This paper explores the ethical and conceptual implications of the findings from an empirical study (reported elsewhere) of decision-making capacity in anorexia nervosa. In the study, ten female patients aged thirteen to twenty-one years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semistructured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient-participants were also tested using the (...) MacArthur Competence Assessment Tool—Treatment test of competence. This is a formalized, structured, interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief, self-administered questionnaires to assess their levels of psychopathology. The issues identified from the interviews are described under two headings: difficulties with thought processing and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches. (shrink)

Authenticity has recently emerged as an important issue in discussions of mental disorder. We show, on the basis of personal accounts and empirical studies, that many people with psychological disorders are preoccupied with questions of authenticity. Most of the data considered in this paper are from studies of people with bipolar disorder and anorexia nervosa. We distinguish the various ways in which these people view the relationship between the disorder and their sense of their authentic self. We discuss the principal (...) modern ac-counts of authenticity within the analytic philosophical tradition. We argue that accounts based on autonomous, or wholehearted, endorsement of personal characteris-tics fail to provide an adequate analysis of authenticity in the context of mental disorder. Significant elements of true self accounts of authenticity are required. The concept of authenticity is a basic one that can be of particular value, in the context of self-development, to people with mental disorder and to others experiencing substantial inner conflict. (shrink)

I attempt first to disentangle three aspects of Kant’s distinction between perfect and imperfect duty. There is the central distinction between principles of duty contrary to that which is contradictory in conception/consistent in conception but contradictory in will. There is also a distinction between essential and non-essential duties: those which cannot, or occasionally can, be passed over consistent with the requirements of morality. Finally, there is a distinction between duties that exhibit a scalar aspect – degrees of goodness or virtue (...) – and duties that do not. My aim is to show how these distinct considerations can be reconciled as aspects of a single distinction, and I conclude that the remarkable complexity of Kant’s perfect/imperfect distinction is actually a strength, rather than a weakness. (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came to the (...) concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that conceptualizing anorexia (...) nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

Most studies into the performance of socially responsible investment vehicles have focused on the performance of sustainable or socially responsible mutual funds. This research has been complemented recently by a number of studies that have examined the performance of sustainable investment indices. In both cases, the majority of studies have concluded that the returns of socially responsible investment vehicles have either underperformed, or failed to outperform, comparable market indices. Although the impact of sustainable indices to date has been limited, the (...) recent launch of sustainable indices by Dow Jones and FTSE suggests that more attention is being paid to the subject by financial markets, investors, and companies. This development raises a number of important issues which are reviewed in this article: (a) the performance of indices compared with their benchmark indices; (b) the methodologies employed in compiling the indices; and (c) the impact of the indices on companies and the investment community. The article concludes with a number of suggestions for areas that merit future research. (shrink)

Issues in medical ethics are rarely out of the media and it is an area of ethics that has particular interest for the general public as well as the medical practitioner. This short and accessible introduction provides an invaluable tool with which to think about the ethical values that lie at the heart of medicine. Tony Hope deals with thorny moral questions, such as euthanasia and the morality of killing, and also explores political questions such as: how should health care (...) resources be distributed fairly? (shrink)

I address the usefulness of thinking about a human right to subsistence within conceptions of human rights grounded in ordinary moral reasoning. I argue that that natural rights should be understood as rights in rem, with their dynamism constrained by the requirements of justification and their scope constrained by the distinction between perfect and imperfect duty. I then suggest that many of the most pressing demands which the moral significance of subsistence needs create are plausibly imperfect duties, and so cannot (...) correlate to a natural right to subsistence. This restricts the helpfulness of a human right to subsistence in our reasoning about what we owe to others. (shrink)

This research examines the possibility of developing a new corporate social responsibility (CSR) auditing system based on the analysis of current CSR literature and interviews conducted with a number of interested and knowledgeable stakeholders. This work attempts to create a framework for social responsibility auditing compatible with an existing commercially successful environmental audit system. The project is unusual in that it tackles the complex issue of CSR auditing with a scientific approach using Grounded Theory. On the evidence discovered to date (...) in the literature review and the interviews, CSR seems to be perceived by many as the social strand of sustainable development. However, there is far less agreement regarding its measurement. Both the literature review and the interview analysis indicate that developing an applied CSR auditing procedure will be a challenging task. This is principally due to the lack of formal study of this complex subject, which, despite the widespread debate it has engendered, still lacks a single and broadly accepted definition. The concepts developed from the findings of this research, together with the key factors identified in a literature review of CSR, were developed into a prospective CSR audit protocol. (shrink)

