Decision-Making Capacity First published Tue Jan 15, 2008; substantive revision Fri Aug 14, 2020 In many Western jurisdictions the law presumes that adult persons, and sometimes children that meet certain criteria, are capable of making their own medical decisions; for example, consenting to a particular medical treatment, or consenting to participate in a research trial. But what exactly does it mean to say that a subject has or lacks the requisite capacity to decide? This question has to do with what (...) is commonly called “decisional capacity”, a central concept in health care law and ethics, and increasingly an independent topic of philosophical inquiry. -/- Decisional capacity can be defined as the ability of subjects to make their own medical decisions. Somewhat similar questions of capacity arise in other contexts, such as capacity to stand trial in a court of law and the ability to make decisions that relate to personal care and finances. However, the history behind the more general legal notions of capacity to stand trial and capacity to manage one’s life is different and operates somewhat differently in law (Roth, Meisel, & Litz 1977; Zapf & Roesch 2005). For the purposes of this discussion the notion of decisional capacity will be limited to medical contexts only; most notably, those where decisions to consent or to refuse treatment or participation in clinical research are concerned. (shrink)

The DSM characterizes major depressive disorder partly in temporal terms: the depressive mood must last for at least two weeks, and also must impact the subject "most of the day, nearly every day." However, from the standpoint of phenomenological psychopathology, the long-lasting quality of the condition hardly captures the distinctiveness of depression. While the DSM refers to objective time as measured by clocks and calendars, what is especially striking about depression is the distortions to lived time that it involves. But (...) is there any relation between a) these disruptions to temporal experience and b) the tendency for depressive symptoms to persist and endure? To explore the connection between lived time and objective time, I investigate the embodied and enactive nature of intentionality among subjects suffering from depression. What I call 'affective framing' is a spontaneous, pre-reflective way of filtering information that involves bodily attunement and allows subjects to focus their attention on what they feel is important. I will argue that affective framing ordinarily has a forward-looking temporal structure and a "teleological direction" that is rooted in our embodiment. However, depression involves a distortion in future-directed intentionality, so that a subject becomes temporally desituated and cut off from the future. This contributes to many of the characteristic features of depression, including apparent lack of motivation, inability to imagine future possibilities, alterations in lived time, and a sense that one is "stuck." To gain a better understanding of this disruption to the futuredirected structure of affective framing in cases of depression, I look to concepts from complex dynamic systems theory and the notion of 'habit.' My proposed account aims to shed light on how a disruption to future-directedness impacts bodily attunement and reinforces depression as a long-term condition. (shrink)

This paper seeks to develop a phenomenological account of the disorientation of grief, specifically the relationship between disorientation and the breakdown in practical self-understanding at the heart of grief. I argue that this breakdown cannot be sufficiently understood as a breakdown of formerly shared practices and habitual patterns of navigating lived-in space that leaves the bereaved individual at a loss as to how to go on. Examining the experience of losing a loved person and a loved person-to-be, I instead propose (...) that this breakdown should be understood primarily in relation to a distinctive kind of futurity operative in disorientation, irrespective of the extent to which there is a breakdown of formerly shared practices and habitual patterns of navigating lived-in space. Drawing on the resources afforded by Heidegger’s phenomenology, I argue that it is a core characteristic of the experience of disorientation in grief that the grieving person can no longer meaningfully press ahead into a specific futural self. This view comes with certain advantages over existing accounts of the temporality of grief for making sense of the disorientated relationship to futurity, which the appeal to Heideggerian resources makes possible. (shrink)

This paper seeks to develop a phenomenological account of the disorientation of grief, specifically the relationship between disorientation and the breakdown in practical self-understanding at the heart of grief. I argue that this breakdown cannot be sufficiently understood as a breakdown of formerly shared practices and habitual patterns of navigating lived-in space that leaves the bereaved individual at a loss as to how to go on. Examining the experience of losing a loved person and a loved person-to-be, I instead propose (...) that this breakdown should be understood primarily in relation to a distinctive kind of futurity operative in disorientation,irrespectiveof the extent to which there is a breakdown of formerly shared practices and habitual patterns of navigating lived-in space. Drawing on the resources afforded by Heidegger’s phenomenology, I argue that it is acore characteristicof the experience of disorientation in grief that the grieving person can no longer meaningfully press ahead into aspecific futural self. This view comes with certain advantages over existing accounts of the temporality of grief for making sense of the disorientated relationship to futurity, which the appeal to Heideggerian resources makes possible. (shrink)

Schuklenk and van de Vathorst's paper is a very welcome addition to the literature on the assisted dying debate and will be of great interest to clinicians working in the field of mental health.1 Many psychiatrists will have had patients who have asked them to allow them to die, to desist in their efforts to prevent their suicide, and one of us has had personal experience, outside of professional life, of being asked to aid in someone's attempt to end their (...) life in the context of an episode of mood disorder. The person with depression asking professionals, friends and family members to aid them in ending their life is a very real phenomenon. In their discussion, Schuklenk and van de Vathorst's paper uses two principles that we endorse and add weight to their argument: namely, the reality of suffering in depression and the parity of mental and physical illness. Indeed, the case Schuklenk and van de Vathorst make is a strong one and our commentary will focus on the premise of the argument around choosing death and some empirical clarification about competence in depression and the nature of treatment-resistant depression (TRD) and its prognosis. The conceptual concern we wish to discuss in relation to assisted dying, endorsed by the state and legislature, is not linked to any moral or religious concern, or even on grounds related to ‘slippery slope’ or ‘abuse’ arguments. Rather the worry is how one could operationalise decisions around assisted dying as based on competence and capacity and view such decisions as rational. I think this concern is not limited to depressive illness, but to all decisions regarding choosing non-existence. Schuklenk and van de Vathorst offer the following useful criteria to regulate assisted suicide:1. (shrink)

