Pre-commitment directives or Ulysses contracts are often defended as instruments that may strengthen the autonomous self-control of episodically disordered psychiatric patients. Autonomy is understood in this context in terms of sovereignty ("governing" or "managing" oneself). After critically analyzing this idea of autonomy in the context of various forms of self-commitment and pre-commitment, we argue that what is at stake in using Ulysses contracts in psychiatry is not autonomy as sovereignty, but autonomy as authenticity. Pre-commitment directives do not function to protect (...) autonomous self-control. They serve in upholding the guidance that is provided by one's deepest identity conferring concerns. We elucidate this concept of autonomy as authenticity, by showing how Ulysses contracts protect the possibility of being "a self.". (shrink)

In contemporary liberal ethics patient autonomy is often interpreted as the right to self-determination: when it comes to treatment decisions, the patient is given the right to give or withhold informed consent. This paper joins in the philosophical and ethical criticism of the liberal interpretation as it does not regard patient autonomy as a right, rule or principle, but rather as a practice. Patient autonomy, or so I will argue, is realised in the concrete activities of day-to-day health care, in (...) the material and technological context of care, in arrangements of health care institutions, in the physical training of people with disabilities, as well as in the concrete activities of care-giving. This move from conversations in the consultation room to other sites and situations in the practice of care takes seriously the empirical reality of medical care and intends to show that patient autonomy is practically realised in a much richer and more creative way than most ethical theory seems to assume. (shrink)

Moral rights feature prominently and are relied on substantially in debates in bioethics. Conceptually, however, duties can perform the logical work of rights, but not vice versa, and reference to rights is therefore inessential. Normatively, rights, like duties, depend on more basic moral values or principles, and attempts to establish the logical priority of rights over duties or the reverse are misguided. In practical decision making, however, an analysis in terms of duties is more fruitful than one based on rights. (...) A right may function as a proxy term for a consequentialist rule, or for a deontological constraint, but does not thereby enrich these concepts. Rights may also help in a purely expressive sense and may assist an initial focusing on a moral conflict. However, their role in bioethics discourse is more one of convenience than of necessity. Moreover, unless rights are firmly founded on fundamental moral values, their use encourages rhetoric rather than argument. (shrink)

Lisa A. Eckenwiler, Long-term care, globalization, and justice, Baltimore: The Johns Hopkins University Press, 2012, reviewed by Lynette Reid.

One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: (...) the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles. (shrink)

This paper challenges the traditional assumption that descriptive and prescriptive sciences are essentially distinct by presenting a study on the implicit normativity of the production and presentation of biomedical scientific facts within evidence-based medicine. This interdisciplinary study serves as an illustration of the potential worth of the concept of implicit normativity for bioethics in general and for integrated empirical ethics research in particular. It demonstrates how both the production and presentation of scientific information in an evidence-based decision-support contain implicit presuppositions (...) and values, which pre-structure the moral environment of the clinical process of decision-making. As a consequence, the evidence-based decision support did not only support the clinical decision-making process; it also transformed it in a morally significant way. This phenomenon undermines the assumption within much of the literature on patient autonomy that information disclosure is a conditional requirement before patient autonomy even starts; patient autonomy is already influenced during the production and presentation of information. These results imply an increased responsibility of those who produce and present evidence-based facts(i.e. scientists in general and physicians in particular). The insights of this study not only involve a different focus on both theory and practice of patient autonomy and informed consent, but they also call for a broader scope of morality than does traditional empirical research in bioethics. The concept of implicit normativity within integrated empirical ethics research calls for a strong cooperation between bioethicists and descriptive scientists, i.e., a cooperation that goes beyond the discipline-specific epistemic values and that takes place during all phases of the research process. (shrink)

