This discussion paper continues the debate over risk‐related standards of mental competence which appears in Bioethics 5. Dan Brock there defends an approach to mental competence in patients which defines it as being relative to differing standards, more or less rigorous depending on the degree of risk involved in proposed treatments. But Mark Wicclair raises a problem for this approach: if significantly different levels of risk attach, respectively, to accepting and refusing the same treatment, then it is possible, on this (...) account, for a patient to be considered competent to accept, but not refuse, the treatment, or vice versa. I argue that this puzzle does not constitute a genuine problem for a risk‐related standard. To this end I focus on the situation where, of two mutually exclusive options, one is riskier, but offering more pronounced benefit, while the other is safer, but offering less benefit. I argue for this proposition: it can take far less insight to know that the safe option is good than to know that the risky option is better. Now say one is actually informed enough to know that the safe option is good, but not enough to know whether the risky option is better; in such a case one is competent to say yes to that first option (the safe one), but not to say yes to the other. (I argue in passing that Pascal's Wager can be interpreted as having precisely this deliberative structure.) I thus conclude that cases do indeed exist where one can be competent to say yes but not no, or vice versa; and that it is thus not an anomaly in the risk‐related standard that it entails the existence of such cases. (shrink)

Ulysses contracts are a method by which one person binds himself by agreeing to be bound by others. In medicine such contracts have primarily been discussed as ways of treating people with episodic mental illnesses, where the features of the illness are such that they now judge that they will refuse treatment at the time it is needed. Enforcing Ulysses contracts in these circumstances would require medical professionals to override the express refusal of the patient at the time treatment is (...) required, something that is generally problematic both ethically and legally. In this paper I will argue that despite appearances Ulysses contracts can make it the case that treating a patient in such circumstances is an instance of treating him with his consent, although safeguards are needed to ensure that this is the case. Given the potential benefits to patients I further argue that modified Ulysses contracts should be made legally enforceable. (shrink)

Donald VanDeVeer probes the moral complexities of the question: under what conditions is it permissible to intervene invasively in the lives of competent persons--for example, by deception, force, or coercive threat--for their own good? In a work with broad significance for law, public policy, professional-client relations, and private interactions, he presents a theory of an autonomy-respecting" paternalism. Originally published in 1986. The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist (...) of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905. (shrink)

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)

: Ulysses contracts have faced paternalism objections since they first were proposed. Since the contracts are designed to override a present request from a legally competent patient in favor of a past request made by that patient, enforcement of these contracts was argued to be unjustifiable strong paternalism. Recent legal developments and new theories of practical reasoning suggest that the discussion of Ulysses contracts should be revived. This paper argues that with a proper understanding of the future-directed planning embodied in (...) Ulysses contracts, the charge of strong paternalism can be answered, and the enforcement of some Ulysses contracts may be justified under the rubric of weak paternalism. (shrink)

This book addresses these and a cluster of other questions about changes in the self through time and about the moral attitudes we adopt in the face of these...

: Debates on precedent autonomy and some forms of paternalistic interventions, which are related to questions of personal identity, are analyzed. The discussion is based on the distinction between personal identity as persistence and as biographical identity. It first is shown that categorical objections to advance directives and "Ulysses contracts" are based on false assumptions about personal identity that conflate persistence and biographical identity. Therefore, advance directives and "Ulysses contracts" are ethically acceptable tools for prolonging one's autonomy. The notions of (...) personality and biographical identity are used to analyze the ethically relevant features. Thereby, it is shown that these concepts are operative in and useful for thinking in biomedical ethics. The overall conclusion is that categorical arguments against precedent autonomy or "Ulysses contracts" are based on misleading theories of personal identity and that advance directives are an ethically respectable tool for prolonging individuals' autonomy in cases of dementia and mental illness. (shrink)

In this article I wish to show how care ethics puts forward a fundamental critique on the ideal of independency in human life without thereby discounting autonomy as a moral value altogether. In care ethics, a relational account of autonomy is developed instead. Because care ethics is sometimes criticized in the literature as hopelessly vague and ambiguous, I shall begin by elaborating on how care ethics and its place in ethical theory can be understood. I shall stipulate a definition of (...) care ethics as a moral perspective or orientation from which ethical theorizing can take place. This will mean that care ethics is more a stance from which we can theorize ethically, than ready-made theory in itself. In conceiving care ethics in this way, it becomes possible to make clear that, for instance, a moral concept of autonomy is not abandoned, but instead is given a particular place and interpretation. In the final part of this article I will show how ‘relational autonomy’ can be applied fruitfully in the practice of psychiatric care. (shrink)

