Tania Gergel

Background: Electroconvulsive therapy (ECT) is provided for patients with severe and often lifethreatening illness, who lack decision making capacity to consent to treatment (DMC-T) in clinical settings. Objective: The aim of this study is to summarize previous studies investigating clinical outcomes of ECT in patients lacking DMC-T. Methods: A systematic review and meta-analysis of studies reporting clinical outcomes of ECT in patients lacking DMC-T with any psychiatric diagnoses was conducted. The primary outcome was clinical improvement. Secondary outcomes were cognitive outcomes and six month readmission rate. Hedges' g and odds ratios were calculated using a random-effects model. The protocol was registered in Open Science Framework (https://osf.io/rxjkm). Results: Of 3552 identified articles, 41 studies (n ¼ 1299) were included. Approximately 80% of patients lacking DMC-T responded to ECT, and part of the patients regained capacity to consent and consented to further treatment with ECT. A total of seven studies (n ¼ 1081) were included for meta-analysis. Patients without DMC-T showed superior clinical improvement and less cognitive side effects compared with those with DMC-T, whereas the groups did not show any difference in readmission rate. Several clinical characteristics at baseline and ECT techniques were significantly different between the groups. Conclusion: ECT is equally, if not superiorly, effective in patients lacking DMC-T compared to patients with DMC-T. ECT can potentially enhance patients' autonomy, without increasing the risk of cognitive side effects. These results support the clinical and ethical legitimacy of ECT provision for patients with the most severe illness who lack DMC-T at start of treatment.

Charland's article suggests that we need to think more about whether decision-making capacity is impaired in severe addiction, working from the idea that drug dealers rely on this understanding of addiction to draw in their clients. Charland argues that it is possible to make a choice without being in control (to make decisions without having decision-making capacity). I argue in support of Charland's ideas by examining the reasons supporting a medical model of addiction and its importance. (Charland article and full commentaries included)

The full dataset of responses to accompany - ‘Reasons for endorsing or rejecting ‘self-binding directives’ in bipolar disorder: a qualitative study of survey responses from UK service users’ - https://pubmed.ncbi.nlm.nih.gov/34022972/ .  For full author list and description see - the article.

Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on selfbinding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human rights. Methods This qualitative study used data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision making for patients with bipolar disorder. We included participants who reported that they have been diagnosed with bipolar disorder by a professional (doctor or psychiatrist). In a previous study, quantitative analysis of a closed question about self-binding directives had shown endorsement among a high proportion of participants with bipolar disorder who completed the survey. In this study, we did a thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was done within a multidisciplinary team, including team members with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methods associated with all these areas of expertise were used in the thematic analysis to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues.

An article exploring the synthesis between conceptual and practical work within the Mental Health and Justice Project.  This editorial describes the articles within the MHJ Special Issue in International Journal of Law and Psychiatry and how interdisciplinary exploration in mental health ethics and law can advance human rights debates and have practical impact on clinical practice and law.

The PACT (Preferences and Advance decisions for Crisis and Treatment) is a fillable template for advance decision making in fluctuating mental health conditions. For more details on how it was produced see preprint of ‘Stephenson, L.*, Gergel, T.*, Ruck Keene, A., Rifkin, L., & Owen, G. (2020). The PACT advance decision-making template: Preparing for mental health act reforms with co-production, focus groups and consultation. International Journal of Law and Psychiatry (https://www.researchgate.net/publication/342305448_The_PACT_advance_decision-making_template_preparing_for_Mental_Health_Act_reforms_with_co-production_focus_groups_and_consultation)

This paper argues that existing English and Welsh mental health legislation (The Mental Health Act 1983 (MHA)) should be changed to make provision for advance decision-making (ADM) within statute and makes detailed recommendations as to what should constitute this statutory provision. The recommendations seek to enable a culture change in relation to written statements made with capacity such that they are developed within mental health services and involve joint working on mental health requests as well as potential refusals.  In formulating our recommendations we consider the historical background of ADM, similarities and differences between physical and mental health, a taxonomy of ADM, the evidence base for mental health ADM, the ethics of ADM, the necessity for statutory ADM and the possibility of capacity based ‘fusion’ law on ADM. It is argued that the introduction of mental health ADM into the MHA will provide clarity within what has become a confusing area and will enable and promote the development and realisation of ADM as a form of self-determination.  The paper originated as a report commissioned by, and submitted to, the UK Government’s 2018 Independent Review of the Mental Health Act