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in determining the (...) relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others. (shrink)

The non-identity problem arises when an intervention or behavior changes the identity of those affected. Delaying pregnancy is an example of such a behavior. The problem is whether and in what ways such changes in identity affect moral considerations. While a great deal has been written about the non-identity problem, relatively little has been written about the implications for physicians and how they should understand their duties. We argue that the non-identity problem can make a crucial moral difference in some (...) circumstances, and that it has some interesting implications for when it is or is not right for a physician to refuse to accede to a patient's request. If a physician is asked to provide an intervention (identity preserving) that makes a person worse off, then such harm provides a good reason for the physician to refuse to provide the intervention. However, in cases where different (identity-altering) interventions result in different people having a better or worse life, physicians should normally respect patient choice. (shrink)

We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.

Health care systems across the world are unable to afford the best treatment for all patients in all situations. Choices have to be made. One key ethical issue that arises for health authorities is whether the principle of the “rule of rescue” should be adopted or rejected. According to this principle more funding should be available in order to save lives of identifiable, compared with unidentifiable, individuals. Six reasons for giving such priority to identifiable individuals are considered. All are rejected. (...) It is concluded that the principle of the rule of rescue should not be used in determining the allocation of health resources. (shrink)

abstract The argument that scarce health care resources should be distributed so that patients in ‘need’ are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, each of which focuses on separate intuitions. Although this (...) account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting‐point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs‐based priority setting to social welfare maximisation. (shrink)

There is a long history of medical research that involves intentionally infecting healthy people in order to study diseases and their treatments. Such research—what might be called “human challenge studies”—are an important strand of much current research—for example, in the development of vaccinations. The many international and national guidelines about the proper conduct of medical research do not specifically address human challenge studies. In this paper we review the guidelines on the risk of harm that healthy volunteers may be exposed (...) to in the course of medical research. We examine the ethical arguments that are implicit or explicit in these guidelines. We then ask whether there is reason for limiting such studies on grounds independent of risk of harm. We conclude that the major ethical concern with challenge studies is that of risk of harm and that the fact that a study is a challenge study is not a wrong in itself. (shrink)

To reduce the spread of the human immunodeficiency virus (HIV), Granich et al. 1 ( 2009 ) have proposed a new strategy for universal voluntary HIV testing immediately followed by antiretroviral therapy. Although this proposal is likely to benefit the partners of those affected and thus promote public health, it is by no means clear that it benefits the infected people themselves and indeed it may be harmful. Since the proposal involves an intervention that is not clinically indicated, it falls (...) foul of the normal ethical standards of clinical medicine, which is to act in the best interests of patients. Neither is it a measure that would be imposed under the protection of public health law on people who are seen as representing such danger to others that significant restrictions in liberty are appropriate. Thus, the proposal represents a third category of public health measure. We argue that a coherent ethical framework including a robust process is appropriate to proposals of this kind and that medical research offers a useful model since some research, like this proposal, is motivated not by the interests of the individual participants but by the common good. We outline some possible elements of such an ethical framework. (shrink)

David Hume famously states, in his A Treatise of Human Nature, “that ’tis only from the selfishness and confin’d generosity of men, along with the scanty provision nature has made for his wants, that justice derives its origin”.1 This is Hume’s summary of the conditions under which the very idea of rules of justice makes practical sense, and he effectively repeats it in the Enquiry Concerning the Principles of Morals.2 To put it briefly at the outset, Hume’s point is simply (...) this: if there was either a superabundance or drastic scarcity of resources, or if everyone were either completely and unfailingly virtuous or completely and unfailingly wicked, we would not need rules. (shrink)

Hope and Gabbert review and distil the relevant research examining the mnemonic consequences associated with conversations within an eyewitness context. In particular, they focus on how co‐witnesses’ retellings of witnessed events impair the quantity and quality of information subsequently reported to law enforcement authorities. Notably, they also provide interventions (e.g., careful witness management and post incident procedures, use of warnings, early individual accounts, etc.) to mitigate these negative, well‐documented mnemonic effects.