This collection of original essays explores the social and relational dimensions of individual autonomy. Rejecting the feminist charge that autonomy is inherently masculinist, the contributors draw on feminist critiques of autonomy to challenge and enrich contemporary philosophical debates about agency, identity, and moral responsibility. The essays analyze the complex ways in which oppression can impair an agent's capacity for autonomy, and investigate connections, neglected by standard accounts, between autonomy and other aspects of the agent, including self-conception, self-worth, memory, and the (...) imagination. (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)

Virginia Held assesses the ethics of care as a promising alternative to the familiar moral theories that serve so inadequately to guide our lives. The ethics of care is only a few decades old, yet it is by now a distinct moral theory or normative approach to the problems we face. It is relevant to global and political matters as well as to the personal relations that can most clearly exemplify care. This book clarifies just what the ethics of care (...) is: what its characteristics are, what it holds, and what it enables us to do. It discusses the feminist roots of this moral approach and why the ethics of care can be a morality with universal appeal. Held examines what we mean by "care," and what a caring person is like. Where other moral theories demand impartiality above all, the ethics of care understands the moral import of our ties to our families and groups. It evaluates such ties, focusing on caring relations rather than simply on the virtues of individuals. The book proposes how such values as justice, equality, and individual rights can "fit together" with such values as care, trust, mutual consideration, and solidarity. In the second part of the book, Held examines the potential of the ethics of care for dealing with social issues. She shows how the ethics of care is more promising than Kantian moral theory and utilitarianism for advice on how expansive, or not, markets should be, and on when other values than market ones should prevail. She connects the ethics of care with the rising interest in civil society, and considers the limits appropriate for the language of rights. Finally, she shows the promise of the ethics of care for dealing with global problems and seeing anew the outlines of international civility. (shrink)

"Most modern philosophers attempt to solve the problem of morality from within the epistemological assumptions that define the dominant cultural perspective of our age. Alan Gewirth's Reason and Morality is a major work in this ongoing enterprise. Gewirth develops, with patience and skill, what he calls a 'modified naturalism' in which morality is derived by logic alone from the concept of action.... I think that the publication of Reason and Morality is a major event in the history of moral philosophy. (...) It develops with great power a new and exciting position in ethical naturalism. No one, regardless of philosophical stance, can read this work without an enlargement of mind. It illuminates morality and agency for all."—E. M. Adams, The Review of Metaphysics "This is a fascinating study of an apparently intractable problem. Gewirth has provided plenty of material for further discussion, and his theory deserves serious consideration. He is always aware of possible rejoinders and argues in a rigorous manner, showing a firm grasp of the current state of moral and political philosophy."—Mind. (shrink)

Alan Gewirth extends his fundamental principle of equal and universal human rights, the Principle of Generic Consistency, into the arena of social and political philosophy, exploring its implications for both social and economic rights. He argues that the ethical requirements logically imposed on individual action hold equally for the supportive state as a community of rights, whose chief function is to maintain and promote the universal human rights to freedom and well-being. Such social afflictions as unemployment, homelessness, and poverty are (...) basic violations of these rights, which the supportive state is required to overcome. A critical alternative to both "liberal" and "communitarian" views, this book will command the attention of anyone engaged in the debate over social and economic justice. (shrink)

Justification for psychiatric paternalism is most easily established where mental illness renders the person mentally incompetent, depriving him of the capacity for rational agency and for autonomy, hence undermining the basis for liberal rights against paternalism. But some philosophers, and no doubt some doctors, have been deeply concerned by the inadequacy of the concept of mental incompetence to encapsulate some apparently appealing cases for psychiatric paternalism. We ought to view mental incompetence as just one subset of a broader justification for (...) psychiatric paternalism. The very basis of liberal limitations on psychiatric paternalism, whether described in terms of rights to autonomy or as respect for differences in values and lifestyles, presupposes a sense of moral persistence, and hence some sufficiently persistent self. Paternalistic intervention is warranted when we are unable to govern our lives in a manner consistent with the goals and values that comprise that ‘self’. One way that can occur is when we lack the mental capacities required for autonomy, such that we are unable to interpret and interact with our environment in order to meaningfully pursue our goals, i.e. mental incompetence. But it can also occur when we are subject to impositions that alter our goals without altering our capacity to pursue them — i.e. when it is our ‘self’ that is impaired rather than our competence. (shrink)

