Global Mental Health and Neuroethics

Dan J. Stein, Ilina Singh

• Publisher: Academic Press
• Year: 2020
• ISBN:
  9780128150641
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Global Mental Health and Neuroethics explores conceptual, ethical and clinical issues that have emerged with the expansion of clinical neuroscience into middle- and low-income countries. Conceptual issues covered include avoiding scientism and skepticism in global mental health, integrating evidence-based and value-based global medicine, and developing a welfarist approach to the practice of global psychiatry. Ethical issues addressed include those raised by developments in neurogenetics, cosmetic psychopharmacology and deep brain stimulation. Perspectives drawing on global mental health and neuroethics are used to explore a number of different clinical disorders and developmental stages, ranging from childhood through to old age.

• Synthesizes existing work at the intersection of global mental health and neuroethics
• Presents the work of leading practitioners of global mental health and neuroethics who address clinical issues
• Looks at clinical decision-making in settings with non-Western values and customs
• Covers patient empowerment, human rights, cognitive enhancement, and more

1

Introduction

Dan J. Stein^a; Ilina Singh^b    a Department of Psychiatry, University of Cape Town, Cape Town, South Africa
^b Department of Psychiatry, University of Oxford, Oxford, United Kingdom

Global mental health and neuroethics are two relatively new and highly influential transdisciplinary fields that are based on a solid foundation of prior work, and that have built on this foundation in novel and creative ways. Global mental health has built on earlier work in psychiatric epidemiology, cross-cultural psychiatry, and human rights, in order to emphasize the importance of addressing mental illness and well-being throughout the world. In short shrift, it has become a key approach to rethinking mental health. Neuroethics has built on moral philosophy, philosophy of science, and bioethics, developing key intersections between neuroscience and ethics, including both the ethics of neuroscience and the neuroscience of ethics. Again, although a new discipline, by focusing on these intersections, neuroethics has asked a range of important questions, and provided resources for addressing them.

This volume aims to develop a dialog between global mental health and neuroethics. Any such dialog must again draw on a range of earlier work that has been undertaken at the intersection of psychiatry, neuroscience, and ethics. Philosophy of psychiatry and psychology, psychiatric ethics, and philosophy of neuroscience have all made significant contributions to our understanding of the nature of mental disorder, our concepts of brain and mind, and our appreciation of the values entailed by psychiatric research and practice. With the advent of new ways of conceptualizing and approaching mental health and well-being around the world, and with advances in thinking through the relationships between neuroscience and ethics, it is now timely to bring global mental health and neuroethics into closer juxtaposition.

Global mental health and neuroethics are both exciting and productive transdisciplinary areas of investigation, that are asking and answering a range of overlapping questions. A dialog between them therefore has the potential to make substantial contributions to a number of long-standing debates as well as more recently emerging controversies about the nature of mental disorders and the mechanisms that underlie these conditions, and about the ethics of mental health research and intervention, particularly when considered in a global context. In this volume, three different sets of questions are addressed by a number of leading clinicians, public health practitioners and philosophers, who work in a range of different contexts around the world, and who bring a spectrum of disciplinary backgrounds to bear on the relevant debates and controversies.

A first set of questions are conceptual in nature. Psychiatry has long witnessed a debate between those who regard the field as a scientific endeavor that is making steady progress toward understanding and treating mental disorders, and those who criticize the discipline as focused merely on constraining deviance and paternalistically imposing one particular set of values. A first chapter by Stein and Palk addresses the intersection between global mental health and neuroethics from the contrasting perspectives of scientism and skepticism, arguing that each perspective has important insights which are useful for contributing to a more integrative and sophisticated position that conceptualizes psychiatry as both theory-bound and values-based.