In lieu of an abstract, here is a brief excerpt of the content:Decision-Making as a Broader ConceptJacinta O. A. Tan (bio), Anne Stewart (bio), and Tony Hope (bio)KeywordsCompetence, decision-making, capacity, anorexia nervosa, autonomy, values, identityWe thank Demian Whiting for the thoughtful critique of aspects of our paper (Tan et al. 2006a). A primary aim of our research was to provide empirical grounds on which to stimulate discussion about the nature of decision-making capacity (DMC). Whiting criticizes in particular the concept of (...) 'pathological values' that we suggested might be relevant in the assessment of DMC and in the related issue of deciding when a patient's refusal of beneficial treatment should be overridden.Whiting's central concern is with DMC. Whiting argues that the absence of pathological values should not be a criterion for DMC. We are unclear whether he is also arguing that pathological values do not provide a reason of any kind for overriding treatment refusal. At the end of the paper he writes: "we cannot justify compulsory treatment of patients who have pathological values... on the grounds that these patients lack DMC" (2009, XX). This seems to leave open the possibility that we may be able to justify compulsory treatment of patients who have pathological values on grounds other than that they lack DMC. As we wrote in our response to the discussants of our original paper, "The primary issue for us is whether the reasons for refusal to which we draw attention provide grounds for overriding refusal, and if they do how they can be characterized in such a way as to avoid the ever-present danger of simply overriding autonomy in a patient's best interests" (Tan et al. 2006b, 300).In deciding on whether to use compulsory treatment, there are other relevant factors that may need to be considered, such as the seriousness of the decision, which determines the threshold for competence. However, in this response we consider three issues. First, we argue that the current concept of DMC is by no means so clear cut or generally agreed upon as Whiting implies, and that some of the lack of clarity relates to pathological values. Second, that the concept of DMC is itself dependent on accounts of autonomy, and that it is plausible that pathological values can affect autonomy. Third, we directly consider the question of whether a coherent account of pathological values might be given based on a concept of authenticity.The Current Criteria for DMCWhiting argues that the current criteria for DMC are correct and that an additional criterion along the lines of absence of pathological values should not be added. This argument assumes that there is a clear and agreed understanding of the current criteria. We believe this is not the case for three reasons.(i) Whiting begins his account of DMC by saying that it is normally taken to include: "(1) [End Page 345] understanding (and appreciation)" (2009, 341). Already there is an area of dispute, and the use of parentheses reflects this. The concept of 'appreciation' was developed by Grisso and Applebaum (Grisso, Appelbaum, and Hill-Fotouhi 1997). It is not included in either English common law development, for example (ReC), nor in the criteria specified in the Mental Capacity Act 2005. More important, Grisso and Appelbaum in their comment on our original paper (2006) argue that our work advances thinking about 'appreciation' rather than requiring that we add new elements. The implication is that they believe that what we have called pathological values are relevant to the assessment of capacity and are already included in an account of capacity that incorporates the criterion of 'appreciation.' In our response, we argued that pathological values are not entirely captured within the account of appreciation that Grisso and Appelbaum had previously given. We do not want to revisit that issue here, but the point of relevance is that on one view (that of Grisso and Appelbaum) pathological values are already included in the current criteria for DMC as part of the concept of appreciation, whereas on Whiting's view they are not.(ii) Even if there were agreement over the wording and concepts relevant to DMC there is a further important issue: how are those concepts... (shrink)

ZusammenfassungEntscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

This article argues that hope is of value in clinical ethics and that it can be important for clinicians to be sensitive to both the risks of false hope and the importance of retaining hope. However, this sensitivity requires an understanding of the complexity of hope and how it bears on different aspects of a well-functioning doctor-patient relationship. We discuss hopefulness and distinguish it from three different kinds of hope, or ‘hopes for’, and then relate these distinctions back to differing (...) accounts of autonomy. This analysis matters because it shows how an overly narrow view of the ethical obligations of a clinician to their patient, and autonomy, might lead to scenarios where patients regret the choices they make. (shrink)

Entscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

Journal of Political Philosophy, EarlyView.

