Psychiatric Treatment and the Problem of Equality: Whose Justice, Which Rationality?

Craig Edwards in his article "Ethical Decisions in the Classification of Mental Conditions As Mental Illness" provides the reader with a socially normative, rather than a naturalistic understanding of mental illness, one that, in particular, promotes a normative understanding of mental illness as a form of evaluating dysfunctional personhood. In doing so, Edwards is not interested in undermining psychiatric expertise, but exploring some of the practical consequences that flow from it, such as involuntary psychiatric treatment.

My concern about psychiatric treatment in general and involuntary psychiatric treatment in particular, is three-fold, the third concern adding to the arguments already rehearsed by Edwards and others. The first concern is about the value neutrality of mental illness. Any dysfunctional conception of mental illness is not value neutral according to Fulford; dysfunction is, straightaway, a normative concept and is heavily influenced by a patient's desires and values. The second concern is about competing and conflicting values that arise in a person's psychiatric treatment. Again, there exists a legitimate variation in people's evaluative judgments about mental health conditions, for which a degree of democratic compromise might be required in negotiating conflicting values in a person's psychiatric treatment (Fulford and Colombo 2004). Without wishing to examine any of the philosophical foundations or counter-arguments to these claims in this short discussion paper, my third concern is about how to ethically negotiate between conflicting values in a person's psychiatric treatment. In other words, what might democratic compromise consist in? How might democratic compromise be implemented in terms of an ethically relevant principle?

Any democratic enterprise, by definition, favors or is characterized by social equality and is egalitarian in nature (New Oxford English Dictionary 1999, 490). To be able to negotiate in the spirit of democratic compromise between competing and conflicting values in the process of psychiatric treatment, a principle of equal consideration of interests is vital.

The essence of the principle of equal consideration of interests is that we give equal weight in our moral deliberation to the like interests of all those affected by our actions (Singer 1979, 19). In other words, an interest is an interest whoever's interest that may be. So, for example, if the principle is about relieving pain, then the moral principle is about relieving the undesirability of pain as such, and not the undesirability of A's pain, which might be different from the undesirability of B's pain. Naturally, one may be able to distinguish that A's pain is greater than B's pain, in which case, under the equal consideration of interests principle, A's pain should be given greater weighting than B's pain in any conflict of interests. In short, in the evaluation of like interests, major interests outweigh minor interests.

The significance of the principle of equal consideration of interests in decisions about mental health treatment in general, and about involuntary psychiatric detention and treatment more specifically, is that it should be possible (in theory at least) to able to democratically arbitrate on the basis of utility, whose interests take precedence when legitimate conflicts arise. The great practical advantage to the principle of equal consideration of interests is that it weighs' interests impartially—like well-balanced weighing scales; they favor where the interest is stronger or where several interests combine to outweigh a smaller number of similar interests. Most important, in the case of psychiatric treatment, it is a principle that takes no account of whose interests they are, avoiding any discriminatory stigma that may arise because of having made certain assumptions about being mentally ill. From the point of view of the equal consideration of interests, who the bearer is and how they are classified is, in itself, incidental to what the actual bearer's interests are and how they compete and conflict with others who have like interests. There are a number of practical consequences that flow from the principle of equal consideration when applied to psychiatric treatment (voluntary and involuntary) that need to be pinned down.

Simple Negative Discrimination

Clearly...