In complementary vein, Fulford and van Staden, who have long emphasized the importance of both evidence-based and values-based practice, extend their conceptual framework to the arena of global mental health and neuroethics. They use tools from ordinary language philosophy to advocate for a Fact-plus-Value model to meet the challenges of global mental health and neuroethics. McConnell and Savulescu articulate a critical view of contemporary psychiatry, and argue that a welfarist approach is useful in correcting these flaws and so provides a useful framework for global mental health. Finally, Tomlinson expands on the issue of the social determinants of health, exploring a range of social, economic, and environmental risks that global mental health and neuroethics will need to explore in the next two decades.

A second set of questions emerges from the juxtaposition of global mental health and neuroscience, addressing key questions about the nature of neuroscience research, and the ethics of various neurotechnologies, in a global context. Neurogenetics is a major focus of contemporary psychiatric research, and has raised a range of ethical issues. de Vries addresses the ethical issues that arise when such work is undertaken in under-resourced and diverse areas of the globe. Psychopharmacology is a major intervention in contemporary psychiatry, and has led to a neuroethics debate on the value of cosmetic psychopharmacology. Palk and Stein consider the ethics of cosmetic psychopharmacology in a global context, arguing for the value of a relational account, informed by an African moral framework, that in many ways complements a welfarist approach.

Deep brain stimulation is currently restricted to treatment of extremely refractory cases of mental disorder, but the potential use of such interventions raises a range of questions about whether and how this neurotechnology alters the self. In their contribution, Skorburg and Sinnott-Armstrong emphasize the importance of empirical work on changes in identity with deep brain stimulation, and highlight a range of ethical issues raised by such interventions, including cross-cultural considerations. Herrera-Ferrá proposes that it may be possible to draw on current knowledge and practices in neuroeducation, in order to facilitate efforts in global mental health to address the mental health treatment gap within a human rights framework. Finally, Jotterand and colleagues discuss some of the issues that arise in the context of civil unrest, political violence, and continuous exposure to stressors, addressing the question of how best to improve access to new neuroscientific knowledge and treatment options relevant to the impact of poverty and violence.

A third set of questions employs resources at the intersection of global mental health and neuroscience to address questions that are relevant to a number of specific illnesses and populations. Illes and colleagues discuss practical and theoretical strengths of role-playing games to understand health-related quality of life (HRQoL) in children with neurocognitive challenges; Sahakian and her colleagues discuss cannabis use and abuse in youth; Barnett, Hall, and Carter discuss addiction and substance use disorders in general; Dubljevic discusses dementia in the elderly; and Wu discusses focuses on individuals with disability. Taken together, these chapters therefore cover a number of important conditions, as well as various issues that are relevant to different stages of the human lifecycle.

Across each of the chapters in this third section of the volume there is an emphasis on advances in neurotechnologies (e.g., brain imaging), on the application of such technologies in a range of different contexts, and on the use of global mental health and neuroethics as resources that may be useful in addressing areas of controversy and debate. Thus, for example, in their chapter on childhood neurocognitive impairments, Illes and colleagues discuss the role of participant research, and the importance of children’s rights. And, in their chapter on addiction, Barnett and colleagues explore the role of neuroethics in setting funding priorities and allocating scarce financial resources.

In a concluding chapter, Palk and Stein provide an overview of the broad intersection of global mental health and ethics, drawing on the work in this volume, and outlining a framework for ethical global mental health. Their discussion of key ethical issues in global mental health is organized in terms of ethical challenges associated with global collaboration in mental health, with global mental health research, and with global mental health care. They go on to support calls for a more appropriate bioethics paradigm for health on a global scale, justified by principles such as equity, inclusivity and rectification—which are central in global health. They conclude by arguing that the relational principle of solidarity is an appropriate guiding principle for global health in general, and for global mental health in particular.

Taken together, then, these chapters demonstrate the rich potential of discussions at the intersection of global mental health and neuroethics for addressing a range of long-standing psychiatric debates (e.g., about the nature and boundaries of mental illness), as well as new controversies raised by novel neurotechnologies (e.g., deep brain stimulation). While they undoubtedly do not provide the last word on these debates and controversies, the frameworks that they provide for addressing them, provide useful resources for global mental health, for neuroethics, and for work at the intersection of these two rapidly developing and impactful fields.

