospitals and outpatient clinics with a strong psychosocial orientation. Evidence of the effectiveness is well documented in randomized controlled studies. This article describes three systemic approaches in which the authors are actively involved: (1) systemic constructivist family therapy developed in Heidelberg for outpatient contexts, (2) need-adapted treatment and open dialogue developed in northern Europe that has gained access to psychiatric clinics through regional training within integrated care projects and (3) the concept of systemic therapeutic methods of acute psychiatric treatment (SYMPA) a systemic family-oriented inpatient treatment.     

Reasons for Actions and Desires

It is an assumption common to many theories of rationality that allpractical reasons are based on a person's given desires. I shall callany approach to practical reasons which accepts this assumption a `Humean approach'.In spite of many criticisms, the Humean approach has numerous followers who take it to be the natural and inevitable view of practical reason. I will develop an argument against the Humean view aimingto explain its appeal, as well as to expose its mistake. I focus on just one argument in favour of the Humean approach, which I believe can be constructed as the background idea of many Humean accounts: the argument from motivation.I first present the argument from motivation and explain why it seems so compelling. However, I then develop an equally compellingobjection to desire-based approaches to reason, showing that they cannot accommodate the justificatory role of reasons. I show that this objection suggests that at least one of the premises of the argument from motivation must be false. And, finally, I argue thatwe should reject the premise that claims that only desires can explain actions. This result is fatal for desire-based views of practical reason. My conclusion is that practical reasons should be based not on desires, but on values.     

Health (care) and human rights: a fundamental conditions approach

Many international declarations state that human beings have a human right to health care. However, is there a human right to health care? What grounds this right, and who has the corresponding duties to promote this right? Elsewhere, I have argued that human beings have human rights to the fundamental conditions for pursuing a good life. Drawing on this fundamental conditions approach of human rights, I offer a novel way of grounding a human right to health care.     

Military psychology in the age of managed care: The Wilford Hall model

Military medicine is currently being overhauled through Tricare, a comprehensive, managed care program designed to reduce costs and increase clients' access to health care. This article presents reforms initiated by the psychologists at Wilford Hall Medical Center, the largest military hospital in the world, in response to Tricare. These reforms have resulted in adult, outpatient services that are immediately accessible, effective, and cost efficient. The Wilford Hall approach to psychological services is offered as model that can be used in other outpatient settings. Additionally, potential limitations of this approach to psychological care are presented.     

COHERENTISM AND THE EPISTEMIC JUSTIFICATION OF MORAL BELIEFS: A CASE STUDY IN HOW TO DO PRACTICAL ETHICS WITHOUT APPEAL TO A MORAL THEORY

This paper defends a coherentist approach to moral epistemology. In “The Immorality of Eating Meat” (2000), I offer a coherentist consistency argument to show that our own beliefs rationally commit us to the immorality of eating meat. Elsewhere, I use our own beliefs as premises to argue that we have positive duties to assist the poor (2004) and to argue that biomedical animal experimentation is wrong (2012). The present paper explores whether this consistency‐based coherentist approach of grounding particular moral judgments on beliefs we already hold, with no appeal to moral theory, is a legitimate way of doing practical ethics. I argue (i) that grounding particular moral judgments on our core moral convictions and other core nonmoral beliefs is a legitimate way to justify moral judgments, (ii) that these moral judgments possess as much epistemic justification and have as much claim to objectivity as moral judgments grounded on particular ethical theories, and (iii) that this internalistic coherentist method of grounding moral judgments is more likely to result in behavioral guidance than traditional theory‐based approaches to practical ethics. By way of illustrating the approach, I briefly recapitulate my consistency‐based argument for ethical vegetarianism. I then defend the coherentist approach implicit in the argument against a number of potentially fatal metatheoretical attacks.     

John W. Hinckley, Jr.: A Case of Narcissistic Personality Disorder

This article is about John W. Hinckley, Jr., whose attempt to assassinate President Ronald Reagan on March 30, 1981 was unsuccessful and whose trial in 1982 resulted in a verdict of not guilty by reason of insanity. It focuses on the view of psychiatric experts that he has a narcissistic personality disorder and on the fact that this diagnosis is the primary rationale for his continuing confinement to St. Elizabeth’s Hospital in Washington, D.C. I conclude that the question of his release raises the difficult issue of the possible conflict between justice and care.     

A Feminist Ethic and the New Romanticism Mothering as a Model of Moral Relations

This paper claims that recent attempts to draw on the maternal experiences of women in order to articulate an ethic of care and compassion is a new romanticism. Like earlier romantic views, it is both attractive and potentially dangerous. The paper examines the basic claims of this new romanticism in order to identify both its strengths and weaknesses. I conclude that there are at least two versions of this new romanticism, one that relies primarily on the experiences of child-bearing in grounding” an ethic of care and compassion, and a second that relies primarily on child-rearing. I suggest that the former version of the new romanticism is deeply flawed be-cause such a view ought to be unacceptable to women and will be inaccessible to men.     

