The idea of ‘self’ is difficult to define but represents a set of ideas, representations and beliefs that are held about what it is to be a person.  As psychiatry is a subject concerned with thoughts, feelings, behaviours and relationships, how people view themselves and the accompanying attitudes of psychiatrists to this (our ‘gaze’) are central to its execution.  In Western cultures, we overwhelmingly choose to define ourselves in terms of our individual direction and achievements.  This orientation is often portrayed as an objective truth, but is in fact simply an extremely powerful cultural construction.

Construction or not, individualistic ideology has had a substantial influence on thinking about mental distress.  Psychiatrists have based much of their work on individualistic notions which as a consequence assume that emotional problems can be studied and understood separately from any other context.  When seeking to diagnose an individual as having a mental health disorder, current classification systems, when rigidly interpreted, require no consideration to be given to circumstances beyond a patient’s psychopathology.  Forms of emotional distress are then defined in terms of disordered individual experience and social and cultural factors are seen as secondary and may or may not be taken into account.

This approach sits ill at ease alongside patient experience.  The lives of people with mental health problems have often been very eventful, and normally not in a good way.  The message that life stories are largely irrelevant is then not always popular.  Gail A. Hornstein writes in OpenMind on this subject (link no longer available):

Many patients feel deeply wounded by the assumption that madness has no link to life experience. As Jacqui Dillon, Chair of the National Hearing Voices Network, England, said at a recent conference, “Pathologising the experience of people like me, who have suffered terrible trauma, only adds insult to injury and protects those who have abused us. Instead of asking, what’s wrong with you? people should ask, what’s happened to you?”

Our individualistic beliefs are understandable.  They are welcomed by some patients as they allow entry to the sick role and it can be comforting to regard suffering as something separable from the self and which for amelioration can be passed over to an expert.  It would also be strange if psychiatry had been immune to this central tenet of capitalist societies and the approach also proves expedient to research, where individual phenomena can be captured by way of surveys and rating scales.

However as a profession with regards to this, I would hope that we could, collectively, be more ‘self aware’.  This is not to suggest that mental health professionals are deliberately ignoring patients’ stories, that they are bad people, or even that mental health systems have been purposely set up in order to ignore the needs of vulnerable groups but it is interesting how dominant and rarely questioned ideas and discourses can work to render us blind to systemic inconsistencies and inadequacies.

The current paradigm allows the social and ideological origins of distress to be ignored and its implications side-stepped.  Our helpful – but not too helpful – approach makes possible the propagation of mental health services, who are actually supported by a fragmented and individualistic society.

In order to be truly transformative, mental health services would then need to be honest about the social, political and ideological conditions that often lead to mental distress.  Alas even if this were to magically happen, our message would be lost unless there was a corresponding move in greater society toward a value system where people seek satisfaction more from helping others rather than pursuing private advantage.

Proper leadership, that’s what we need.


Interesting link:

Individualism – Wikipedia


Addendum 10 September 2009

Here’s an interesting paragraph from Richard Bentall’s Madness Explained

When constructing the self, the child internalizes historically and culturally determined values.  It is therefore possible that the self as known to people of the past may have been quite different from the self as known to people living in the modern world.  Roy Baumeister has argued that for medieval Europeans, the self was relatively transparent, and was equated with visible manifestations and actions.  As life on earth was, at that time, believed to be a preamble to eternal bliss, there was no need to search for self fulfilment.  In modern Western societies, in contrast, the self is often viewed as a hidden territory that can only be known with difficulty, but which must be explored (perhaps with the technical assistance of a psychotherapist) if its special talents are to be fostered and self-actualization achieved.

Also from Psychiatric imperialism: The medicalisation of modern living by Joanna Moncrieff (link no longer available)

The medical model of mental illness has facilitated the move towards greater restriction by cloaking it under the mantle of treatment. This process of medicalisation of deviant behaviour conceals complex political issues about the tolerance of diversity, the control of disruptive behaviour and the management of dependency. It enables a society that professes liberal values and individualism to impose and reinforce conformity. It disguises the economics of a system in which human labour is valued only for the profit it can generate, marginalising all those who are not fit or not willing to be so exploited.