Section A

Conceptual issues

2

Moving beyond scientism and skepticism

Dan J. Stein; Andrea C. Palk Department of Psychiatry, University of Cape Town, Cape Town, South Africa

Abstract

This chapter aims to address key conceptual debates in philosophy of psychiatry, putting forward an integrative position that is a useful resource for global mental health, neuroethics, and a dialog between these fields. The chapter outlines a number of perennial controversies about the diagnosis, pathogenesis, and treatment of mental disorders, and delineates “classical” and “critical” approaches to each. An integrative position that draws on the strength of each of these approaches, while avoiding the scientism of the classical approach and the skepticism of the critical approach is then put forward. This integrative position is consistent with key features of global mental health and neuroethics, and may also be useful in providing further support for them.

Keywords

Global mental health; Scientism; Skepticism; Psychiatry; Neuroethics; Psychiatric diagnosis; Psychiatric nosology; Pathogenesis of psychiatric disorders

Introduction

The philosophy of psychiatry has long been characterized by a debate between those who see psychiatry as an important branch of medicine, and those who regard psychiatry as simply a sociopolitical mechanism for addressing deviance. These contrasting positions, which we have previously termed “classical” and “critical” (Stein, 2012a), are in turn informed by various foundational oppositions in philosophy of science, philosophy of language, and moral philosophy. Furthermore, those who take classical and critical positions likely differ on a range of other issues, including their view of the nature of psychiatric diagnosis, causal mechanisms underlying psychiatric disorders, and the value of psychiatry research and treatment (Stein, 2008).

In this chapter we aim to apply this conceptual framework to addressing the intersection between global mental health and neuroethics, arguing for an integrative approach to debates in the philosophy of psychiatry and neuroscience that draws on valuable insights from both the classical and critical positions. We begin by outlining a number of characteristics shared by global mental health and neuroethics, which also help provide a foundation for an integrative position. We then go on to suggest that an integrative position in turn helps provide a useful conceptual foundation for global mental health, for neuroethics, and for their intersection.

Global mental health and neuroethics

Global mental health and neuroethics are relatively new multidisciplinary fields that have been widely influential, reshaping our approach to psychiatric disorders and to intersections between neuroscience and ethics. Importantly, although the two fields have disparate agendas and contents, they also share key features in their conceptual approach and focus (Stein & Giordano, 2015; Stein & Illes, 2015). In this section, we emphasize that both global mental health and neuroethics take a naturalistic and empirical approach, are concerned with both disease and wellness, and emphasize human rights and patient empowerment. A dialog between these fields may benefit from understanding their similarities, as well as their differences.

First, both global mental health and neuroethics have emphasized a naturalistic and empirical approach to investigating questions in their domains. Global mental health, for example, advocates for resources for mental health based on evidence about the burden of mental disease, undertakes randomized clinical trials to assess whether interventions adapted for under-resourced contexts are feasible and effective, and advocates for more research in low and middle-income countries (Patel et al., 2018). Neuroethics, on the other hand, has emphasized that advances in neuroscience may shed light on philosophical questions, and has advocated for empirical approaches to addressing bioethical questions (Illes & Hossain, 2017).

Second, both global mental health and neuroethics are concerned not only with disease, but also with wellness. Global mental health has emphasized the spectrum ranging from distress and disease, through to health and well-being, and has argued that both ends of this spectrum need to be conceptualized and addressed using public health principles (Collins et al., 2011). It has also emphasized the import...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Contributors
• Foreword
• 1: Introduction
• Section A: Conceptual issues
• Section B: Global neuroethics
• Section C: Disorders/developmental stages
• Section D: Conclusion
• Index