Contractualism,Person-Affecting Wrongness and the Non-identity Problem

A number of theorists have argued that Scanlon's contractualist theory both "gets around" and "solves" the non-identity problem. They argue that it gets around the problem because hypothetical deliberation on general moral principles excludes the considerations that lead to the problem. They argue that it solves the problem because violating a contractualist moral principle in one's treatment of another wrongs that particular other, grounding a person-affecting moral claim. In this paper, I agree with the first claim but note that all it shows is that the act is impersonally wrong. I then dispute the second claim. On Scanlon's contractualist view, one wrongs a particular other if one treats the other in a way that is unjustifiable to that other on reasons she could not reasonably reject. We should think of person-affecting wronging in terms of the reasons had by the actual agent and the actual person affected by the agent's action. In non-identity cases, interpersonal justifiability is therefore shaped both by the reason to reject the treatment provided by the bad suffered and the reason to affirm the treatment provided by the goods had as a result of existing. I argue it would be reasonable for the actual person to find the treatment justifiable, and so I conclude that Scanlon's contractualist metaethics does not provide a narrow person-affecting solution to the non-identity problem on its own terms. I conclude that the two claims represent a tension within Scanlon's contractualist theory itself.     

An Auto‐Ethnographic Study of “Open Dialogue”: The Illumination of Snow

This auto‐ethnographic study describes the changes in the author's thinking and clinical work connected to her first‐hand experience of Open Dialogue, which is an innovative, psychosocial approach to severe psychiatric crises developed in Tornio, Finland. In charting this trajectory, there is an emphasis on three interrelated themes: the micropolitics of U.S. managed mental health care; the practice of “dialogicality” in Open Dialogue; and the historical, cultural, and scientific shifts that are encouraging the adaptation of Open Dialogue in the United States. The work of Gregory Bateson provides a conceptual framework that makes sense of the author's experience and the larger trends. The study portrays and underscores how family and network practices are essential to responding to psychiatric crises and should not be abandoned in favor of a reductionist, biomedical model.     

Grounding Nominalism

The notion of grounding has gained increasing acceptance among metaphysicians in recent years. In this paper, I argue that this notion can be used to formulate a very attractive version of (property) nominalism, a view that I call ‘grounding nominalism’. Simplifying somewhat, this is the view that all properties are grounded in things. I argue that this view is coherent and has a decisive advantage over competing versions of nominalism: it allows us to accept properties as real, while fully accommodating nominalist intuitions. Finally, I defend grounding nominalism against several seemingly troublesome objections.     

Kantian Ethics: After Darwin

In this article I reevaluate Immanuel Kant's moral philosophy from a post–Darwinian perspective. Taking an evolutionary approach to human reasoning and incorporating some recent work on the science of the emotions, I argue that the Kantian bifurcation of reason and emotion, which underlies his moral philosophy, is no longer tenable. Kant's practical defense of his ethics as being the only option that can save morality from the dangers posed by naturalism is also considered and rejected. Instead, I argue that an evolutionary view of reason and emotion can provide an adequate ground for morality and explore the possibility and advantages of such an ethics.     

Theoretical and practical aspects of position and function of the outpatient department in the sectored psychiatric care system

After discussion of the sectoring scheme, its advantages and the necessity for its realisation, important tasks of the sectored outpatient department are described. These include the mediating function of the OPD between local authorities and the whole psychiatric care system, concerns of early rehabilitation (Volovik) and psychotherapy, basic organisational and structural conditions of outpatient services, public relation activities, and continued training, co-operation with other authorities the necessary uniting of special outpatient department and psychiatric advisory centre.     

Truthmaking and Grounding

Abstract

This paper is concerned with the relation between two important metaphysical notions, ‘truthmaking’ and ‘grounding’. I begin by considering various ways in which truthmaking could be explicated in terms of grounding, noting both strengths and weaknesses of these analyses. I go on to articulate a problem for any attempt to analyze truthmaking in terms of a generic and primitive notion of grounding based on differences we find among examples of grounding. Finally, I outline a more complex view of how truthmaking and grounding could relate. On the view explored, truthmaking is a species of grounding differentiated from other species of grounding by the unique form of dependence it involves.     

Social construction: big-G grounding,small-g realization

The goal of this paper is to make headway on a metaphysics of social construction. In recent work (forthcoming), I’ve argued that social construction should be understood in terms of metaphysical grounding. However, I agree with grounding skeptics like Wilson (Inquiry 1–45, 2014) that bare claims about what grounds what are insufficient for capturing, with fine enough grain, metaphysical dependence structures. To that end, I develop a view on which the social construction of human social kinds (e.g., race) is a kind of realization relation. Social kinds, I argue, are multiply realizable kinds. I depart from the Wilson by further arguing that an appeal to grounding is not otiose when it comes to social construction. Social construction, I claim, belongs to the “big-G” Grounding genus, but it is the specific “small-g” relation of realization at work in cases of human kind social construction.     

Predictors and Outcomes of Psychiatric Hospitalization in Youth Presenting to the Emergency Department with Suicidality

Youth suicide attempters presenting to the emergency department (ED) are frequently admitted to psychiatric inpatient hospitals, yet little is known about how clinicians decide which youths to admit versus discharge to outpatient care. We examine predictors of inpatient hospitalization and describe service use outcomes associated with hospitalization in 181 youths drawn from consecutive ED admissions for suicidality. Predictors of hospitalization include ED site, suicide plan, and parent report of problems. Hospitalization was associated with improved linkage to outpatient treatment and more intensive service use. Future research is needed to understand the best service delivery and treatments for these high‐risk youth.