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)

In several jurisdictions, irremediable suffering from a medical condition is a legal requirement for access to assisted dying. According to the expressivist objection, allowing assisted dying for a specific group of persons, such as those with irremediable medical conditions, expresses the judgment that their lives are not worth living. While the expressivist objection has often been used to argue that assisted dying should not be legalised, I show that there is an alternative solution available to its proponents. An autonomy-based approach (...) to assisted suicide regards the provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests. Such an approach has been put forward by a recent judgment of the German Federal Constitutional Court, which understands assisted suicide as an expression of the person’s right to a self-determined death. It does not allow for beneficence-based restrictions regarding the person’s suffering or medical diagnosis and therefore avoids the expressivist objection. I argue that on an autonomy-based approach, assisted suicide should not be understood as a medical procedure but rather as the person’s autonomous action. (shrink)

In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first (...) demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account. (shrink)

According to the “discrimination argument,” it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe two (...) distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread “joint” approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy‐based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence‐ and autonomy‐based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS. (shrink)

In a recent article, Wilkinson puts forward the notion of identity-relative paternalism. According to Wilkinson’s final formulation of this principle, ‘[i]ndividuals should be prevented from doing to future selves (where there are weakened prudential unity relations between the current and future self) what it would be justified to prevent them from doing to others’.1 In medical ethics, it is usually assumed that hard paternalism, that is, acting against a competent person’s wishes for their own benefit, is not justified. According to (...) Mill’s harm principle, we may only limit people’s freedom if they cause harm to others.2 Harm to self is not a sufficient reason for overriding competent persons’ decisions. Wilkinson, however, draws on Parfit’s reductionist view of personal identity to argue that sometimes, patients’ future selves are sufficiently disconnected from their present selves to treat future selves like different persons. If a competent person’s medical decision negatively affects a future self, this should be treated like a case of harm to others. Thus, overriding competent persons’ decisions in such cases—and treating them against their will—could be justified. In this commentary, I point out two problems with this approach. First, I demonstrate that the cases Wilkinson’s argument is based on are not examples of harm to others but rather cases of surrogate decision making gone wrong, …. (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...

Regulations implemented by World Athletics (WA) require female athletes with differences of sexual development to suppress their blood testosterone levels in order to participate in certain women’s sporting competitions. These regulations have been justified by reference to fairness. In this paper, we reconstruct WA’s understanding of fairness, which requires a “level playing field” where no athlete should have a significant performance advantage based on factors other than talent, dedication, and hard work over an average athlete in their category. We demonstrate (...) that by placing regulations only on testosterone levels, while ignoring physical as well as socioeconomic advantages, WA consistently fails to meet its own definition of fairness. We then discuss several ways in which this definition could be met. Our analysis shows that a categorical system, in which athletes are divided into categories based on properties leading to significant performance advantages, is best suited for meeting WA’s definition of fairness. (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...

According to the expressivist objection, laws that only allow assisted dying for those suffering from certain medical conditions express the judgement that their lives are not worth living. I have recently argued that an autonomy-based approach that legally allows assisted suicide for all who make an autonomous request is a way to avoid the expressivist objection. In response to this, Thomas Donaldson has argued that rather than avoiding the expressivist objection, an autonomy-based approach extends this objection. According to Donaldson, this (...) is because helping a person achieve a goal requires endorsement of that goal. In this reply, I show that Donaldson misunderstands the target of the expressivist objection: it is not aimed at an individual’s attitude towards another person’s death but rather at a legal regulation. Moreover, helping someone end their life does not necessarily require endorsing this goal—instead, respect for a person’s autonomous choice can be another reason for providing assisted suicide. Donaldson also assumes that the autonomy-based approach requires doctors to accept autonomous requests for assisted dying. Yet, this approach merely makes it legal for individuals (not necessarily only doctors) to provide assisted suicide to autonomous persons but does not require anyone to do so. (shrink)