The use of coercive measures in the care for the addicted has changed over the past 20 years. Laws that have adopted the “dangerousness” criterion in order to secure patients’ rights to non-intervention are increasingly subjected to critique as many authors plead for wider dangerousness criteria. One of the most salient moral issues at stake is whether addicts who are at risk of causing danger to themselves should be involuntarily admitted and/or treated. In this article, it is argued that the (...) dilemma between coercion on the one hand and abandonment on the other cannot be analysed without differentiated perspectives on the key notions that are used in these debates. The ambiguity these notions carry within care practice indicates that the conflict between the prevention of danger and respect for autonomy is not as sharp as the legal systems seem to imply. Some coercive measures need not be interpreted as an infringement of autonomy—rather, they should be interpreted as a way to provide good care. (shrink)

This paper explores the dominant rational approach to informed consent and challenges the appropriateness of this approach to ethical decision‐making with people with dementia. In dementia care a dominant assumption exists that people are not autonomous because of their inability to make decisions and exercise freedom of choice. The rational understanding of autonomy being the capacity to exercise freedom of choice means that health and social care professionals feel justified in making decisions on behalf of the person with dementia. If (...) a person cannot consent to an intervention then a proxy is used to make the decision. This paper argues that such an approach reinforces the mind‐body dualism that dominates health and social care discourse. Whilst acknowledging the place of proxy decision‐making, it is argued that there is a need to hear the voice of the person with dementia that goes beyond rational understandings of what is heard and that does not reinforce separation of the mind and body. An understanding of the person through their ‘narrative identity’ is proposed and illustrated through a case example. Drawing on the philosophy of Ricoeur it is argued that an individual's narrative identity can be developed and used to underpin informed consent decisions. Using a case example it is argued that paying attention to an individual's narrative identity provides a way of respecting the autonomy of the individual with dementia in a way that is consistent with their overall life plan. (shrink)

In 2015, the Israeli Knesset passed the force-feeding act that permits the director of the Israeli prison authority to appeal to the district court with a request to force-feed a prisoner against his expressed will. A recent position paper by top Israeli clinicians and bioethicists, published in Hebrew, advocates for force-feeding by medical professionals and presents several arguments that this would be appropriate. Here, we first posit three interrelated questions: 1. Do prisoners have a right to hunger-strike? 2. Should governing (...) institutions force-feed prisoners and/or is it ethical to force-feed prisoners? 3. Should healthcare professionals force-feed prisoners? We then focus on the first and third questions. We first briefly provide several arguments to support the right of prisoners to refuse treatment. Next, we critically review the arguments presented in the Israeli position paper, demonstrating that they are all misguided at best. Lastly, we briefly present arguments against force-feeding by medical professionals. We conclude that healthcare providers should not participate in the force-feeding of prisoners. (shrink)

BackgroundThe COVID-19 pandemic has changed the healthcare landscape drastically. Stricken by sharp surges in morbidity and mortality with resource and manpower shortages confounding their efforts, the medical community has witnessed high rates of burnout and post-traumatic stress amongst themselves. Whilst the prevailing literature has offered glimpses into their professional war, no review thus far has collated the deeply personal reflections of physicians and ascertained how their self-concept, self-esteem and perceived self-worth has altered during this crisis. Without adequate intervention, this may (...) have profound effects on their mental and physical health, personal relationships and professional efficacy.MethodsWith mentions of the coronavirus pervading social media by the millions, this paper set out to collate and thematically analyse social media posts containing first-person physician reflections on how COVID-19 affected their lives and their coping mechanisms. A consistent search strategy was employed and a PRISMA flowchart was used to map out the inclusion/exclusion criteria.ResultsA total of 590 social media posts were screened, 511 evaluated, and 108 included for analysis. Salient themes identified include Disruptions to Personal Psycho-Emotional State, Disruptions to Professional Care Delivery, Concern for Family, Response from Institution, Response from Society and Coping Mechanisms.ConclusionIt is evident that the distress experienced by physicians during this time has been manifold, multi-faceted and dominantly negative. Self-concepts were distorted with weakened self-esteem and perceived self-worth observed. The Ring Theory of Personhood (RToP) was adopted to explain COVID-19’s impact on physician personhood as it considers existential, individual, relational and social concepts of the self. These entwined self-concepts serve as ‘compensatory’ to one another, with coping mechanisms buffering and fortifying the physician’s overall personhood. With healthcare institutions playing a vital role in providing timely and targeted support, it was further proposed that a comprehensive assessment tool based on the RToP could be developed to detect at-risk physicians and evaluate the presence and effectiveness of established support structures. (shrink)

