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Clinical ethics
NICE guidelines, clinical practice and antisocial personality disorder: the ethical implications of ontological uncertainty
  1. M D Pickersgill
  1. Correspondence to Dr M D Pickersgill, Public Health Sciences Section, Division of Community Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, UK; martyn.pickersgill{at}


The British National Institute for Health and Clinical Excellence (NICE) has recently (28 January 2009) released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personality disorder (ASPD). Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This paper argues that in refraining from emphasising uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals “at risk” of raising antisocial children. Although this paper does not argue that NICE is “wrong” in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE.

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  • Funding The empirical research from which this analysis draws was supported primarily by the ESRC. Additional funds supporting the specific fieldwork detailed in this article were provided by the AL Charitable Trust and the British Sociological Association.

  • Competing interests Declared. I am part of a non-profit think-tank on the policy, legal and ethical aspects of personality disorder. Also part of this think-tank is the former Chair of the National Institute for Health and Clinical Excellence Antisocial Personality Disorder Guideline Development Group. The think-tank is convened under the auspices of the Personality Disorder Institute (PDI). The Director of the PDI was also a member of the Guideline Development Group. Both these professionals are part of the University of Nottingham/Nottinghamshire Healthcare NHS Trust Institute of Mental Health, of which I am an associate fellow.

  • Ethics approval Ethics approval was obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i Sociologists have advanced several useful analyses of the politics of identifying “at risk” individuals over the past decade.27 28 29

  • ii Issues of ontological uncertainty regarding ASPD and psychopathy are also germane to scientific research in this area.21

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