Next SectionMaking threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way (...) that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong. (shrink)

It is sometimes held that modern institutionally-focussed conceptions of social justice are lacking in one essential respect: they ignore the importance of civic friendship or solidarity. It is also, typically simultaneously, held that Aristotle’s thought provides a fertile ground for elucidating an account of civic friendship. I argue, first, that Aristotle is no help on this score: he has no conception of distinctively civic friendship. I then go on to argue that the Kantian distinction between perfect and imperfect duties is (...) more useful than talk of civic friendship in capturing the non-institutional demands of social justice. (shrink)

In this paper I assess the possibility of advancing a modern conception of social justice under neo-Aristotelian lights, focussing primarily on conceptions that assert a fundamental connection between social justice and eudaimonia. After some preliminary remarks on the extent to which a neo-Aristotelian account must stay close to Aristotle’s own, I focus on Martha Nussbaum’s sophisticated neo-Aristotelian approach, which I argue implausibly overworks the aspects of Aristotle’s thought it appeals to. I then outline the shape of a deeper and more (...) general, and as yet unanswered, problem facing neo-Aristotelian accounts: how to justify the claim that the point of a just society is to assist or enable its members to flourish. (shrink)

Ethics, communication skills, and the law ('practice skills') are important in all aspects of modern health care. Doctors and nurses must be sensitive to the ethical aspects of their work and understand the legal framework within which clinical decisions are made. Well developed skills of communication, with patients, their relatives and other members of the clinical team, are a key feature of good clinical practice Until recently, the important of practice skills has been relatively neglected in health care education. This (...) situation is changing. The UK General Medical Council, for example, has recently identified three aspects as part of the core of the medical course, and the move to degree courses in nursing has led to an increasing focus of practice skills in nurse education. The Oxford Practice Skills Project (OPSP) team have developed a course, within the University of Oxford Clinical School, which covers the teaching of practice skills in an integrated manner. This course is widely recognized as one of the most systematic developments of education in these areas. This manual describes the OPSP course in detail and provides teaching materials. Although developed initially for medical students, it should be helpful to all those involved in teaching ethics, communication skills, and law in health care. Each Seminar is described in detail Tutors' guides are provided Student handouts are included Contains guidelines for introducing 'practice skills' into a busy clinical curriculum Includes over forty case histories for teaching and examination Gives details of many useful sources and resources Details a variety of teaching methods together with their advantages and disadvantages Provides an ethics teaching toolkit for clinical teachers new to this area Readers are welcome to photocopy any part of this manual for their own teaching. (shrink)

OBJECTIVES: To study the resources available and resources needed for ethics teaching to medical students in UK medical schools as required by the new GMC core curriculum. DESIGN: A structured questionnaire was piloted and then circulated to deans of medical schools. SETTING: All UK medical schools. RESULTS: Eighteen out of 28 schools completed the questionnaire, the remainder either indicating that their arrangements were "under review" (4) or not responding (6). Among those responding: 1) library resources, including video and information technology (...) were found to be fairly well developed; 2) many schools had a good supply of handouts and sample cases for teaching; 3) most had a written syllabus, and 4) two-thirds examined in the subject. However, many schools indicated that there was an urgent need for: 1) full-time teachers (most ethics teaching is still by part-time and voluntary staff); funding for books and journals, and 3) additional teaching materials (including further case vignettes, handouts and sample exam questions). CONCLUSIONS: There has been a considerable overall improvement in resources for medical ethics teaching since the time of the last national survey (The Pond Report). However, provision varies widely from medical school to medical school. The particular needs identified were for full-time teachers, library resources and teaching materials. Wider use of existing organisations concerned with medical ethics could help to meet these needs. (shrink)

We describe the teaching programme in ethics, law and communication skills for clinical medical students which is being developed as part of the Oxford Practice Skills Project. These three elements of practice are approached in an integrated teaching programme which aims to address everyday clinical practice. The role of a central value of patient-centred health care in guiding the teaching is described. Although the final aim of the teaching is to improve actual practice, we have found three 'sub-aims' helpful in (...) the development of the programme. These sub-aims are: increasing students' awareness of ethical issues; enhancing their analytical thinking skills, and teaching specific knowledge. (shrink)

Kerstein and Bognar (2010) and Persad, Wertheimer, and Emanuel (2009) defend specific principles for the allocation of health care resources, but their choice of principles is influenced by the exa...