(this one makes more sense if you read the entire article…)

The person in the patient BMJ personal view Alastair Santhouse 1 November 2008 (restricted access)

Assisted suicide, Dignitas, Sir Edward Downes

I wrote a post about rational suicide a few weeks ago which attracted a lot of interest, and even spawned a post on another site dedicated to debunking my viewpoint.  This issue and that of physician assisted suicide is rarely far from the headlines and clearly is a subject which excites strongly held opinions.  Most recently conductor Sir Edward Downes and his wife are reported to have died together at the controversial Swiss assisted suicide clinic Dignitas.  For a small organisation it attracts an impressive amount of coverage and its actions may have a substantial influence on future UK legislation.

For many people the discussion of the right to die is a simple one: people should not have to suffer toward the end of their lives and have the right to choose the time and means of their own passing.  This attitude is in line with the increasing emphasis on choice and self determination in our society of which suicide is perhaps the ultimate expression.  There are strong emotions involved and polarized viewpoints, but shouldn’t mean that we shy away from discussion both about philosophical underpinnings as well as more practical aspects.

I am concerned that where assisted dying to become legal in this country doctors would be expected to take a central role and this would sit unhappily with our usual duties.  Psychiatrists would regularly be called up to make difficult assessments about capacity and some of us might find being asked to assist in someone’s death very distressing.  Outside these professional concerns, and more fundamentally, is the message that legalised assisted dying would send out to vulnerable people who are near to the end of their lives.  Elderly people may worry that they are a burden or that their care is costing too much, and with a legal way of reaching a swift resolution may feel a duty to move on.  I cannot see how we could safe guard against this.

Sir Edward was elderly and frail but not terminally ill when he chose to take his life.  Apparently decided that he could not live without his wife and choose to end his life when she was choosing to end hers.  Most discussion about assisted suicide has focused on incurable conditions, which Sir Edward did not have.  Enabling people in similar situations to Sir Edward to take their own lives is disquieting to me.

Addendum 16 July 2009
What I think about Sir Edward Downes’ decision to ‘die with dignity’ Guardian

Examination of the concept of ‘rational suicide’

It has been estimated that approximately 1 000 000 people die of suicide yearly worldwide  and whilst most studies indicate that people who commit suicide have a disturbance of mental functioning this does not exclude a relatively small number of people who, for whatever reason, might express the wish for an early death but yet lack any state that may impair their mental function.  For these people the paternalistic approach applied to many with a desire for suicide appears less appropriate and has lead to the notion of a ‘rational suicide’.  Many people feel strongly that this option for rational thinkers to end their lives should be available and argue that there is a historical precedent; it was in reference to manner of Socrates’ death that Compassion and Choices, an American euthanasia pressure group, was initially called the Hemlock Society.

The emergence of rational suicide as a concept has happened within a framework of contemporary era cultural, technological and philosophical shifts where individualistic attitudes lead people to treat their own goals and desires as paramount whilst advances in medical treatments have lead to increased lifespan.  Therefore at the end of life we are both encouraged, and afforded more opportunity, to contemplate the manner of our own passing.  Judgement of suicide has simultaneously moved away from assigning a successful suicide to be a moral or religious failure towards one where most suicides have come to be seen as the result of disturbance of mind.

Werth and others have suggested criteria under which a rational suicide should be allowed.  That these are notably circumscribed reflects the negative value that suicide generally holds and the concerns of others with this approach.  Proposed are that for a suicide to be considered rational the person in question must have an unremittingly hopeless condition, should make their decision as a free choice and have engaged in a sound decision making process, including assessment by a mental health professional.

Despite the face validity of this line, analysis of what is meant by ‘rational suicide’ and its implications reveal a more nuanced situation than the casual inquirer might anticipate.  From the definitions of the word ‘suicide’, taken from the latin sui meaning ‘of oneself’ and cidium meaning ‘to slay or kill’, and that of rational, an act that it is characterized by reason or is intelligible, sensible, or can be understood , one can surmise that ‘rational suicide’ is self slaying that is characterized by reason or ‘makes sense’ to others .  The arguments in favour of rational suicide generally come in two flavours.  The first emphasizes the need to respect an individual’s autonomy, the modern meaning of which was developed by the philosopher Kant.  In common usage it implies ‘being one’s own person or being able to act according to one’s beliefs or desires without interference’.  Kant expressed it as a respect for persons and wrote that to violate a person’s autonomy is to treat them as a means rather than as an end in themselves.  The ‘right to die’ is then an expression of the most extreme form of autonomy, that is the right to choose the time and manner of one’s passing.  The second argument in support of rational suicide involves the ability of an individual to make rational assessment of utility or ‘good’ that is gained by ending their life and here proponents argue that suicide can provide freedom from painful and hopeless disease.  In this argument the consideration that an individual has for their quality of life is of paramount importance.