Examples of patients with anorexia nervosa, depression or borderline personality disorder who have decision-making capacity as currently operationalized, but refuse treatment, are discussed. It appears counterintuitive to respect their treatment refusal because their wish seems to be fuelled by their illness and the consequences of their refusal of treatment are severe. Some proposed solutions have focused on broadening the criteria for decision-making capacity, either in general or for specific patient groups, but these adjustments might discriminate against particular groups of patients (...) and render the process less transparent. Other solutions focus on preferences expressed when patients are not ill, but this information is often not available. The reason for such difficulties with assessing decision-making capacity is that the underlying psychological processes of normal decision-making are not well known and one cannot differentiate between unwise decisions caused by an illness or other factors. The proposed alternative, set out in this paper, is to allow compulsory treatment of patients with decision-making capacity in cases of an emergency, if the refusal is potentially life threatening, but only for a time-limited period. The argument is also made for investigating hindsight agreement, in particular after compulsory measures. -/- . (shrink)

ABSTRACTTime-consciousness has long been a focus of research in phenomenology and phenomenological psychology. We advance and extend this tradition of research by focusing on the character of temporal experience under conditions of mania. Symptom scales and diagnostic criteria for mania are peppered with temporally inflected language: increased rate of speech, racing thoughts, flight-of-ideas, hyperactivity. But what is the underlying structure of temporal experience in manic episodes? We tackle this question using a strategically hybrid approach. We recover and reconstruct three hypotheses (...) regarding manic temporality that were advanced and modeled by two pioneers of clinical phenomenology: Eugène Minkowski and Ludwig Binswanger. We then test, critique, and refine these hypotheses using heterophenomenological methods in an interview-based study of persons with a history of bipolar and a current diagnosis of acute mania. Our conclusions support a central hypothesis due to Minkowski... (shrink)

In May 2013 a new Assisted Dying Bill was tabled in the House of Lords and is currently scheduled for a second reading in May 2014. The Bill was informed by the report of the Commission on Assisted Dying which itself was informed by evidence presented by invited experts.

This article explores the idea that there is a spectrum of individuals who feel compelled to dwell in the past, either due to psychological or social conditions. I analyze both conditions respectively by critically examining two cases: post-traumatic stress disorder and racialized oppression. I propose that individuals with PTSD can feel psychologically compelled to dwell in the past in a dually negative sense: the individual lives in the past but also broods on it, causing them to feel “stuck” in the (...) past. This kind of “dwelling” can cause individuals to suffer disruptions to their sense of self and intersubjectivity. After exploring the psychological case of dwelling in the past, I explore the social sense in which individuals can dwell in the past due to oppressive social structures by examining the case of racialized oppression. The case of racialization is philosophically stimulating because of its intersubjective dimensions—it subverts the idea that dwelling in the past is simply a psychological phenomenon by capturing that others can help or hinder us with maintaining a sense of self and future-directed intentionality. By putting the phenomenological work of Al-Saji into conversation with recent phenomenological research on incarceration, I propose that racialization can be similarly disruptive to one’s sense of self and intersubjectivity. The proposed account is suggestive that traumatic and oppressive experiences may amplify and compound each other in ways not yet well elucidated in the literature. If this account is taken to be persuasive, it is indicative that both psychological and social conditions mediate one’s temporality and well-being. (shrink)

There are two extreme poles in the literature on akrasia. Internalists hold that it's impossible to act intentionally against your better judgment, because there's a necessary internal relation between judgment and intentional action. To the contrary, externalists maintain that we can act intentionally against our better judgment, because the will operates independently of judgment. Critics of internalism argue that it fails a realism test—most people seem to think that we can and do act intentionally against our better judgment. And critics (...) of externalism argue that it flirts with incoherence by severing the intimate link between judgment and action. Drawing on resources from phenomenology, the cognitive sciences, analytic action theory, and recent “hybrid models” of skilled action, I argue that one route beyond this theoretical impasse is to understand akrasia as a form of skillful pre-reflective intentional action. This strategy, I argue, preserves the internalist insight that there is indeed an intimate relation between judgment and intentional action; and it also confirms the externalist claim that this relation is defeasible, but it does so without falling into incoherence. (shrink)

I offer an approach to Dreyer's film Ordet as a contribution to the phenomenology of a certain kind of religious experience. The experience in question is one of a moment that disrupts the chronological flow of time and that, in the lived experience of it, is charged with eternal significance. I propose that the notoriously divisive ending of Ordet reflects an aim to provide the film's viewers with an experience of this very sort. l draw throughout on some central ideas (...) in Kierkegaard’s work, especially his category of ‘the moment’. (shrink)

The aim of the article is to discuss the specifics of human actions and decision-making processes from the psychopathological perspective. The concepts of action and decision making are reported in the context of human experience and the experiential structure of self-determination. The starting point is provided by considerations related to the notion of mental illness as described by Lennart Nordenfelt, as well as Antoni Kępiński’s concept of informational metabolism. The consequences of and changes to decision-making processes in mental disorders will (...) be presented on the example of depressive experience. Decision-making process can be understood in terms of three-dimensional pre-reflexive experience that undergoes changes in depressive patients: space of possibility, sense of agency and time experience. The analysis will allow us to better understand the structure of experience attributable to people suffering from depression. (shrink)