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)

In healthcare ethics there is a discussion regarding whether autonomy of personal preferences, what sometimes is referred to as authenticity, is necessary for autonomous decision-making. It has been argued that patients’ decisions that lack sufficient authenticity could be deemed as non-autonomous and be justifiably overruled by healthcare staff. The present paper discusses this issue in relation certain psychiatric disorders. It takes its starting point in recent qualitative studies of the experiences and thoughts of patients’ with anorexia nervosa where issues related (...) to authenticity seem particularly relevant. The paper examines different interpretations of authenticity relevant for autonomy and concludes that the concept, as it has been elaborated in recent debate, is highly problematic to use as a criterion for autonomous decision-making in healthcare. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

This book was first published in 1984, as the revised edition of a 1979 original. The text is composed of studies in a descending sequence from perfect rationality, through imperfect and problematical rationality, to irrationality. Specifically human rationality is characterized by its capacity to relate strategically to the future, in contrast to the myopic 'gradient climbing' of natural selection. There is trenchant analysis of some of the parallels proposed in this connection between the biological and the social sciences. In the (...) chapter on imperfect rationality the crucial notion is that of 'binding oneself', as Ulysses did before setting out to the Sirens, when weakness of will may prevent us from using our capacity for perfect rationality. The second half of the book deals with rational-actor theory, comparing its logical power and success to rival approaches, and with the varieties of irrationality expressed in contradictory beliefs and desires. (shrink)

When philosophers address personal identity, they usually explore numerical identity: what are the criteria for a person's continuing existence? When non-philosophers address personal identity, they often have in mind narrative identity: Which characteristics of a particular person are salient to her self-conception? This book develops accounts of both senses of identity, arguing that both are normatively important, and is unique in its exploration of a range of issues in bioethics through the lens of identity. Defending a biological view of our (...) numerical identity and a framework for understanding narrative identity, DeGrazia investigates various issues for which considerations of identity prove critical: the definition of death; the authority of advance directives in cases of severe dementia; the use of enhancement technologies; prenatal genetic interventions; and certain types of reproductive choices. He demonstrates the power of personal identity theory to illuminate issues in bioethics as they bring philosophical theory to life. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

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)

I examine current models of self-destructive addictive behaviour, and argue that there is an important place for Ulysses contracts in coping with addictive behaviour that stems from certain problematic preference structures. Given the relevant preference structures, interference based on a Ulysses contract need not involve questionably favouring an agent’s past preferences over her current preferences, but can actually be justified in terms of the agent’s current concerns and commitments.

In this dissertation, I argue for what I call “practical perspective compatibilism”. According to this thesis, an agent with practical freedom is sufficiently free to be a moral agent and morally responsible for his or her actions. The concept of practical freedom is originally found in the writings of Kant. Kant argued that we can view the world from either a theoretical or a practical perspective. The theoretical perspective is that of causal explanation and prediction, whereas the practical perspective is (...) that of choosing what to do and how to act. We see that we are free when we view things from a practical perspective. Determinism cannot threaten our practical freedom, since from a practical perspective we must choose what to do even if everything ultimately is determined. I argue that practical freedom is sufficient freedom-wise for moral agency and moral responsibility because morality is action-guiding. Right and wrong are concepts to be employed in deliberation and advice. This is a strong reason to regard factors irrelevant to deliberators and advisers as irrelevant when making judgements of right and wrong, and whether somebody had some other kind of freedom than practical freedom is irrelevant to deliberators and advisers. There are also prima facie reasons to regard moral responsibility as tied to rightness and wrongness, so that agents are blameworthy when they did wrong and praiseworthy when they did right. I also show that no classic arguments for incompatibilism about determinism and moral responsibility work when directed against practical perspective compatibilism. Finally, this thesis discusses metaethics in relation to compatibilism. Since competing theories imply the falsity of some respected metaethical positions, metaethical considerations lend further support to practical perspective compatibilism. (shrink)

Introduction Compulsory care is controversial, since respect for the patient’s autonomy is a standard requirement in health care. Many psychiatrists have experienced that patients with borderline personality syndrome sometimes demand compulsory care for themselves in order not to exert self-harm—like Ulysses contracts. The aim of this study was to examine the possible existence and extent of borderline personality syndrome-patient demands for Ulysses contracts regarding compulsory care in acute psychiatry, and how external influences and demands could affect the caregivers’ decisions about (...) compulsory care. Method An anonymous questionnaire, with three questions with fixed answers, was distributed to 42 licensed medical doctors on call at the psychiatric emergency unit in the city of Stockholm. Thirty-three questionnaires were answered, giving a response rate of 79%. Results Ninety-four percent of the respondents recognized the phenomenon of borderline personality syndrome patients requesting compulsory care, 21% stated that this request had affected their clinical decision, and 55% had used compulsory care for other reasons than the patient’s best interest. Discussion The results indicate that compulsory care is sometimes given in the form of Ulysses contracts for borderline personality syndrome patients. Also, compulsory care is sometimes used for other reasons than the borderline personality syndrome patient’s best interest. Psychological mechanisms affect the decisions of both patients and caregivers. More research should be done concerning to whom, why, and with what consequences compulsory care is prescribed. (shrink)

Whether treatment decision-making capacity can be meaningfully applied to patients with a diagnosis of “personality disorder” is examined. Patients presenting to a psychiatric emergency clinic with threats of self-harm are considered, two having been assessed and reviewed in detail. It was found that capacity can be meaningfully assessed in such patients, although the process is more complex than in patients with diagnoses of a more conventional kind. The process of assessing capacity in such patients is very time-consuming and may become, (...) in itself, a therapeutic intervention. (shrink)