However the concepts of autonomy, utility and rationality alone are inadequate arguments for the acceptance of rational suicide as none are ever identifiable in so pure a form as to be considered a philosophical trump card.  Werth’s guidelines are first and foremost pragmatic and with an irreversible decision at stake the standards of rationality must of necessity be high.  To come to a conclusion that an act or intention of suicide is reasonable is not a straightforward matter.

We must also recognize that in seeking a rational suicide, the components that inform this decision are culturally determined, thereby introducing considerable subjectivity and possible external disagreement.  Furthermore if the decision to end one’s life is informed by persistent suffering, then it is unlikely to be made on entirely non-emotional grounds and likely to be subject to cognitive distortions.  It is a curious position to seek to solve a problem in life, by ending the life itself and those intending a rational suicide would presumably actually prefer to be alive, just not under the current circumstances, indicating the presence of significant ambivalence regarding their decision.

There are few people who would argue that autonomy for a patient, at any stage of care, is not important.  However when we respect autonomy we are respecting a person’s right to exercise their right to make independent decisions about their life and these decisions will be made on the basis of considerations which are consistent with a person’s moral values or a personal code.  These values or code would ideally be independently derived; however this is not possible as people are heavily influenced by such things as their culture, parents and friends.  Thus the sense of autonomy as the exercise of independent thought is compromised.

Alternatively, if one wishes to frame rational suicide as the outcome of an audit of a life’s merits and demerits a pertinent question is what the continuation of this life is to be weighed up against.  If the decision is to be truly informed this should involve gaining all possible facts and imagining all consequences.  However since the experience of being dead is entirely unknown it is questionable whether it is possible to adequately foresee the outcome of one’s actions in this regard.

These concerns indicate that it may be difficult to satisfactorily reach a conclusion that rational suicide is possible.  The concept of a suicide being ‘understandable’ is probably more meaningful and suitable although may not carry the same weight.

Comment on this piece

Life is a disease so cut the bullshit please

Further reading:

Autonomy, rationality and the wish to die Clarke Journal of Medical Ethics 1999;25:457-462
A Primer on Rational Suicide and Other Forms of Hastened Death Werth and Holdwick The Counseling Psychologist, Vol. 28, No. 4, 511-539 (2000)
Rational suicide: uncertain moral ground Rich and Butts Journal of Advanced Nursing Volume 46 Issue 3 270 – 278

Encyclopedia of  death and dying – suicide types

Suicide – a rational choice?

The economics of suicide – Slate magazine

Thought for the day 9 June 2009

Addendum 23 June 2009 Neither euthanasia nor suicide but end of life choice,  Guardian 23 June 2009.  More about physician assisted suicide than rational suicide but the comments are interesting, as they touch on many of the issues raised above

What is a Person?

There is no exact and agreed concept or definition of ‘person’ in either common usage or philosophy. Instead the word ‘person’ has numerous uses. The English word is said to come from the Latin persona. This word was used to refer to the mask worn by actors in dramatic performances and also variously to the person speaking through the mask. It has been suggested in turn that persona is in itself derived from per-sonando (‘sounding through’). This murky beginning may account in part for our current ambiguous usage.

With this in mind, when we discuss the question of ‘personhood’ we are in fact attempting to give a more or less vague term a degree of precision by locating it within a set of terms which constitute the vocabulary of a scientific or philosophical theory. It is therefore misleading to speak of a particular philosopher’s theory of persons for there is no previously agreed definition of what this should a theory of. We must instead talk of the philosopher’s use of ‘person’ as a semi-technical term in his or her system. There must be some connection between this philosophical term and the ordinary concept otherwise there would be no justification for using this term rather than any other; but we cannot criticize a philosophical use of the term by citing certain facts about persons that the theory in which it is used fails to account or accounts for incorrectly. We may criticize it only by showing that its rules of usage are incoherent or that there is nothing in the world that satisfies the characterisation of ‘person’ as given by the theory.

