Editors' Introduction

In this issue we are launching a new feature—the philosophical case conference—which we hope will build on the success of PPP in promoting high quality discussion of the conceptual issues at the heart of everyday practice and research in psychiatry and clinical psychology.

Case conference issues of PPP will focus on a topic of current importance in clinical work or research. The topic will be illustrated in a target article with actual case histories or a problem arising in a specific research program (this might be a problem of design or execution). Beyond this there will be no fixed format. But the aim will be to produce a lively mix of commentaries and longer articles, all focused on the practical problems illustrated in the target article. The final test of the success of a philosophical case conference is that the contributions from philosophers, lawyers, and others should make a difference to practice.

Psychiatric euthanasia is the topic of our inaugural philosophical case conference. In their target article, Sally Burgess and Keith Hawton (from the University of Oxford) argue that in the practical management of suicidal patients, psychiatrists are increasingly caught between a rock and a hard place. The “rock” is society’s ever-more liberal attitudes to euthanasia; the “hard place” is society’s growing demand for suicide prevention. Burgess and Hawton set this problem in its historical and cultural context; they illustrate it with three very challenging case histories made suitably anonymous; and they argue that the available bioethical and legal “tools” for resolving issues about euthanasia, which have been developed mainly in physical medicine, are largely unhelpful when transposed to the contingencies of clinical psychiatry.

The target article is introduced from a philosophical perspective by Eric Matthews, a philosopher with a long-term interest in psychiatry. Five commentaries, expressing a remarkably diverse range of responses to Burgess and Hawton’s cases, are provided by Mary Warnock (a moral philosopher with a wide experience of public policy issues), Ron Berghmans (a bioethicist working in Holland, where euthanasia is de facto legal), Chris Heginbotham (a former Director of the British patient advocacy group, MIND, and currently heading a large National Health Service Trust), John W. Burnside (a general internist), and Michael Kelleher (a psychiatrist who has written widely on end-of-life issues). A “legal footnote” is offered by the mental health lawyer, Jonathan Montgomery.

In a supplementary main paper, Gavin Fairbairn, a philosopher working on the language of suicide, argues that part of our difficulty is plain confusion arising from an inadequate lexicon; Rom Harré, commenting from his work in discursive psychology, agrees; and John Sadler, responding as a clinician, emphasizes the pragmatic differences between naming and understanding, and their differential utilities.

Is our inaugural philosophical case conference a success? Have we indeed made a difference to practice? Burgess and Hawton, responding to the commentaries on their paper, note that, the protestations of bioethicists notwithstanding, their original contention that the standard “tools” are unhelpful in psychiatry, seems vindicated: these tools, inadequate as they are recognized to be, are very much in use, and the alternatives seem to be “common sense” on the one hand, or to become “moral guardians” of society on the other.

The central clinical difficulty, though, has at least been clarified—that of judging the rationality of the “patient.” This is assumed as a precondition for medical euthanasia; it is the very problem for psychiatric euthanasia. That it is a problem psychiatrists cannot avoid is the conclusion of Eric Matthews’s survey of philosophical accounts of suicide. That it is a problem in need of clarification is evident, if in no other ways, from the fact (noted by Burgess and Hawton in their response) that the draft guidelines for psychiatrists even from so experienced a body as the Royal Dutch Medical Association, would have led to an intuitively disastrous result in at least one of their cases. That it is a problem to which philosophers, alongside other disciplines, can make a key contribution to practice is indicated by Mary Warnock’s conclusion, that, in psychiatry at least, there will never...