The use of Intelligent Assistive Technology in dementia care opens the prospects of reducing the global burden of dementia and enabling novel opportunities to improve the lives of dementia patients. However, with current adoption rates being reportedly low, the potential of IATs might remain under-expressed as long as the reasons for suboptimal adoption remain unaddressed. Among these, ethical and social considerations are critical. This article reviews the spectrum of IATs for dementia and investigates the prevalence of ethical considerations in the (...) design of current IATs. Our screening shows that a significant portion of current IATs is designed in the absence of explicit ethical considerations. These results suggest that the lack of ethical consideration might be a codeterminant of current structural limitations in the translation of IATs from designing labs to bedside. Based on these data, we call for a coordinated effort to proactively incorporate ethical considerations early in the design and development of new products. (shrink)

ZusammenfassungOnora O’Neill hat 1984 den Zusammenhang zwischen grundsätzlichen Bedenken gegenüber dem ethischen Autonomiebegriff und der Kritik an der paternalistisch geprägten medizinethischen Praxis hergestellt, nicht die tatsächliche Einwilligung des konkreten Patienten zu berücksichtigen, sondern die angenommene, hypothetische Einwilligung, die ein idealisierter, völlig rationaler Patient geben würde. Im Anschluss an experimentalpsychologische Studien zur subliminalen Wahrnehmung, zu Volition und Handlungskontrolle erfahren kompatibilistische Theorien menschlicher Freiheit innerhalb der theoretischen Philosophie neue Popularität. Eine Handlung ist demnach frei, wenn sie das Resultat bestimmter Fähigkeiten einer Person (...) ist („Kompetenztheorie“). Der Artikel setzt sich mit zwei dieser Theorien, Henrik Walters Konzept „natürlicher Freiheit“ und Michael Pauens „Minimalkonzeption personaler Freiheit“ näher auseinander—und zwar vorderhand im Hinblick auf den Entwurf eines nichtidealisierten ethischen Autonomiekonzeptes. Als solches ist es an der aktualen bzw. faktischen Fähigkeit einer Person ausgerichtet, rekurrierend auf die spezifische Determiniertheit autonomer Entscheidungen und Handlungen sowie auf ein relativiertes Konzept menschlicher Vernunft. (shrink)

Onora O’Neill hat 1984 den Zusammenhang zwischen grundsätzlichen Bedenken gegenüber dem ethischen Autonomiebegriff und der Kritik an der paternalistisch geprägten medizinethischen Praxis hergestellt, nicht die tatsächliche Einwilligung des konkreten Patienten zu berücksichtigen, sondern die angenommene, hypothetische Einwilligung, die ein idealisierter, völlig rationaler Patient geben würde. Im Anschluss an experimentalpsychologische Studien zur subliminalen Wahrnehmung, zu Volition und Handlungskontrolle erfahren kompatibilistische Theorien menschlicher Freiheit innerhalb der theoretischen Philosophie neue Popularität. Eine Handlung ist demnach frei, wenn sie das Resultat bestimmter Fähigkeiten einer Person (...) ist („Kompetenztheorie“). Der Artikel setzt sich mit zwei dieser Theorien, Henrik Walters Konzept „natürlicher Freiheit“ und Michael Pauens „Minimalkonzeption personaler Freiheit“ näher auseinander—und zwar vorderhand im Hinblick auf den Entwurf eines nichtidealisierten ethischen Autonomiekonzeptes. Als solches ist es an der aktualen bzw. faktischen Fähigkeit einer Person ausgerichtet, rekurrierend auf die spezifische Determiniertheit autonomer Entscheidungen und Handlungen sowie auf ein relativiertes Konzept menschlicher Vernunft. (shrink)