Sometimes the mentally ill have sufficient mental capacity to refuse treatment competently, and others have a moral duty to respect their refusal. However, those with episodic mental disorders may wish to precommit themselves to treatment, using Ulysses contracts known as “mental health advance directives.” How can health care providers justify enforcing such contracts over an agent’s current, competent refusal? I argue that providers respect an agent’s autonomy not retrospectively—by reference to his or her past wishes—and not merely synchronically—so that the (...) agent gets what he or she wants right now—but diachronically and prospectively, acting so that the agent can shape his or her circumstances as the agent wishes over time, for the agent will experience the consequences of providers’ actions over time. Mental health directives accomplish this, so they are a way of respecting the agent’s autonomy even when providers override the agent’s current competent refusal. (shrink)

Ethical and legal discourse pertaining to the ability to consent to treatment and research in England operates within a dualist framework of “competence” and “capacity”. This is confusing, as while there exists in England two possible senses of legal capacity – “first person” legal capacity and “delegable” legal capacity, currently neither is formulated to bear a necessary relationship with decision-making competence. Notwithstanding this, judges and academic commentators frequently invoke competence to consent in discussions involving the validity of offering or withholding (...) consent as a synonym for legal capacity to consent. I argue that this gives rise to a conflation, jeopardising clarity and consistency in law. This is somewhat less problematic in instances of “first-person” legal capacity that are heavily informed by criteria for decision-making competence than in the second sense of legal capacity, which is qualitatively different from decision-making competence, or with first-person legal capacity when defined in different terms from competence. The paper concludes by proposing that the soundest resolution to this problem is by making decision-making competence a necessary and sufficient condition of first-person legal capacity, affording a more scrupulous distinction between the two different forms of legal capacity that exist. (shrink)

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance (...) directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike. (shrink)

In each of these areas, he reviews the contributions of earlier care theorists and then extends their arguments to provide a more complete description of the ...

This is the third volume of Joel Feinberg's highly regarded The Moral Limits of the Criminal Law, a four-volume series in which Feinberg skillfully addresses a complex question: What kinds of conduct may the state make criminal without infringing on the moral autonomy of individual citizens? In Harm to Self, Feinberg offers insightful commentary into various notions attached to self-inflicted harm, covering such topics as legal paternalism, personal sovereignty and its boundaries, voluntariness and assumptions of risk, consent and its counterfeits, (...) coercive force, incapacity, and choice of death. (shrink)

Linda Morrison brings the voices and issues of a little-known, complex social movement to the attention of sociologists, mental health professionals, and the general public. The members of this social movement work to gain voice for their own experience, to raise consciousness of injustice and inequality, to expose the darker side of psychiatry, and to promote alternatives for people in emotional distress. Talking Back to Psychiatry explores the movement's history, its complex membership, its strategies and goals, and the varied response (...) it has received from psychiatry, policy makers, and the public at large. (shrink)

This book is a critical, forward-looking and interdisciplinary text. Its chief aim is to advance understanding of medical law by reference both moral theory and the regulatory context. The first chapter seeks to map competing approaches within moral objectivism and outline the pressures created by the impact of market forces and medical tourism, political interests, medical and professional interests, changing perceptions of medicine, developing technologies, limited resources and the impact of increasingly direct (international and domestic) recognition of human rights. Chapters (...) 2 to 16 apply the analytical tools presented in chapter 1 to the topics of medical law and seek to demonstrate the need for a moral epistemology of the type defended in chapter 17. (shrink)

Explains the concept of legal competence (or power). This book then discusses the analysis and definition of legal concepts in general; the relation between the concept of competence and (in)validity; what it means to exercise competence; different types of competence; and competence norms.

The concept of human dignity is increasingly invoked in bioethical debate and, indeed, in international instruments concerned with biotechnology and biomedicine. While some commentators consider appeals to human dignity to be little more than rhetoric and not worthy of serious consideration, the authors of this groundbreaking new study give such appeals distinct and defensible meaning through an application of the moral theory of Alan Gewirth.

In this article we discuss the validity of previous preferences and advance directives in cases of severe mental illness.