The primary aims are to consider whether a range of paternalistic medical interventions can be justified in the treatment of factitious disorder (FD) and to show that the particularities of FD and its management make it an ideal phenomenon to highlight the difficulties of balancing respect for self-determination, responsibility and duty of care in psychiatry. FD is usually classified as a mental disorder involving deliberate and hidden feigning or inducement of illness, in order to achieve patient status. Both the nature of the disorder and the approach to treatment are controversial and under-researched. It is argued that FD should be classified as a mental disorder; may well expose the patient to extreme risk; can warrant paternalistic interventions, in order to fulfil duty of care. Moreover, treatment of FD is inherently paternalistic and therefore raises interesting questions about justifications and type of paternalistic interventions in psychiatry both for FD and in general. A brief account of key questions concerning psychiatry and paternalism is followed by some case histories of FD, the clinical dilemmas posed and the question of how this disorder might warrant paternalistic interventions. In order to answer this question, two things are considered: the legitimacy and character of FD as a mental disorder; possible frameworks for and types of paternalistic interventions. To conclude, it is argued that there are no compelling reasons for rejecting the use of paternalistic interventions for FD, but that further investigation of FD and type and frameworks for psychiatric paternalism, in relation to FD and other mental disorders, are urgently needed.

Borrett joins other phenomenologists in using phenomenological ideas on temporality to explain how illness affects the individual's experience of time. Unlike others, he attempts to synthesize this use of phenomenology with a biomedical understanding of the relation between time and illness. My paper expands on Borrett's ideas by reviewing current medical scholarship on time and illness perception, including Heidegger's ideas on tem-porality. The first section considers questions and suggestions emerging from contemporary medicine. After a short review of theories of time perception, I describe and critique how Borrett and others use phenomenological temporality in a medical context. My conclusion suggests how Heideggerian temporality might help with the questions and recommendations emerging within diverse medical fields.

This document gives instructions and a template for writing a 'Mental Health Advance Statement' to provide relevant information and advise others on your healthcare if you become unwell. It can be downloaded and adapted to fit your own needs. [It is not a formal/legally binding document or a formal research output]

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician–patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research.

Challenges to psychiatric stigma fall between a rock and a hard place.
Decreasing one prejudice may inadvertently increase another. Emphasising similaritiesbetween mental illness and ‘ordinary’ experience to escape the fear-related prejudicesassociated with the imagined ‘otherness’ of persons with mental illness risks
conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’and ‘unlikeness-based’
conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.

Background. Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated. Methods. We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses. Results. A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were strongly associated with lack of DMC-R and to a lesser extent DMC-T. With the exception of years of education, there was no evidence for an association with socio-demographic factors. Conclusions. Insight and neurocognitive deficits are most closely associated with DMC in schizophrenia. The lack of an association with socio-demographic factors dispels common misperceptions regarding DMC and characteristics such as age. Although our results reveal a wide spectrum of DMC-T and DMC-R in schizophrenia, this could be partly due to the complexity of the DMC construct and the heterogeneity of existing studies. To facilitate systematic review research, there is a need for improvement within research study design and increased consistency of concepts and tools.

The issue of how to incorporate the individual's first-hand experience of illness into broader medical understanding is a major question in medical theory and practice. In a philosophical context, phenomenology, with its emphasis on the subject's perception of phenomena as the basis for knowledge and its questioning of naturalism, seems an obvious candidate for addressing these issues. This is a review of current phenomenological approaches to medicine, looking at what has motivated this philosophical approach, the main problems it faces and suggesting how it might become a useful philosophical tool within medicine, with its own individual, but interrelated, contribution to make to current medical debates. After the general background, there is a brief summary of phenomeno-logical ideas and their current usage in a medical context. Next is a critique of four key claims within current phenomenological medical works, concerning both the role phenom-enology plays and the supposedly clear divide between phenomenology and other approaches. There are significant problems within these claims, largely because they overlook the complexity of the questions they consider. Finally, there is some more in-depth examination of phenomenology itself and the true complexity of phenomenologi-cal debate concerning subjectivity. The aim is to show that it will be both more productive and truer to phenomenology itself, if we use phenomenology as a philosophical method for explicating and gaining deeper understanding of complex and fundamental problems, which are central to medicine, rather than as providing simple, but flawed solutions.