ZusammenfassungOnora O’Neill hat 1984 den Zusammenhang zwischen grundsätzlichen Bedenken gegenüber dem ethischen Autonomiebegriff und der Kritik an der paternalistisch geprägten medizinethischen Praxis hergestellt, nicht die tatsächliche Einwilligung des konkreten Patienten zu berücksichtigen, sondern die angenommene, hypothetische Einwilligung, die ein idealisierter, völlig rationaler Patient geben würde. Im Anschluss an experimentalpsychologische Studien zur subliminalen Wahrnehmung, zu Volition und Handlungskontrolle erfahren kompatibilistische Theorien menschlicher Freiheit innerhalb der theoretischen Philosophie neue Popularität. Eine Handlung ist demnach frei, wenn sie das Resultat bestimmter Fähigkeiten einer Person (...) ist. Der Artikel setzt sich mit zwei dieser Theorien, Henrik Walters Konzept „natürlicher Freiheit“ und Michael Pauens „Minimalkonzeption personaler Freiheit“ näher auseinander—und zwar vorderhand im Hinblick auf den Entwurf eines nichtidealisierten ethischen Autonomiekonzeptes. Als solches ist es an der aktualen bzw. faktischen Fähigkeit einer Person ausgerichtet, rekurrierend auf die spezifische Determiniertheit autonomer Entscheidungen und Handlungen sowie auf ein relativiertes Konzept menschlicher Vernunft. (shrink)

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives , it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could be minimised.Ulysses (...) contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. (shrink)

BackgroundVulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this (...) gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept.MethodsUsing PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher’s Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology.ResultsThirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults’ vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults’ vulnerability: understanding older adults’ vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures.ConclusionsThe way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human. (shrink)

This article is an analysis of the relationship between US hospice structure and the feeling of being a burden to others (FBO). A goal of US hospice care is to reduce the FBO. But in America, hospice is limited in its ability to do so because of the high caregiver burden it places on family members of dying people. Through a historical study, I show that this burden was excessive when the hospice system was created and has worsened over time. (...) Through three ethnographic vignettes, I demonstrate how this burden inculcates in dying people the FBO. I then examine the bioethical implications of this finding for the existing US debate about physician-assisted suicide (PAS). The presence of FBO due to insufficient hospice care supports arguments made by PAS opponents about the social pressure placed on dying people. This finding is not itself sufficient to resolve the “right to die” debate. But it provides the ground for a compromise, across the debate, to reduce the FBO by changing US hospice structure. The resulting consensus will further the goals of both PAS proponents and opponents. (shrink)

This article is an analysis of the relationship between US hospice structure and the feeling of being a burden to others. A goal of US hospice care is to reduce the FBO. But in America, hospice is limited in its ability to do so because of the high caregiver burden it places on family members of dying people. Through a historical study, I show that this burden was excessive when the hospice system was created and has worsened over time. Through (...) three ethnographic vignettes, I demonstrate how this burden inculcates in dying people the FBO. I then examine the bioethical implications of this finding for the existing US debate about physician-assisted suicide. The presence of FBO due to insufficient hospice care supports arguments made by PAS opponents about the social pressure placed on dying people. This finding is not itself sufficient to resolve the “right to die” debate. But it provides the ground for a compromise, across the debate, to reduce the FBO by changing US hospice structure. The resulting consensus will further the goals of both PAS proponents and opponents. (shrink)

This article is an analysis of the relationship between US hospice structure and the feeling of being a burden to others. A goal of US hospice care is to reduce the FBO. But in America, hospice is limited in its ability to do so because of the high caregiver burden it places on family members of dying people. Through a historical study, I show that this burden was excessive when the hospice system was created and has worsened over time. Through (...) three ethnographic vignettes, I demonstrate how this burden inculcates in dying people the FBO. I then examine the bioethical implications of this finding for the existing US debate about physician-assisted suicide. The presence of FBO due to insufficient hospice care supports arguments made by PAS opponents about the social pressure placed on dying people. This finding is not itself sufficient to resolve the “right to die” debate. But it provides the ground for a compromise, across the debate, to reduce the FBO by changing US hospice structure. The resulting consensus will further the goals of both PAS proponents and opponents. (shrink)

