Euthanasia and assisted suicide for psychiatric disorders

This chapter discusses reasons for and against euthanasia and physician-assisted suicide for patients with treatment-resistant depression or other psychiatric disorders. Although these actions may seem anathema to the goal of treating psychiatric patients in order to prevent suicide, there may be cases in which it would be permissible to bring about or assist in the death of a person with one of these disorders. The permissibility of these actions depends on four conditions. First, the patient must be competent enough to weigh the reasons for and against euthanasia and assisted suicide. Second, the patient must make an informed and persistent request for it. Third, the suffering the patient experiences from the disorder must be unbearable and interminable. Fourth, the disorder must be resistant to all indicated treatments given to the patient over many years. There must be a reasonable limit to the time a patient could be expected to wait for a possible treatment that might relieve symptoms. Any right to euthanasia or assisted suicide entails at most a permission and not an obligation for a physician to perform these actions.

Psychiatric neurosurgery

This chapter discusses functional neurosurgery designed to modulate dysfunctional neural circuits mediating sensorimotor, cognitive, emotional, and volitional capacities. The chapter assesses the comparative benefits and risks of neural ablation and deep brain stimulation as the two most invasive forms of neuromodulation. It discusses the question of whether individuals with a severe or moderately severe psychiatric disorder have enough cognitive and emotional capacity to weigh reasons for and against ablation or deep brain stimulation and give informed consent to undergo it. The chapter also discusses the obligations of investigators conducting these trials to research subjects. In addition, it examines the medical and ethical justification for a sham control arm in psychiatric neurosurgery clinical trials. It considers the therapeutic potential of optogenetics as a novel form of neuromodulation. The fact that this technique manipulates both genetic material and neural circuits and has been tested only in animal models makes it unclear what its benefit–risk ratio would be. The chapter concludes with a brief discussion of the potential of neuromodulation to stimulate endogenous repair and growth mechanisms in the brain.

Disorders of consciousness, memory, and will

This chapter examines major psychiatric disorders as disorders of consciousness, memory, and will. All of these disorders involve disturbances in how the brain processes and integrates information about the body and external world. Distorted mental content in these psychopathologies impairs the capacity to consider different action plans, and to form and execute particular plans in particular actions. Dysfunctional mental states correlating with dysfunctional neural states impair the capacity for flexible behavior and adaptability to the environment. This dysfunction also impairs the capacity for insight into a psychiatric disorder and understanding the need for and motivation to seek treatment.

Treating psychiatric disorders: Less invasive and noninvasive interventions

This chapter analyzes and discusses different types of psychopharmacology. It examines the view that the monoamine hypothesis to explain and treat psychiatric disorders may be mistaken and considers alternative hypotheses. It also questions the distinction between noninvasive and invasive treatments in psychiatry, pointing out that some presumably noninvasive treatments are invasive because they can cause changes in the brain. The chapter discusses the potential benefits, risks and limitations of electroconvulsive therapy, transcranial magnetic stimulation, and transcranial current stimulation. Placebos and neurofeedback are distinct from these interventions because they do not involve psychotropic drugs or neurostimulation. With a view to potential future therapies, the chapter considers novel neuromodulating techniques such as temporal interference.

A paradigm for psychiatry

This chapter examines the idea that psychiatric disorders are disorders of the brain, mind, and the person’s relation to the world. The etiology, pathophysiology, and symptomatology of these disorders are influenced by interactions between the brain, mind, immune and endocrine systems, and the person’s relation to the environment. A biopsychosocial model provides the best account of the development of these disorders and a guide for research and treatment. The chapter also discusses some of the merits and limitations of the symptom-based DSM-5 and the more recent circuit-based RDoC, and defends the view that they can be complementary models in a paradigm for psychiatry research and clinical practice. The chapter defends nonreductive materialism as the theory best able to account for the different dimensions of the brain–mind relation in psychiatry.

Introduction

This Introduction describes the book as an analysis and discussion of questions at the intersection of psychiatry, philosophy and law that have arisen from advances in psychiatric research and practice in the last 30 years. After pointing out the extent to which mental illness constitutes the global burden of disease, it outlines a paradigm for major psychiatric conditions as diseases of the brain and mind consisting in a biopsychosocial model in which the DSM-5 and RDoC are complementary frameworks. The Introduction explains psychiatric disorders as disorders of consciousness, memory and will, examines invasive and non-invasive treatments for them, how these treatments affect autonomous agency and the obligations of researchers to subjects participating in psychiatric research. In addition, it explores ethical and legal issues in brain interventions for psychopathy, arguments for and against euthanasia and assisted suicide for psychiatric disorders and how to prevent them.

Prediction and prevention

This chapter considers reasons for and against intervening with psychotropic drugs during the prodromal phase of disease. It also discusses how the identification of biomarkers for psychiatric disorders in childhood or adolescence might predict who would be at risk of developing these disorders. Biomarkers could indicate which interventions could reduce this risk or eliminate it altogether. But there are questions about their predictive value. Abnormal neuroimmune and neuroendocrine interactions may disrupt normal rates of synaptic pruning and myelination in childhood and adolescence and increase the risk of schizophrenia and other disorders with an onset in adolescence or early adulthood. Immune-modulating drugs could reverse this process, but require careful weighing of potential benefits and risks. The chapter also discusses different interventions before birth that might prevent people from having a psychiatric disorder after birth.

Epilogue: Psychiatry, neuroscience, philosophy

This Epilogue summarizes the main points of the book's eight chapters. It emphasizes a biopsychosocial model for understanding, treating and possibly psychiatric disorders. It also points out that major forms of mental illness are disorders of this brain as well as disorders of the mind and the person relations to others and the world. Advances in neuroscience may lead to better explanations of the pathophysiology of psychiatric disorders and their philosophical implications. But these advances may not completely account for the experience of living with these disorders. Given the global burden of disease from mental illness, it should receive priority in medical research over other types of disease to improve the quality of life of the people affected by it.

Intervening in the psychopath’s brain

This chapter discusses whether pharmacological intervention in the brains of criminal psychopaths to modify and enable them to control their behavior could be justified as an alternative to continued incarceration. It also considers the question of whether treatment designed to rehabilitate the offender following release from prison could be forced on him against his wishes and whether it would violate his cognitive liberty. The chapter examines the connection between psychiatric disorders and mental integrity and whether mental impairment can weaken the presumed right to noninterference in the brain. It also considers whether direct brain interventions could be justified in adolescents with risk factors for criminal psychopathy. The key issue is weighing the interests and rights of the offender against the interest of society in preventing recidivism and protecting the public from harm.

Neuromodulation: Control, identity, and justice

This chapter addresses concerns that people with devices in their brains regulating neural and mental functions are not in control of their thoughts and actions. It defends the view that, by restoring motor and mental capacities, deep brain stimulation enables autonomous agency that has been impaired or undermined by a psychiatric disorder. There is shared control between the person and the device. Neuromodulation does not necessarily cause substantial changes in a person’s mental states and alter her identity. Rather than disrupting psychological connectedness and continuity, deep brain stimulation and other techniques can re-establish these relations and return the patient to her premorbid self. In some cases, symptom relief may result in significant personality changes. The chapter also considers social justice issues regarding access to neuromodulating devices.