Philosophers have mainly concerned themselves with two issues regarding personhood.

  • What qualities must a ‘person’ possess?
  • Are ‘persons’ essentially physical or mental entities?

With regards to the first question Boethius regarded rationality has been an important quality. Writing in the sixth century he said:

[a person is] an individual substance of a rational kind (naturae rationalis individua substania)

This rationality approach was echoed by Locke who said that the term ‘person’ should be applied:

Only to intelligent agents capable of a law and happiness and misery (An Essay concerning Human Understanding, Book II Chapter 27)

And that a person is a:

Thinking, intelligent being, that has reason and reflection, and can consider itself as itself (Ibid.)

In his Introduction to the Metaphysics of Morals Kant made a similar point:

A Person is the subject whose actions are capable of imputation

Kant wished to make a distinction between ‘persons’ and ‘things’. He felt that ‘persons’ as contrasted with ‘things’ are of an
unconditional worth and that ‘respect’ is an attitude which has an application to ‘persons’ only and never to ‘things’. In view of this, ‘things’ may be pre-empted for our own purposes; their value depending upon the degree and kind of service that they may be to us in the execution of our aims. Persons may not be used in this way. They are ‘ends-in-themselves and sources of value in their own right’ (Kant)

By this view a person simply is any being having legal rights and duties. But not every human being is legally a person and not every legal person is a human being (a corporation is considered to be a judicial person). A slave by definition is used as a means to another’s ends. In ancient legal tradition slaves had no rights in the eyes of the law and were therefore not regarded as persons. Aristotle regarded them not as human beings, but as ‘[living]instruments for the conduct of life’. In Aristotle’s vew to be a ‘person’ such an entity must take part in the community of which he or she is a member. However, as in the case of slaves, not everyone who might be a member of the community is recognized as being fit to play a role in its public life. So, in the view of Aristotle, a ‘person’ is required to meet certain criteria of enfranchisement; satisfaction of these criteria constitutes someone a person or citizen.

Finally commonly a necessary condition for having rights is being responsible for one’s acts. Rights may be ascribable only to persons and accordingly persons alone are responsible.

With respect to the mental/physical debate Locke and Strawson have made major contributions: Locke wrote again in An Essay Concerning Human Understanding:

In the ordinary way of speaking, the same person and the same man stand for one and the same thing.

Yet Locke himself believed that these two expressions stand for two distinct ideas: ‘person’ having to do with the rational self, and ‘man’ having to do with a certain physical shape. A rational parrot, he argued, would not be called a man, nor would a non-rational human being be called anything but a man. The former however might be a person, while the latter, failing in rationality, might not be. A person then is not a rational man since ‘man’ has reference to corporeal form and
it is not, as he saw it, part of the meaning of ‘person’. Then Locke inferred that ‘person’ must denote something incorporeal and invisible. This deviates from common usage as a standard dictionary definition states ‘person’ means ‘the bodily form of a human being’. For Locke the identity of a person was simply the identity of consciousness, so that I remain the same person if I am conscious of being so even though my body could drastically change or indeed cease to exist at all.

For Locke persons were essentially non-corporeal simple entities. A difficulty with this is that it becomes difficult to distinguish persons from metaphysical selves. If we follow their reasoning in ascribing rights and responsibilities to human beings we are implicitly referring to some bodiless entity.

P. F. Strawson adopted a term for ‘person’ for philosophical use which is much closer to the common usage. A Strawsonian person is understood as distinct from a material body. For Strawson, a thing, or material body is a basic particular specifically in the sense that a physical body can be identified without reference to any other particular than its physical existence. He states that we are not our physical bodies, but does not follow the Lockian path that we are then immaterial entities.

Strawson chooses to introduce two terms: M-predicates and P-predicates, applicable respectively to material bodies and to persons. There is an overlap in that some M-predicates are applicable to persons, but there are some P-predicates that we would not be able to apply to material bodies (for example, states of consciousness). Persons therefore are distinct from material bodies but they are not therefore immaterial bodies or incorporeal nonbodies. A person has states of consciousness as well as physical attributes and is not merely to be identified with one or another.