Background: Within psychiatric practice and policy there is considerable controversy surrounding the nature and assessment of impairments of decision-making capacity (DMC) for treatment in persons diagnosed with affective disorders. We identify the problems of "cognitive bias" and "outcome bias" in assessment of DMC for treatment in affective disorder and aim to help resolve these problems with an analysis of how time is experienced in depression and mania. Sampling and Methods: We conducted purposeful sampling and a qualitative phenomenological analysis of interview data on patients with depression and mania, exploring temporal experience and decision-making regarding treatment. Results: In both severe depression and mania there is a distinctive experience of the future. Two consequences can follow: a loss of evaluative differentiation concerning future outcomes and, relatedly, inductive failure. This temporal inability can compromise an individual's ability to appreciate or "use or weigh" treatment information. Conclusions: The decision-making abilities required for self-determination involve an ability to evaluate alternative future outcomes. Our results show that, within severe depression or mania, anticipation of future outcomes is inflexibly fixed at one end of the value spectrum. We therefore propose a temporal model of decision-making abilities, which could be used to improve assessment of DMC in affective disorder.

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research

A book chapter exploring the potential consquences and ethical ramifications of using coercive measures within community mental healthcare. We argue that, althogh the move towards 'care in the community' may have had liberalising motivations, the subsequent reduction in inpatient or other supported residential provision, means that there has been an increasing move towards coercive measures outside of formal inpatient detention. We consider measures such as Community Treatment Orders, inducements, and other forms of leverage, explaining the underlying concepts, aims, and exploring adverse consequences and ethical difficulties

Charland's article suggests that we need to think more about whether decision-making capacity is impaired in severe addiction, working from the idea that drug dealers rely on this understanding of addiction to draw in their clients. Charland argues that it is possible to make a choice without being in control (to make decisions without having decision-making capacity). I argue in support of Charland's ideas by examining the reasons supporting a medical model of addiction and its importance. (Charland article and full commentaries included)

‘If only I could use this to show people that there really was something different about my brain, my life would be so much easier’ this was the recent reaction of a service user with a history of severe depression to a presentation of magnetic resonance imaging (MRI) images highlighting particularities of the depressed brain. He had experienced discrimination because his condition was viewed not as legitimate illness, but ‘weakness and malingering’, and he expressed a common desire for something to demonstrate a physical difference accompanying mental illness to display an objective reason for his symptoms, outside of his control. Prejudice against him seems rooted in ideas that he is too weak, lazy, selfish or devoid of willpower to manage the challenges of life like others, despite being, fundamentally, the same. Meanwhile, there is an important theme within anti-stigma work to emphasise the normality, prevalence and universality of mental illness, in the hope that stressing likeness and commonality will lead to a reduction in public fear and alienation. Stigma is defined as ‘a mark of disgrace’ or as a distinguishing negative token. Thornicroft, for example, calls it ‘a characteristic that individuals possess (or are believed to possess) that conveys a social identity that is devalued, or a mark of disgrace associated with a particular circumstance, quality, or person’ (p. 9ff ) and explains how it engenders prejudicial beliefs, which lead to discriminatory behaviour. The idea of ‘otherness’ is central to psychiatric stigma. Yet my example shows a victim of discrimination actually suggesting that a substantive marker of difference could potentially reverse prejudice. It seems that, for some, psychiatric stigma cannot be eradicated by simply convincing people that mental illness involves no fundamental difference. So we have a perplexing paradox stigma appears to stem from two opposing beliefs that those with mental illness are both different and also not actually different. Although there may be no simple solution to the problem of psychiatric stigma, a conceptual framework for explaining this central paradox might at least shed some light on the difficulties. Although clearly multifaceted and complex, psychiatric stigma is also full of puzzling contradictions. It still appears that fear on the one hand and blame on the other dominate discriminatory attitudes towards mental illness. We find ourselves stuck between a rock and a hard place, where decreasing one stigmatising attitude may inadvertently increase another. Biomedical models might reduce blame and promote treatment, but they can increase perceptions of danger, desire for social distance and acceptance of more coercive treatment measures. Stressing affinity or psychosocial factors risks further alienating those with more severe mental illness, minimising the problems they face and taking us full circle back to the idea of mental illness as an inability to manage the stresses and challenges of life, resulting from weakness of personality, moral strength or self-control (not to mention the concomitant dangers of over-pathologising and medicating ‘ordinary’ stress reactions). In this journal, Kingdon argued that even ideas like the one in four mantra do not sufficiently highlight commonality, and recommended replacing ‘mental disorder’ with a more ‘socially inclusive’ stress continuum model of mental illnesses as extreme variants of reaction to stresses faced by everybody. In response, Braithwaite maintains EDITORIALS