In lieu of an abstract, here is a brief excerpt of the content:Studying Penguins to Understand BirdsJacinta O. A. Tan (bio), Anne Stewart (bio), Ray Fitzpatrick (bio), and Tony Hope (bio)Keywordsanorexia nervosa, treatment decision-making, competence, valuesWe are grateful to Grisso, Appelbaum, Charland, and Vollmann for their thoughtful commentaries on our paper. We would like to respond by picking up on some of the points they make, although we do not address all the issues raised.Our general aims in the paper are (...) less immediately pragmatic than are the central concerns of Grisso and Appelbaum. Our interest is primarily in a number of ethical, and related conceptual, issues that arise from empirical data. In the long run, of course, we believe that these ethical and conceptual issues are important to the care of people with mental disorders, but our focus is philosophical.Our central interest is what justifies overriding treatment refusal. We are unhappy with a "status" approach according to which, for example, the mere fact that a person suffers a mental disorder provides grounds for overriding her wishes. Such an approach, it seems to us, fails to identify reasons, and discriminates against those with mental disorder, a view shared by the Law Commission (The Law Commission 1995). We are, on the other hand, attracted by the approach that grounds any overriding of treatment refusal on lack of capacity (or competence) to make treatment decisions. The concept of capacity has been well developed through legal cases and conceptual analysis, not least by Grisso and Appelbaum themselves. We were struck, however, first through clinical experience, and subsequently from the pilot study reported in our paper, that many patients with anorexia nervosa who refuse treatment do not necessarily lack capacity, using the current criteria, and yet show features or give reasons that raise serious doubts as to whether it is right to respect their refusal of treatment.To avoid reliance on a "status" approach, the issue with which we are grappling is whether the concept of capacity (and therefore lack of capacity) can be developed to encompass some of our findings, and whether it is ethically right to do so. Charland makes the important point that the concept of competence, or capacity, has both a descriptive and a prescriptive component. It is for this reason that the question of whether, for example, we should extend the criteria for capacity is part of the question of when it is morally right to override treatment refusal.Grisso and Appelbaum suggest that our work advances "our thinking about appreciation, rather than requiring that we add new elements" (2006, 297). From our perspective, and at this stage, it is a secondary issue whether we are suggesting a development of appreciation, or a new element (e.g., "pathological values"). The primary issue for us is whether the reasons for refusal to which we draw attention provide grounds for overriding refusal, and if they do how they can be characterized in [End Page 299] such a way as to avoid the ever-present danger of simply overriding autonomy in a patient's best interests.We chose to study anorexia nervosa for various reasons, but we expect that the issues raised have a more general relevance (such as to substance abuse and impulse control disorders as Grisso and Appelbaum and Charland suggest). We do not expect the results to be relevant to all, or even most, mental disorders. Our main interest is not the specific management of people with anorexia, but how the data challenge, and help to develop, the concept of capacity, and the ethical analysis of overriding patient refusal of treatment. Our paper aims to address what we understand Charland to be referring to by the "pretheoretical desiderata" (2006, 283) of the concept of capacity. One reason why we chose anorexia as the focus of this work is because it is different from many mental disorders in the issues that it raises. In this it is, perhaps, rather like studying penguins to better understand the concept of bird just because penguins, although clearly birds, have unusual features.We agree, therefore, with Grisso and Appelbaum's caution that it would be unwise to jump in and change the MacCAT-T on the basis of the results... (shrink)

The Mental Capacity Act is an impressive piece of legislation that deserves serious ethical attention, but much of the commentary on the Act has focussed on its legal and practical implications rather than the underlying ethical concepts. This paper examines the approach that the Act takes to best interests. The Act does not provide an account of the underlying concept of best interests. Instead it lists factors that must be considered in determining best interests, and the Code of Practice to (...) the Act states that this list is incomplete. This paper argues that this general approach is correct, contrary to some accounts of best interests. The checklist includes items that are unhelpful. Furthermore, neither the Act nor its Code of Practice provides sufficient guidance to carers faced with difficult decisions concerning best interests. This paper suggests ways in which the checklist can be developed and discusses cases that could be used in an updated Code of Practice. (shrink)

ZusammenfassungEntscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

Some of the most important achievements in the field of empiricist ethics were made by the School of Moral Sentiment, comprising Francis Hutcheson, David Hume, and Adam Smith. This book throws new light on their consensus theory of virtue. Hope works some of their ideas into a merit theory of rights applicable to conventional rights, defends ethical cognitivism, and analyzes pleasure.

:Current debates about ideal theory and idealization in modern moral and political philosophy do not typically scrutinize the form of reflection itself. This is an unfortunate oversight: assumptions about the form of reflection shape the positions defended in those debates. I argue that the appropriate form of reflection on the nature and justification of standards of justice and morality is the form of practical reason. I further argue that the form of practical reason cannot support many of the idealizations typically (...) deployed in modern moral and political philosophy. (shrink)