Free and informed consent is generally acknowledged as the legal andethical basis for living organ donation, but assessments of livingdonors are not always an easy matter. Sometimes it is necessary toinvolve psychosomatics or ethics consultation to evaluate a prospectivedonor to make certain that the requirements for a voluntary andautonomous decision are met. The paper focuses on the conceptualquestions underlying this evaluation process. In order to illustrate howdifferent views of autonomy influence the decision if a donor's offer isethically acceptable, three cases (...) are presented – from Germany, theUnited States, and India. Each case features a person with questionabledecision-making capacity who offered to donate a kidney for a siblingwith severe renal insufficiency. Although the normative framework issimilar in the three countries, different or sometimes even contraryarguments for and against accepting the offer were brought forward. Thesubsequent analysis offers two explanations for the differences inargumentation and outcome in spite of the shared reference to autonomyas the guiding principle: (1) Decisions on the acceptability of a livingdonor cannot simply be deducted from the principle of autonomy but needto integrate contextual information; (2) understandings of the wayautonomy should be contextualized have an important influence on theevaluation of individual cases. Conclusion: Analyzing the conceptualassumptions about autonomy and its relationship to contextual factorscan help in working towards more transparent and better justifieddecisions in the assessment of living organ donors. (shrink)

In this paper we develop a hermeneutic approach to the concept of competence. Patient competence, according to a hermeneutic approach, is not primarily a matter of being able to reason, but of being able to interpret the world and respond to it. Capacity should then not be seen as theoretical, but as practical. From the perspective of practical rationality, competence and capacity are two sides of the same coin. If a person has the capacity to understand the world and give (...) meaning to the situation, he or she is able to make decisions, and is thus competent. People can fail in the area of practical rationality. They can feel ill at ease, uncomfortable or not at home in the situation. Under such conditions, they appear as incompetent, and urge caregivers to respond in such a way that their competence can be raised. The issue is not how to measure their incompetence, but how to help them to become more competent, that is to get a practical grip on their situation and to be able to live out their lives in such a way that they develop their identity in relations with others. From a hermeneutic point of view, assessing a patient's capacity implies focusing on the patient's way of meaning making and regarding her behavior from the perspective of practical rationality. The focus should not be on the assessment as a matter of fact, but on improving capacity. This requires allowing the patient to experience the world meaningfully and affording her, in the context of a supportive and trustful institutional environment, the possibility of developing a personal narrative where her choices are expressed verbally or non-verbally. (shrink)

This essay lays the groundwork for a novel conception of autonomy that may be called “effective autonomy”—a conception designed to be genuinely action guiding in bioethics. As empirical psychology research on the heuristics and biases approach shows, decision making commonly fails to correspond to people’s desires because of the biases arising from bounded cognition. People who are classified as autonomous on contemporary philosophical accounts may fail to be effectively autonomous because their decisions are uncoupled from their autonomous desires. Accordingly, continuing (...) attempts to value patient autonomy must go beyond existing philosophical conceptions of autonomy to consider the background conditions of human decision making. (shrink)

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still (...) ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does. Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power. (shrink)

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still (...) ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does.Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power. (shrink)

The so-called Substituted Judgment Standard is one of several competing principles on how certain health care decisions ought to be made for patients who are not themselves capable of making decisions of the relevant kind. It says that a surrogate decision-maker, acting on behalf of the patient, ought to make the decision the patient would have made, had the latter been competent. The most common way of justifying the Substituted Judgment Standard is to maintain that this standard protects patients’ right (...) to autonomy, or self-determination, in the situation where they are no longer able to exercise this right on their own. In this paper we question this justification, by arguing that the most commonly suggested moral reasons for allowing and encouraging people to make their own choices seem not to apply when the patient’s decision-making is merely hypothetical. We end with some brief sketches of possible alternative ways of justifying the Substituted Judgment Standard. (shrink)