It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of (...) Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. (shrink)

Coercion in the treatment of persons suffering from mental disorders is one of the major ethical controversies in psychiatry. Despite great efforts to reduce the use of coercive interventions, they are still widespread and differ between European countries regarding the specific type of intervention and the number of patients affected. It is common to justify measures against the present will of patients under the assumption that they promote their well-being, that is, by reference to the ethical principal of beneficence. However, (...) it is indisputable that such measures can also cause severe harm to the patients concerned and that these measures are often experienced as degrading. In which situations can coercive interventions be labeled justifiably as “beneficial”? How can they be reduced to a minimum? This volume addresses these issues from an interdisciplinary and international perspective, combining contributions from, among others, medical ethicists, philosophers, legal scholars, psychologists and psychiatrists from different European countries. Theoretical and conceptual essays are complemented by contributions with a strong relationship to clinical practice. (shrink)

According to what we propose to call “the competence model,” competence is a necessary condition for valid informed consent. If a person is not competent to make a treatment decision, the decision must be made by a substitute decision-maker on her behalf. Recent reports of various United Nations human rights bodies claim that article 12 of the Convention on the Rights of Persons with Disabilities involves a wholesale rejection of this model, regardless of whether the model is based on a (...) status, outcome, or functional approach to competence. The alleged rationale of this rejection is that denying persons the right to make their own treatment decisions based on an assessment of competence necessarily discriminates against persons with mental disorders. Based on a philosophical account of the nature of discrimination, we argue that a version of the competence model that combines supported decision-making with a functional approach to competence does not discriminate against persons with mental disorders. Furthermore, we argue that status- and outcome-based versions of the competence model are discriminatory. (shrink)

The extra-therapeutic use of psychotropic drugs to improve cognition and to enhance mood has been the subject of controversial discussion in bioethics, in medicine but also in public for many years. Concerns over a liberal dealing with pharmacological enhancers are raised not only from a biomedical–pharmacological perspective, but particularly from an ethical one. Within these ethical concerns, there is one objection about the normative differentiation between “natural” and “artificial” enhancers, which is theoretically indeed widely discredited in bioethics, which has, however, (...) entrenched itself in such a persistent way in everyday moral consciousness that it keeps a crucial influence on the assessment of pharmacological enhancers made by the public and medical professionals. This paper tries to first show why a normative differentiation between “natural” and “artificial” enhancers is highly problematic. In a second step, the resulting implications for our current dealing with pharmacological enhancers shall be examined. In a specific comparison of synthetic pharmaceuticals (modafinil, SSRIs) with phytopharmaceuticals (ginkgo biloba, St. John’s wort) and other already established enhancers (alcohol, caffeine), argumentative inconsistencies are pointed out which, at least partly, result from a rationally untenable preference for the “natural” over the “artificial”. Therefore, it is conclusively argued the case for an unprejudiced assessment of pharmacological enhancers beyond a “natural”–“artificial” dichotomy, which equally takes into account biomedical and ethical aspects. The goal is to reach a coherent dealing with pharmacological enhancement in the long run. (shrink)

ZusammenfassungBei gerichtlich angeordneten Unterbringungen aufgrund von Eigen- oder Fremdgefährdung können Patientenverfügungen zu klinisch und ethisch schwierigen Situationen führen. Dies gilt vor allem dann, wenn darin medizinisch indizierte psychiatrische Behandlungsmaßnahmen abgelehnt werden. In solchen Situationen können Patienten zunächst weder aus dem psychiatrischen Krankenhaus entlassen noch psychiatrisch behandelt werden. Der vorliegende Beitrag erörtert ethische Herausforderungen im Zusammenhang mit Therapieablehnungen durch Patientenverfügungen bei psychischen Erkrankungen aus interdisziplinärer Perspektive. Dabei werden die rechtlichen Grundlagen und Grenzen einer Patientenverfügung aufgezeigt. Mit Blick auf die klinische Praxis (...) werden die normativen Voraussetzungen einer wirksamen Vorausverfügung analysiert. Darüber hinaus werden ethische Argumente für und gegen die Anwendung von Zwangsmaßnahmen und -behandlungen in Situationen von Eigen- oder Fremdgefährdung diskutiert. Die Identifizierung normativ relevanter Aspekte soll dazu beitragen, in der klinisch-psychiatrischen Praxis zu ethisch begründeten Entscheidungen im Kontext von vorausverfügten Therapieablehnungen zu gelangen.In der Schlussbetrachtung wird aufgezeigt, welche Implikationen sich aus der rechtlichen Bindungskraft von Patientenverfügungen für die klinische Praxis ergeben. Auf einer übergeordneten Ebene wird das ethische Spannungsverhältnis, das sich durch den bestehenden gesellschaftlichen Sicherungsauftrag der Psychiatrie in Situationen von Eigen- oder Fremdgefährdung ergibt, problematisiert. Auf der Ebene des individuellen Arzt-Patienten-Verhältnisses stellen wir die Bedeutung von Beratungs- und Unterstützungsangeboten für die Abfassung von Vorausverfügungen dar und plädieren dafür, in Beratungsgesprächen auch die weitreichenden und komplexen Konsequenzen Therapieablehnungen zu erörtern. (shrink)

