Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

The principle of respect for autonomy in clinical ethics is frequently linked to bioethics’ neglect of community-level ethical considerations. I argue that the latter is not an inevitable consequence of the former; rather, that neglect results from a common interpretation of respect for autonomy in solely synchronic and individual terms. A relational understanding of autonomy reveals the way in which respect inescapably involves diachronic and social dimensions. When these are acknowledged, the association between respect for autonomy and liberal individualism is (...) weakened. Such respect has more in common with communitarian approaches, and it need not conflict with the incorporation of collective-level values into ethical deliberation. (shrink)

Recent criticism of the role of respect for autonomy in bioethics has focused on that principle's status as ‘dogma’ or ‘ideology’. I suggest that lying beneath many applications of respect for autonomy in medical ethics are some influential dogmas — propositions accepted, not as explicit premises or as a consequence of reasoned argument, but simply because moral problems are so frequently framed in such terms. Furthermore, I will argue that rejecting these dogmas is vital to secure and protect an autonomy (...) worthy of respect. The concept of autonomy that is widely applied in clinical ethics emphasises decision-making competence, at the expense of considering the authenticity of those decisions. Respect for such autonomy is interpreted in largely synchronic and individual terms — concerned with the isolated decisions of individual agents — and thus neglects the diachronic and social dimensions of many moral dilemmas arising in the health care context. I will examine how these unwritten rules lead to an impoverished understanding of respect and a systematic neglect in bioethics of certain kinds of ethical consideration, and draw on insights from feminist and communitarian work on autonomy to sketch an alternative approach to understanding respect, modelled on the norms of respectful conversation — a respect that is firstly concerned with engaging with the another as a potential giver and bearer or reasons, and working with them to promote both individual and social flourishing. (shrink)

Failure to follow prescribed treatment has devastating consequences for those who are seriously and persistently mentally ill. Nurses, therefore, try to get clients to take psychotropic medication on a long-term basis. The goal is either compliance or adherence. Although current nursing literature has abandoned the term compliance because of its implications of coercion, in psychiatric nursing practice with patients suffering from serious long-term mental illness compliance and adherence are in fact different goals. The ideal goal is adherence, which requires the (...) patient to be an active participant in the team. This goal is consistent with nurses’ ethical values, but for such patients this is frequently unrealistic. If the person is severely psychotic, treatment may be involuntary and the goal compliance. Psychiatric nurses participate in involuntary treatment and thus should acknowledge the ethical implications of compliance as a goal and not obscure the issue by calling compliance adherence. (shrink)

Harm minimisation has been proposed as a means of supporting people who self-injure. When adopting this approach, rather than trying to stop self-injury immediately the person is allowed to injure safely whilst developing more appropriate ways of dealing with distress. The approach is controversial as the health care professional actively allows harm to occur. This paper will consider a specific objection to harm minimisation. That is, it is a misguided collaboration between the health care professional and the person who self-injures (...) that is morally and clinically questionable. The objection has two components. The first component is moral in nature and asserts that the health care professional is complicit in any harm that occurs and as a result they can be held morally responsible and subject to moral blame. The second component is clinical in nature and suggests that harm minimisation involves the health care professional in colluding in the perpetuation of self-injury. This element of the objection i... (shrink)

The practice of coercive measures in psychiatry is controversial. Although some have suggested that it may be acceptable if patients are a danger to others or to themselves, others committed themselves to eliminate it. Ethical, legal and clinical considerations become more complex when the mental incapacity is temporary and when the coercive measures serve to restore autonomy. We discuss these issues, addressing the conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the effects of coercive measures. We (...) argue that an appeal to respect autonomy and/or human dignity cannot be a sufficient reason to reject coercive measures. All together, these ethical aspects can be used both to support and to reject a non-seclusion approach. The total lack of controlled trials about the beneficial effects of coercive measures in different populations however, argues against the use of coercive measures. (shrink)

Ageism within the context of care has attracted increasing attention in recent years. Similarly, autonomy has developed into a prominent concept within health care law and ethics. This paper explores the way that ageism, understood as a set of negative attitudes about old age or older people, may impact on an older person’s ability to make maximally autonomous decisions within health care. In particular, by appealing to feminist constructions of autonomy as relational, I will argue that the key to establishing (...) this link is the concept of self-relations such as self-trust, self-worth and self-esteem. This paper aims to demonstrate how these may be impacted by the internalisation of negative attitudes associated with old age and care. In light of this, any legal or policy response must be sensitive to and flexible enough to deal with the way in which ageism impacts autonomy. (shrink)