The idea that people with severe mental illness should be able to plan in advance for periods of illness as a means of enhancing autonomy has been long debated and is increasingly being enshrined in codes of practice and mental health legislation. It has been argued that the ethical imperative for this is especially pronounced in bipolar (BP), a condition in which sufferers often experience episodic crises interspersed with periods of wellness. However, there is a paucity of published research investigating experiences of advance decision making (ADM) in people with BP or their attitudes towards it. Therefore an online survey of BPUK's mailing list was conducted. 932 people with BP completed the survey (response rate 5.61%). Here we present (a) the questionnaire designed specifically for this study and (b) the study's supplementary information (generation of outcomes of interest, missing data analysis and cross-tabulations of outcomes of interest with independent variables)

Inspired in his leadership, fearless in battle, and boundless in his ambition, Alexander the Great inherited his father's empire at the age of 20 and resolved to expand it. By the time of his death at 32, his empire covered most of the known world - from Greece to India - and comprised 2 million square miles. His achievement was - and remains - unparalleled. He was worshipped as a god in his lifetime and his legend has only grown with time. A chronological selection of extracts taken from Arrian's The Campaigns of Alexander, Plutarch's The Age of Alexander, Quintus Curtus Rufus's History of Alexander.

An article exploring the synthesis between conceptual and practical work within the Mental Health and Justice Project. This editorial describes the articles within the MHJ Special Issue in International Journal of Law and Psychiatry and how interdisciplinary exploration in mental health ethics and law can advance human rights debates and have practical impact on clinical practice and law.

Consent to research with decision-making capacity for research (DMC-R) is normally a requirement for study participation. Although the symptoms of schizophrenia and related psychoses are known to affect decision-making capacity for treatment (DMC-T), we know little about their effect on DMC-R.AimsWe aimed to determine if DMC-R differs from DMC-T in proportion and associated symptoms in an in-patient sample of people with schizophrenia and related psychoses. Cross-sectional study of psychiatric in-patients admitted for assessment and/or treatment of schizophrenia and related psychoses. We measured DMC-R and DMC-T using 'expert judgement' clinical assessment guided by the MacArthur Competence Assessment Tool for Clinical Research, the MacArthur Competence Assessment Tool for Treatment and the legal framework of the Mental Capacity Act (2005), in addition to symptoms of psychosis. There were 84 participants in the study. Half the participants had DMC-R (51%, 95% CI 40-62%) and ...

Background Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated. Methods We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses. Results A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were s...

The primary aims are to consider whether a range of paternalistic medical interventions can be justified in the treatment of factitious disorder (FD) and to show that the particularities of FD and its management make it an ideal phenomenon to highlight the difficulties of balancing respect for self-determination, responsibility and duty of care in psychiatry. FD is usually classified as a mental disorder involving deliberate and hidden feigning or inducement of illness, in order to achieve patient status. Both the nature of the disorder and the approach to treatment are controversial and under-researched. It is argued that FD should be classified as a mental disorder; may well expose the patient to extreme risk; can warrant paternalistic interventions, in order to fulfil duty of care. Moreover, treatment of FD is inherently paternalistic and therefore raises interesting questions about justifications and type of paternalistic interventions in psychiatry both for FD and in general. A brief account of key questions concerning psychiatry and paternalism is followed by some case histories of FD, the clinical dilemmas posed and the question of how this disorder might warrant paternalistic interventions. In order to answer this question, two things are considered: the legitimacy and character of FD as a mental disorder; possible frameworks for and types of paternalistic interventions. To conclude, it is argued that there are no compelling reasons for rejecting the use of paternalistic interventions for FD, but that further investigation of FD and type and frameworks for psychiatric paternalism, in relation to FD and other mental disorders, are urgently needed.

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T)...

The use of coercion is one of the defining issues of mental health care and has been intensely controversial since the very earliest attempts to contain and treat the mentally ill. The balance between respecting autonomy and ensuring that those who most need treatment and support are provided with it has never been finer, with the ‘move into the community’ in many high-income countries over the last 50 years and the development of community services. The vast majority of patients worldwide now receive mental health care outside hospital, and this trend is increasing. New models of community care, such as assertive community treatment (ACT), have evolved as a result and there are widespread provisions for compulsory treatment in the community in the form of community treatment orders. These legal mechanisms now exist in over 75 jurisdictions worldwide. Many people using community services feel coerced, but at the same time intensive forms of treatment such as ACT, which arguably add ...