Strawson’s concept is close to the whole concept of a person in ordinary usage. However, relative to the known laws of physics and chemistry, persons are indeed primitive and irreducible entities. A person is a body; is an appearance, is self conscious and rational; is the source and object of rights and obligations; is that which takes roles and discharges functions. In this sense then the dual nature of a person resembles the quantum mechanical particle neither a being a particle nor a wave but rather different things depending on how one might choose to observe it.

The Encyclopedia of Philosophy Volume 6 pg112-113; Paul Edwards
Editor: Collier-Macmillan Ltd London 1967.

A Dictionary of Philosophy Pan Books Antony Flew Editor 1979

The Internet Encyclopedia of Philosophy

What is Philosophy?

Quite literally the term ‘philosophy’ derives from the Greek philosophos means ‘love of knowledge’. Defined broadly, philosophy is an activity people undertake when they seek to understand fundamental truths about themselves, the world in which they live and their relationships to the world and to each other.

This is only one definition and there are many others, as even philosophers between themselves cannot agree on what philosophy is: a search for the wisdom of life; an attempt to understand the universe as a whole; an examination of human kind’s moral responsibilities and social obligations; an effort to fathom the divine intentions and our place with reference to them; an effort to ground the enterprise of natural science; a rigorous examination of the origin, extent, and validity of people’s ideas; an exploration of the place of will or consciousness in the universe; an examination of the values of truth, goodness, and beauty; an effort to codify the rules of human thought in order to promote rationality and the extension of clear thinking, or simply engaging in asking, answering, and arguing to gain answers to life’s most basic questions. And even these do not exhaust the meanings that have been attached to the philosophical enterprise, but give some idea of its extreme complexity and multi-facetedness.

What this confusion does illustrate is a pertinent issue relating to philosophy, namely that it aims to leave nothing unquestioned, even the nature of its very existence. It is difficult to determine whether any common element can be found and whether any core meaning can be discovered that could serve as a universal and all-inclusive definition. Vague and indefinite as the above interpretations are, they do suggest two important facts about philosophizing: that it is a reflective, activity and that it has no explicitly designated subject matter of its own but is a method or type of mental operation that can take any area or subject matter or type of experience as its object. Thus, although there are a few single-term divisions of philosophy such as logic, ethics, epistemology (the theory of knowledge), or metaphysics (theory of the nature of Being) its divisions are often best expressed by phrases that contain the word ‘of’. Thus we have philosophy of nature, philosophy of mind, philosophy of law, and philosophy of art.

Philosophy’s goal is broad: whereas other fields study particular kinds of things, philosophy asks how they all fit together. For example biological sciences study the body, and psychologists study the mind, but in order to discuss how the mind relates to the body we need philosophy. Furthermore philosophy also ponders whether we can consider any belief we hold to be ‘knowledge’ and whether it is possible to have any ‘knowledge’ at all. Such arguments are very abstract, but this is what enables philosophy to cover so many difference fields at once.

On a more practical level, unlike other disciplines, in order to study philosophy you also need to do it. For instance to study poetry you do not need to be a poet, yet to study philosophy you have to engage in philosophical argument, not perhaps reaching the level of great thinkers of the past, but developing some of the same skills as them. Whilst doing this, it is not simply enough to express one’s views but one must try to convince others. It is also of note that the history of philosophy has a living significance, which the history of science does not enjoy. In science, the present confronts the past as truth confronts error; thus, for science, the past is important only out of historical interest. In philosophy it is different. Philosophical systems are never definitively proved false; they are simply discarded or put aside for future use. And this means that the history of philosophy consists not simply of dead museum pieces but of ever-living classic works comprising a permanent repository of ideas, doctrines, and arguments and a continuing source of philosophical inspiration to those in any succeeding age. It is for this reason that any attempt to separate philosophizing from the history of philosophy an unnecessary impoverishment of its rich natural resources.

Finally, why is philosophy important? Some people choose to characterise philosophy as something with no relevance to modern life; they think it a subject to be studied from an armchair purely for intellectual satisfaction. Intellectual satisfaction is no small justification in itself but this is nevertheless a serious misrepresentation of the subject. Many debates that we have as a part of society have, as their basis, underlying assumptions amenable to philosophical enquiry. Every domain of human experience raises questions to which its techniques and theories apply, and its methods may be used in the study of any subject or the pursuit of any vocation. Philosophy is in a sense inescapable: life confronts every thoughtful person with some philosophical questions, and nearly everyone is guided by philosophical assumptions, even if unconsciously.