Background Seven wards from three Norwegian mental health care institutions participated in a study in which regular ethics reflection groups focusing on coercion had been implemented and evaluated (2011–2015). This article presents (1) a thematic overview of the ethical challenges identified based on a systematic qualitative analyses of 161 ethics reflection groups and (2) some general observations on these ethical challenges. Results The ethical challenges are divided into four main thematic categories: (1) formal coercion, (2) informal coercion, (3) uncertainty related (...) to the Norwegian legislation on coercion and (4) professional role and identity. Some ethical challenges did not fit into these categories. Only 36% of the ethical challenges were related to the use of formal coercion or the interpretation of the health law. Conclusion Even within coercion regulated by law, weighing different moral values remains important to reflect upon the appropriateness of the possible use of coercion. (shrink)

The use of coercion is morally problematic and requires an ongoing critical reflection. We wondered if not knowing or being uncertain whether coercion is morally right or justified is related to professionals’ normative attitudes regarding the use of coercion. This paper describes an explorative statistical analysis based on a cross-sectional survey across seven wards in three Norwegian mental health care institutions. Descriptive analyses showed that in general the 379 respondents a) were not so sure whether coercion should be seen as (...) offending, b) agreed with the viewpoint that coercion is needed for care and security, and c) slightly disagreed that coercion could be seen as treatment. Staff did not report high rates of moral doubt related to the use of coercion, although most of them agreed there will never be a single answer to the question ‘What is the right thing to do?’. Bivariate analyses showed that the more they experienced general moral doubt and relative doubt, the more one thought that coercion is offending. Especially psychologists were critical towards coercion. We found significant differences among ward types. Respondents with decisional responsibility for coercion and leadership responsibility saw coercion less as treatment. Frequent experience with coercion was related to seeing coercion more as care and security. This study showed that experiencing moral doubt is related to some one’s normative attitude towards coercion. Future research could investigate whether moral case deliberation increases professionals’ experience of moral doubt and whether this will evoke more critical thinking and increase staff’s curiosity for alternatives to coercion. (shrink)

The paternalism, autonomy debate was influenced by traditional ideas that reasons are either objective (based on values existing independent of any particular person) or subjective (based on values tied to individual's personal histories). This dichotomy has been rewarding for the health care community. However, the tenets of this debate have influenced the nature of deliberation in a way that seriously compromises the ability of health care professionals and patients to bring reflection (the search for justified reasons) to a successful end. (...) It sets up the moral landscape not as one of unity and reciprocity, but as one of divisiveness and distance-where one person (the physician) does something to another (paternalism) or for another (patient autonomy), rather than with another. This distance and divisiveness undermines the unity of wills and genuine reciprocity that I argue is indispensable for genuinely good relationships and necessary for successfully establishing what reasons there are to act. It has created an abyss in communication that even recent suggestions for change cannot bridge. In this paper, I discuss the nature of this abyss and the problems it has created by demonstrating that traditional theoretical ideas about the nature of reasons have influenced the nature of deliberation in health care. I argue that recent suggestions for “justified paternalism” fail to bridge the abyss. Finally, I suggest that to be successful, we must change the framework; we must reject the ideas of objective and subjective value and embrace instead the idea that values are intersubjective. (shrink)

The expansion of the older population suggests that there will be significant numbers in need of care and support in their own home environment. Yet, little is known about the kind of situations professionals are faced with and how they intervene in the living environment of older people. Qualitative data were collected over a period of 1.5 years from a multi-disciplinary community-based geriatric team in the Netherlands, and participant observations carried out. Forty-two cases discussed within the team meetings were analysed. (...) Results demonstrate that providing care to older people is a dynamic process and revolves around various paradoxes as experienced by professionals. This is illustrated by presenting three paradoxes that emerged within the data: respecting autonomy versus preserving safety; the care needs of the care recipients versus the capacity of their informal carers to cope; and holding a formal orientation versus a tailored orientation on tasks. Providing care in the home environment of older people requires from professionals a continuous anticipation of (un)expected evolutions in situations of their care recipients. In order to optimally support older people professionals need ‘professional discretion’. They must be supported to systematically reflect on and legitimize their intervention strategies. (shrink)

This article concerns the issue of how an ethic of care perspective may contribute to both normative theory and mental health care policy discussions on so called Ulysses arrangements, a special type of advance directives in psychiatry. The debate on Ulysses arrangements has predominantly been waged in terms of autonomy conceived of as the right to non-intervention. On the basis of our empirical investigations into the experiences of persons directly involved with Ulysses arrangements, we argue that a care ethics perspective (...) may broaden and deepen the debate on Ulysses arrangements, by introducing additional concepts, such as vulnerability, responsibility and mutuality, and by refining familiar concepts, such as autonomy. (shrink)