By mid-5th century BC, Athens was governed by democratic rule and power turned upon the ability of the citizen to command the attention of the people, and to sway the crowds of the assembly. It was the Sophists who understood the art of rhetoric and the importance of transforming effective reasoning into persuasive public speaking. Their enquiries - into the status of women, slavery, the distinction between Greeks and barbarians, the existence of the gods, the origins of religion, and whether virtue can be taught - laid the groundwork for the insights of the next generation of thinkers such as Plato and Aristotle.

Despite extensive evidence for its effectiveness, electroconvulsive therapy remains the subject of fierce opposition from those contesting its benefits and claiming extreme harms. Alongside some reflections on my experiences of this treatment, I examine the case against electroconvulsive therapy and find that it appears to rest primarily on unsubstantiated claims about major ethical violations, rather than clinical factors such as effectiveness and risk.

The onset of psychotic disorders often brings major changes to an individual, which, for some, are never fully reversed and remain a dominant force. Despite such changes, the individual still experiences themselves as a continuous person and must find some way to assimilate these shifts into their self‐concept. From a philosophical perspective, the various models of continuing identity all depend upon some notion of fundamental stability, which seems a poor fit for the trajectory associated with psychotic disorders. This article will explore, in more depth, how the transitions that accompany psychotic disorders present a challenge to conventional and philosophical notions of selfhood. If we are not simply to judge psychotic disorders as bringing about a loss of selfhood, we will need an alternative model of identity to use in this context.

The specific context of community mental health care affects the debate surrounding coercion in psychiatry, not by raising radically new questions but by highlighting the complexity of this debate and some of the associated ethical difficulties. This chapter begins by looking at the varying conventional justifications for involuntary treatment and then considers the different mechanisms through which such ‘coercion’ is enforced within the community—from formal compulsion via community treatment orders (CTOs) through to ‘softer’ pressures, such as ‘persuasion’ or ‘interpersonal leverage’. Some commonly accepted ideas surrounding interventions such as ‘incentives’ and ‘threats’ are challenged. The chapter concludes with some broad suggestions as to a how a reformulated ‘decision-making capability and best interests’ approach may be one way to increase the ethical viability of community coercion.

On 13 June 2014, the Centre for the Humanities and Health at King's College London hosted a 1-day workshop on 'parentalism and trust'. This workshop was the sixth in a series of workshops whose aim is to provide a new model for high-quality open interdisciplinary engagement between medical professionals and philosophers. This report briefly describes the workshop methodology and the discussions on the day.

SummaryChallenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and ‘ordinary’ experience to escape the fear-related prejudices associated with the imagined ‘otherness’ of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’ and ‘unlikeness-based’ conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.

Borrett joins other phenomenologists in using phenomenological ideas on temporality to explain how illness affects the individual's experience of time. Unlike others, he attempts to synthesize this use of phenomenology with a biomedical understanding of the relation between time and illness. My paper expands on Borrett's ideas by reviewing current medical scholarship on time and illness perception, including Heidegger's ideas on temporality. The first section considers questions and suggestions emerging from contemporary medicine. After a short review of theories of time perception, I describe and critique how Borrett and others use phenomenological temporality in a medical context. My conclusion suggests how Heideggerian temporality might help with the questions and recommendations emerging within diverse medical fields.

The issue of how to incorporate the individual's first-hand experience of illness into broader medical understanding is a major question in medical theory and practice. In a philosophical context, phenomenology, with its emphasis on the subject's perception of phenomena as the basis for knowledge and its questioning of naturalism, seems an obvious candidate for addressing these issues. This is a review of current phenomenological approaches to medicine, looking at what has motivated this philosophical approach, the main problems it faces and suggesting how it might become a useful philosophical tool within medicine, with its own individual, but interrelated, contribution to make to current medical debates. After the general background, there is a brief summary of phenomenological ideas and their current usage in a medical context. Next is a critique of four key claims within current phenomenological medical works, concerning both the role phenomenology plays and the supposedly clear divide between phenomenology and other approaches. There are significant problems within these claims, largely because they overlook the complexity of the questions they consider. Finally, there is some more in-depth examination of phenomenology itself and the true complexity of phenomenological debate concerning subjectivity. The aim is to show that it will be both more productive and truer to phenomenology itself, if we use phenomenology as a philosophical method for explicating and gaining deeper understanding of complex and fundamental problems, which are central to medicine, rather than as providing simple, but flawed solutions.