Saturday, 21 May 2016

Scattered Thoughts on a Hard Subject

Spurred by Masuma Rahim's thoughtful piece about the issue, I have been thinking about psychiatric assisted suicide. She points out that this is an issue it is "very difficult to have a settled opinion about". I don't yet have one, but it seems important to understand some of what is at stake. This is a list of thoughts. The topic may be triggering, and this post should be approached with that in mind.

1. Any debate about psychiatric assisted suicide concerns the question of whether there are ever circumstances in which people with mental health problems should be allowed to receive help to die.
2. If healthcare professionals are to have any role in this process, part of it must be in trying to provide the best possible assessment of whether a person can reasonably expect their life to improve.
3. Unless we think assisted suicide is always unconscionable, we have to accept that there exist reasons that bear on those cases in which it is not. Clarifying those reasons will help us think more clearly about the issue in general.
4. Whether or not mental health problems are "illnesses" is of no relevance to the question of whether psychiatric assisted suicide is morally palatable. The desire to die seems driven by the intensity, and particular quality, of individual suffering. It is not clear that this suffering is more real in cases where an illness exists. Whether or not a person wants to die is likely to be a function of whether they think their misery will persist.
5. A domain specific prohibition on assisted dying in psychiatry would appear to suggest that it is not possible for mental health service users to make reasoned choices about whether they can end their lives.
6. Psychiatry has a long history of "great and desperate cures", driven by desire to avoid feelings of hopelessness on the part of the doctor. How would we know psychiatric assisted dying isn't just the latest chapter of this ignoble tradition?
7. I have, in the past, walked on to a psychiatric ward and felt a chill at the idea that I could end up locked in a place that is organised almost entirely around the idea that I should be denied, at any cost, the freedom of killing myself.
8. To characterise this debate in terms of one group of people declaring another group "better off dead" is to fail to engage with the experiences of those who have advocated for their own right to psychiatric assisted suicide, or pursued it for themselves.
9. There is a particularly difficult balance to be struck between emotion and reason in this debate. We need to think calmly and clearly about psychiatric assisted suicide, but it is hopeless to try and avoid appeals to emotion. No-one can hope to understand what is at stake unless they take time to imagine what it is like to spend many years very seriously wanting to die. Equally no-one can hope to understand what is at stake unless they take time to imagine what it is like to lose someone to suicide.
10. We might wonder whether a policy like this would have a positive impact on the suicide rate. If people are aware that it is possible for them to die under medical supervision, that may reduce the intensity of some people's despair and desperation, making them less likely to kill themselves. Hope, even the paradoxical hope for death, might help people feel better.
11. Alternatively, a policy like this might increase the social visibility of suicide and diminish the taboo that surrounds it. This might lead to an increase in thoughts of death and more completed suicides, even in a sort of contagion as the idea occurs to more people. Legal protection would put suicide into the "pool" of acceptable solutions.

Thursday, 5 May 2016

Genetic Disavowalism is the Denial of Privilege

Here are two recent strands of thinking about genetics in clinical psychology: 1. Oliver James's (and others) bold position, that genetics play little or even no role in human psychology. Marcus Munafo has called this "genetic denialism" 2. The diffuse suggestion (one recent example here) that to pursue genetic research into mental health problems is related in some way to a eugenic agenda; to wit, that (i.e.) a genome wide association study looking at the diagnosis of schizophrenia may encourage us to think in quasi-fascistic ways. There are some good responses to the first of these strands, in Munafo's article (linked above), and in this piece by Kevin Mitchell at Wiring The Brain. Here, I want to address the second strand, which I will call genetic disavowalism.

The purpose of genetic disavowalism is pretty clear; to encourage us to think of genetic research and theories of genetic risk as inherently negatively morally valenced. This argument (to the extent that there is an argument; it is seldom made explicitly) is a little under-cooked to say the least. It is of course perfectly possible to acknowledge a genetic contribution to human behaviours and mental states without commencing some inexorable slide toward Nazi-ism. Does the genetic aetiology of Down Syndrome commit society to a re-run of the Nazi Aktion T4 programme? Clearly not. For one thing, a eugenic policy is a choice a government makes rather than a necessary consequence of a given set of scientific knowledge. For another, there is nothing to stop any government undertaking such a programme targetting people on the basis of behavioural or cognitive traits it doesn't like, but which are not genetically determined. Even if genetic theories about human behaviours and tendencies do incline some sorts of person towards ideas about eradicating those behaviours and tendencies (by "breeding them out" or what have you), there is no logical entailment, and we carry on with genetically inclined research because we wonder if there might be benefits to be derived from the knowledge.

Apart from all that, I think that genetic disavowalism has itself a moral problem to contend with; the denial of genetic privilege.

We are accustomed to thinking about privilege in terms of race, gender or social class. As a white man, for example, I have the privilege of not being looked on with suspicion in certain neighbourhoods, and I have the privilege of not feeling tense when groups of NYPD officers walk past me. It has come to be seen as crass and offensive to fail to acknowledge our privilege, especially when discussing race (see Peggy McIngtosh's essay on the invisble knapsack here), but the notion of privilege has been linked to mental health as well, by Martin Robbins here, and by me here.

When I first blogged about sane privilege, I was thinking in terms of the social position people have when they are viewed as less rational in virtue of their psychiatric status. When a person is considered deluded, their utterances become generally more suspect in the eyes of people around them They lose certain testimonial privileges (some of their statements about reality are taken less seriously). But privileges are also conferred on us by our genetic predispositions. This is most obviously the case in the way that skin colour or primary and secondary sexual characteristics are genetically determined facts about our appearance, but it presumably has cognitive implications too.

To the extent that IQ is genetically influenced, my course mates or colleagues with IQs two standard deviations above the mean have an advantage relative to me (with my quite middling IQ) in performance on exams or the production of research and logically sound clinical arguments. Equally, to the extent that my genetics plays a role in my tendency to not have debilitating emotional "highs" or feel my relationship with reality become terrifyingly fragmented, I have a sort of privilege conferred on me relative to people who are prone to such experiences. It is no good arguing that actually a tendency toward certain mental states is actually perfectly desirable, and should itself be considered a privilege. That may so for some people, but unless we want to deny that mental health problems are frequently extremely difficult to live with (and unless we want to throw out even the apparently politically neutral term "distress" to refer to such experiences), we have to acknowledge that is not the case for all.

Acknowledging cognitive genetic privilege need not entail acceptance of an illness account of mental health problems. Peter Kinderman has movingly written about his risk for a psychotic experience, given a possible personal high genetic loading for such an occurrence. At the same time, he resists the implication that this means he has a disorder or "attenuated syndrome". Even if you feel more inclined than Kinderman to describe such a genetic loading as predisposition toward illness, his is a perfectly consistent intellectual position.

Genetic influences on psychology have always been a controversial topic, and there is an easy tendency to accuse genetic researchers or thinkers of secretly holding eugenic aspirations. Perhaps some strains of genetic reasoning are infused with a negative moral valence (think of the pub bore who argues that women are genetically inferior), but to the best of our knowledge, genes make certain aspects of our lives more or less easy for us. They confer varying degrees of privilege. To ignore this is not only unrealistic, it is insensitive.