Introduction: We discuss Carol Gilligan's original concept of mature care in the light of the altruistic approach to caring and good clinical judgment. Discussion: In particular, we highlight how the concept of mature care can capture important challenges in today's nursing. Further, we illuminate how mature care might differ normatively from an altruistic approach to caring and the traditional prudential virtues in nursing. We also discuss similarities between mature care and virtue ethics. Conclusion: For nursing and nurses' identity, in today's (...) health care system that is increasingly pressured to ‘produce' health, we believe it is important to both developing further theories on mature care and having normative discussions about care. (shrink)

Coercion and pressure in mental healthcare raise moral questions. This article focuses on moral questions raised by the everyday practice of pressure and coercion in the care for the mentally ill. In view of an example from literature—the story of Ulysses and the Sirens—several ethical issues surrounding this practice of care are discussed. Care giver and patient should be able to express feelings such as frustration, fear and powerlessness, and attention must be paid to those feelings. In order to be (...) able to evaluate the intervention, one has to be aware of the variety of goals the intervention can aim at. One also has to be aware of the variety of methods of intervention, each with its own benefits and drawbacks. Finally, an intervention requires a context of care and responsibility, along with good communication and fair treatment before, during and after the use of coercion and pressure. (shrink)

The approach to managing the involuntary detention of people suffering from psychiatric conditions can be divided into those with clinicians at the forefront of decision-making and those who rely heavily on the judiciary. The system in England and Wales takes a clinical approach where doctors have widespread powers to detain and treat patients involuntarily. A protection in this system is the right of the individual to challenge a decision to deprive them of their liberty or treat them against their will. (...) This protection is provided by the First-tier Tribunal; however, the number of successful appeals is low. In this paper, the system of appeal in England and Wales is outlined. This is followed by a discussion of why so few patients successfully appeal their detention with the conclusion that the current system is flawed. A number of recommendations about how the system might be reformed are offered. (shrink)

Background: In the Netherlands, people with severe cognitive deficits due to Korsakoff syndrome are generally admitted to a specialized nursing home. Professional caregivers experience that these residents are often not aware of their deficits, and consequently, their willingness to accept care is relatively low. However, these residents need permanent support when performing daily tasks due to severe cognitive deficits. The combination of objective care needs and low subjective responsiveness makes caring for people with Korsakoff syndrome a complex undertaking. It is (...) unknown how professional caregivers deal with this complex task and how they manage the associated ethical challenges. Objectives: The aim of this study was to explore the professional caregivers’ perspectives on good care for residents with Korsakoff syndrome. Methods: A qualitative study design was used. Data were collected via semi-structured interviews. The Framework Method was used for the thematic analyses of the interview data. Participants and research context: Five specialized nursing homes participated in this study. Twelve professional caregivers, including nurses, nursing assistants, and support workers, were selected based on the ability to provide rich information on the study topics and to capture a variety of demographic and professional characteristics. Ethical considerations: The institutional review board of the VU University Medical Center Amsterdam approved the research protocol. The study was conducted in accordance with the ethical principles for medical research involving human subjects. Findings: Three perspectives on good care emerged: (1) making daily life a joint effort, (2) being steadfast, and (3) treating with respect. Discussion and conclusion: Professional caregivers try to achieve responsiveness in people with Korsakoff syndrome in three different ways. These perspectives reflect fundamentally different views on the care relationship and the autonomy of the resident. By elucidating the three perspectives, we hope to promote the practitioners’ reflection on their own ideas about good care for people with Korsakoff syndrome. (shrink)

The use of coercion is morally problematic and requires an ongoing critical reflection. We wondered if not knowing or being uncertain whether coercion is morally right or justified (i.e. experiencing moral dou...

Through the vehicle of Nicolas Sarkozy’s so-called “Dakar Address” we will analyse the West’s persisting lack of insight into the need for a Western decolonization. We will try to identify the dangers that come from this refusal, such as the abidance in colonial patterns, the enduring self-understanding as superior com-pared to Africa, and the persisting unwillingness to accept the colonial guilt. Decolonization has to be understood as a two-fold business. Decolonization is over-coming endured and perpetrated violence. It is not only (...) important that the colonial oppressed regain strength, it is equally important that the perpetrator of colonial violence understand their excess of violence and work on effecting its return impossible. We explain how Western thinking remains dangerous and untrustwor-thy if it refuses its own decolonization. Finally, we will draw attention to a fundamental pattern of Western thought that clashes with the fundamental values of the West: contempt. In a final step we suggest how this contempt can be overcome through desuperiorisation and the establishment of elative ethics. (shrink)