Zusammenfassung Hintergrund Stigmatisierung hat einen erheblichen Einfluss auf die Gesundheit verschiedener gesellschaftlicher Gruppen und trägt zu Ungleichheiten im Gesundheitswesen bei. Sexarbeit ist mit erheblichem sozialem Stigma verbunden, das sich nachteilig auf den Zugang von Sexarbeiter*innen zur Gesundheitsversorgung auswirkt. Die vorliegende explorative Studie gibt erste Einblicke in die Sichtweisen von Sexarbeiter*innen und Berater*innen in Deutschland auf den Zugang, die Bedürfnisse und die Barrieren von Sexarbeiter*innen in Bezug auf die Gesundheitsversorgung. Dabei lag der Fokus auf einem etablierten Netzwerk von Gesundheitsangeboten für Sexarbeiter*innen (...) in Bochum. Methoden Leitfadengestützte Interviews wurden mit 4 Berater*innen durchgeführt, die soziale und medizinische Beratung für Sexarbeiter*innen anbieten, sowie mit 3 Sexarbeiter*innen, die diese Angebote nutzen. Die Interviews wurden mittels qualitativer Inhaltsanalyse nach Kuckartz ausgewertet. Ergebnisse Es zeigten sich verschiedene Hürden bei der Inanspruchnahme von Gesundheitsversorgung, insbesondere aufgrund unzureichender Krankenversicherung oder fehlendem Wissen über den eigenen Krankenversicherungsstatus, Sprachbarrieren, Bürokratie, Mobilität und Diskriminierung in der Gesundheitsversorgung. Diskriminierung aufgrund von Sexarbeit überschnitt sich mit anderen Diskriminierungsformen, wie beispielsweise antislawischem Rassismus oder der Stigmatisierung von Schwangerschaftsabbrüchen. Spezifische Bedürfnisse und Barrieren wurden hinsichtlich psychischer Gesundheit angegeben, die sich als wichtiges Thema für Sexarbeiter*innen erwies. Die bestehenden kostenlosen, anonymen und zugänglichen Angebote für Sexarbeiter*innen, insbesondere aufsuchende Angebote, wurden als hilfreich beschrieben. Sexarbeiter*innen und Berater*innen wiesen auf einen Mangel an Angeboten für unterschiedliche Bedürfnisse von Sexarbeiter*innen hin, die über Tests auf sexuell übertragbare Infektionen und deren Behandlung hinausgehen, z. B. im Bereich der psychischen Gesundheit. Schlussfolgerung Nach wie vor bestehen Barrieren für den Zugang zur Gesundheitsversorgung, von denen viele besonders Sexarbeiter*innen mit Migrationsgeschichten aus osteuropäischen Ländern betreffen. Die Studie zeigt, dass die Etablierung antidiskriminierender Gesundheitsangebote für Sexarbeiter*innen notwendig ist. Bei der Entwicklung solcher Angebote sollten die Perspektiven von Sexarbeiter*innen eine zentrale Rolle einnehmen. (shrink)

Mitochondrial replacement techniques (MRTs) usually aim to prevent the genetic transmission of maternally inherited mitochondrial diseases. Until now, only the UK and Australia have implemented specific legal regulations of MRTs. In both countries, clinical trials on these techniques are only permissible for cases with a high risk of severe mitochondrial disease in the offspring. However, these techniques can also be applied to treat infertility, especially for older women with impaired oocyte quality. In some countries without legal regulation of these techniques, (...) MRTs are already offered for this purpose. Yet, this application of MRTs has received insufficient attention in the bioethical literature so far.In this paper, I examine whether there are ethical reasons to prohibit trials on MRTs in the context of infertility when they are permitted for preventing mitochondrial disease. Allowing MRTs in one context but not the other might be justified either because their application in the context of mitochondrial disease (1) is supported by a more convincing evidence base, (2) has a higher potential benefit or (3) has a lower risk. I compare both applications of MRTs with respect to these three factors. I conclude that there is no convincing reason to prohibit clinical trials on MRTs for infertility when they are permitted in the context of mitochondrial disease. (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)

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...