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Hardcover | $8.75 Short | £7.95 | 232 pp. | 6 x 9 in | 1 figure | May 2011 | ISBN: 9780262015493
eBook | $24.95 Short | May 2011 | ISBN: 9780262296359
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The Ethical Treatment of Depression

Autonomy through Psychotherapy


One in six people worldwide will experience depression over the course of a lifetime. Many who seek relief through the healthcare system are treated with antidepressant medication; in the United States, nearly 170 million prescriptions for antidepressants were written in 2005, resulting in more than $12 billion in sales. And yet despite the dominance of antidepressants in the marketplace and the consulting room, another treatment for depression has proven equally effective: psychotherapy—in particular, cognitive behavior therapy (CBT). Antidepressants can lift mood independent of a person’s understanding of symptoms or stressors. By contrast, CBT teaches patients skills for dealing with distressing feelings, negative thoughts, and causal stressors.

In The Ethical Treatment of Depression, Paul Biegler argues that the insights patients gain from the therapeutic process promote autonomy. He shows that depression is a disorder in which autonomy is routinely and extensively undermined and that physicians have a moral obligation to promote the autonomy of depressed patients. He concludes that medical practitioners have an ethical imperative to prescribe psychotherapy—CBT in particular—for depression. To make his case, Biegler draws on a wide philosophical literature relevant to autonomy and the emotions and makes a comprehensive survey of the latest research findings from the psychological sciences.

Forcefully argued, densely researched, and engagingly written, the book issues a challenge to physicians who believe their duty of care to depressed patients is discharged by merely writing prescriptions for antidepressants.

About the Author

Paul Biegler is Adjunct Research Fellow at the Centre for Human Bioethics, Monash University. He was the recipient of a 2011 Australian Museum Eureka Prize.

Table of Contents

  • The Ethical Treatment of Depression
  • Philosophical Psychopathology: Disorders of the Mind
  • Jeffrey Poland and Jennifer Radden, Series Editors
  • The Ethical Treatment of Depression: Autonomy through Psychotherapy,
  • Paul Biegler (2011)
  • Addiction and Responsibility,
  • Edited by Jeffrey S. Poland and George Graham (2011)
  • Psychiatry in the Scientific Image,
  • Dominic Murphy (2006)
  • Brain Fiction: Self-Deception and the Riddle of Confabulation,
  • William Hirstein (2004)
  • Imagination and Its Pathologies,
  • Edited by James Phillips and James Morley (2003)
  • Imagination and the Meaningful Brain,
  • Arnold H. Modell (2003)
  • When Self-Consciousness Breaks: Alien Voices and Inserted Thoughts,
  • G. Lynn Stephens and George Graham (2000)
  • The Myth of Pain,
  • Valerie Gray Hardcastle (1999)
  • Divided Minds and Successive Selves: Ethical Issues in Disorders of Identity and Personality,
  • Jennifer Radden (1996)
  • The Ethical Treatment of Depression
  • Autonomy through Psychotherapy
  • Paul Biegler
  • The MIT Press
  • Cambridge, Massachusetts
  • London, England
  • ©
  • 2011
  • Massachusetts Institute of Technology
  • All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from the publisher.
  • For information about special quantity discounts, please email special_sales@
  • This book was set in Stone Sans and Stone Serif by Toppan Best-set Premedia Limited. Printed and bound in the United States of America.
  • Library of Congress Cataloging-in-Publication Data
  • Biegler, Paul, 1963–
  • The ethical treatment of depression : autonomy through psychotherapy / Paul Biegler.
  •  p. ; cm. — (Philosophical psychopathology)
  • Includes bibliographical references and index.
  • ISBN 978-0-262-01549-3 (hardcover : alk. paper)
  • 1. Depression, Mental—Treatment—Moral and ethical aspects. 2. Cognitive therapy—Moral and ethical aspects. 3. Autonomy (Psychology) I. Title. II. Series: Philosophical psychopathology.
  • [DNLM: 1. Depressive Disorder—therapy. 2. Antidepressive Agents. 3. Cognitive Therapy—ethics. 4. Personal Autonomy. WM 171]
  • RC537.B487 2011
  • 174.2′968527—dc22
  • 2010036606
  • 10 9 8 7 6 5 4 3 2 1
  • To the memory of my mother, Beryl Biegler
  • Contents
  • Series Foreword ix
  • Acknowledgments xi
  • 1 Introduction 1
  • 2 Autonomy:
  • The Importance of Justified Beliefs about Material Facts 9
  • 3 Autonomy:
  • The Importance of Justified Beliefs about Affect 39
  • 4 Depression:
  • Disorder of Affect, Disorder of Autonomy 65
  • 5 Understanding Negative Biases Promotes Autonomy in Depression 97
  • 6 Understanding Causal Stressors Promotes Autonomy in Depression 119
  • 7 A Special Duty to Promote Autonomy in Depression:
  • The Moral Case for Psychotherapy 143
  • Appendix: The Hamilton Rating Scale for Depression 169
  • Notes 175
  • Index 207


“This is not an anti-psychiatry book because, even though he explicitly puts more emphasis on stress than on biology in depression, he never recommends against the use of antidepressants. In that sense The Ethical Treatment of Depression contributes, in my opinion, to a hopeful trend toward more widespread application of insight oriented psychotherapy augmenting or augmented by the use of antidepressants.”—Metapsychology
“This is an important book for clinicians and medical ethicists who are seeking new ways to treat and understand depression's causes…Recommended.”—Choice


“Biegler's wonderful book sheds new light on autonomy, depression, and the moral purposes of medicine, making a strong case for preferring psychotherapeutic over drug treatments for depression. His clearly written, scientifically well-informed book is essential reading for all interested in medical ethics or mental disorders.”
Richard Ashcroft, Professor of Bioethics, University of London
“No other book combines philosophy with so much empirical information to critique overreliance on drugs in the treatment of a mental illness. Biegler's message is both sobering and clear. His book is a significant contribution to the philosophy of psychiatry as well as to the key role that maximizing patient autonomy should play in the choice of therapies for depression.”
George Graham, Professor of Philosophy and Neuroscience, Georgia State University
“This book is long overdue. Biegler gives a compelling analysis of the impact depression has on autonomous decision making—a factor which, he argues, has important implications for its treatment. Given how many people suffer from this debilitating disease worldwide, his insight has the potential to transform the medical, moral, and social well-being of a substantial portion of the world's population. The Ethical Treatment of Depression is essential for clinicians, bioethicists, lawyers, and policy practitioners.”
Patricia Illingworth, Department of Philosophy and Religion, College of Business Adminstration, and School of Law, Northeastern University