ZusammenfassungIn der neueren deutschen Rechtsprechung wurden die Anforderungen an die rechtliche Zulässigkeit von Zwangsbehandlungen verschärft und der Berücksichtigung des natürlichen Willens nicht selbstbestimmungsfähiger Patienten ein höherer Stellenwert eingeräumt. So ist der behandelnde Arzt etwa verpflichtet, einen letzten Versuch zu unternehmen, eine auf Vertrauen gegründete Zustimmung zu erhalten. In Anbetracht dessen, dass ein solches Gespräch im Kontext informellen Zwangs stattfindet, ergibt sich ein medizinethisches Dilemma: Entweder wird eine Zwangsbehandlung durchgeführt und somit direkter körperlicher Zwang angewendet, oder eine Zustimmung wird erzielt, jedoch (...) gegebenenfalls um den Preis, dass informeller Zwang – z. B. in Form einer Drohung, Täuschung oder Manipulation – ausgeübt wird. Es wird dafür argumentiert, dass die Antwort auf dieses Problem im philosophischen Begriff der Anerkennung zu finden ist, der im vorliegenden Kontext als eine spezifische Haltung aufgefasst wird und sich in einem respektvollen Umgang des Klinikpersonals mit den betroffenen Patienten zeigt. Die Ausübung von Zwang ist in solchen Fällen kaum zu vermeiden. Dennoch kann man in dieser Situation besser oder schlechter mit dem Patienten umgehen – und besser heißt hier, dem Patienten Anerkennung entgegenbringen. (shrink)

In a compelling article, Peterson, Karlawish and Largent argue that supported decision-making is preferable to substitute decision-making for people with dynamic impairments. We fully...

Definition of the problem The reform of German guardianship law coming into force in 2023 will remove the term “well-being” from the law. This is intended to emphasise that the legal guardian should be guided by the subjective wishes of the person rather than by an objective understanding of well-being. This article analyses the understanding of well-being underlying the reformed guardianship law in comparison to common conceptions of well-being in philosophy and medical ethics, aiming to promote interdisciplinary understanding between ethics (...) and law. Arguments The justification for the reform emphasises that the law is based on a subjective understanding of well-being. However, this understanding does not correspond to philosophical subjective theories of well-being, according to which only things that a person desires can contribute to her well-being. In contrast, the guardianship law assumes that the fulfilment of certain wishes can lead to objective harm to the person and thus impair her well-being. Negative consequences for the objective well-being of a person are only relevant insofar as they indicate a limit to following current wishes that are based on a natural will and are not an expression of self-determination. Conclusion While the term “well-being” is removed from reformed guardianship law, the law implicitly contains an understanding of well-being comparable to a hybrid conception of well-being from a medical ethics perspective. According to this conception, fulfilment of a person’s wishes generally contributes to her well-being, although certain objective criteria are also taken into consideration. (shrink)

Definition of the problem The reform of German guardianship law coming into force in 2023 will remove the term “well-being” from the law. This is intended to emphasise that the legal guardian should be guided by the subjective wishes of the person rather than by an objective understanding of well-being. This article analyses the understanding of well-being underlying the reformed guardianship law in comparison to common conceptions of well-being in philosophy and medical ethics, aiming to promote interdisciplinary understanding between ethics (...) and law. Arguments The justification for the reform emphasises that the law is based on a subjective understanding of well-being. However, this understanding does not correspond to philosophical subjective theories of well-being, according to which only things that a person desires can contribute to her well-being. In contrast, the guardianship law assumes that the fulfilment of certain wishes can lead to objective harm to the person and thus impair her well-being. Negative consequences for the objective well-being of a person are only relevant insofar as they indicate a limit to following current wishes that are based on a natural will and are not an expression of self-determination. Conclusion While the term “well-being” is removed from reformed guardianship law, the law implicitly contains an understanding of well-being comparable to a hybrid conception of well-being from a medical ethics perspective. According to this conception, fulfilment of a person’s wishes generally contributes to her well-being, although certain objective criteria are also taken into consideration. (shrink)

The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as “procedural ethics” and the identification and handling of ethical issues by researchers during the research process as “ethics in practice.” While some authors dispute and other authors (...) defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors. (shrink)

Crutchfield and Redinger (2024) propose that the use of a chemical restraint that affects only a particular conscious state is ethically permissible if, and only if, (1) it is the least restrictive...

Menschen mit psychischer Erkrankung sterben statistisch gesehen früher als die Allgemeinbevölkerung. Ein Grund hierfür ist, dass sie eine schlechtere somatische Gesundheitsversorgung erhalten. Wir argumentieren, dass ableistische Netzwerke sozialer Bedeutung zu einer Abwertung der epistemischen Kompetenz von Menschen mit psychischer Erkrankung führen. Diese Abwertung kann mit dem Konzept der testimonialen Ungerechtigkeit erfasst werden. Testimoniale Ungerechtigkeit bezeichnet das ungerechtfertigte Herabstufen der Glaubwürdigkeit einer*s Sprecher*in aufgrund eines Vorurteils gegen ihre*seine soziale Identität. Wir analysieren ethische und epistemische Folgen testimonialer Ungerechtigkeit als wichtige Ursachen der (...) schlechteren Gesundheitsversorgung von Menschen mit psychischer Erkrankung. Testimoniale Ungerechtigkeit kann zu medizinischen Behandlungsfehlern führen und für Betroffene schwerwiegende gesundheitliche Folgen nach sich ziehen. Zudem kann sie zu einem Vertrauensverlust von Menschen mit psychischer Erkrankung in das Gesundheitssystem führen. Daher trägt testimoniale Ungerechtigkeit zur strukturellen Diskriminierung von Menschen mit psychischer Erkrankung bei. Vor diesem Hintergrund diskutieren wir, wie die somatische Gesundheitsversorgung unter ethischen Gesichtspunkten verbessert werden kann. (shrink)

Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on (...) a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion. (shrink)

Florijn’s analysis of the Dutch Supreme Court ruling on the Albert Heringa case demonstrates that the Dutch approach to justifying physician-assisted death is based primarily on the physician...

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. (...) Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice. (shrink)