Mental competence and long term care: an uncomfortable relationship

Competency is an important concept in medical ethics as well as in law. It refers to the moral principles of self-determination and autonomy, which are of central importance in the ethics of health care. These moral principles also prevail in nursing home care. Societal prejudice concerning nursing home patients suggests that the inhabitants of a nursing home are almost by definition incompetent. We assert that such prejudice rests on certain societal delusions and misinterpretations of incompetency five of which are subsequently analysed. Next we discuss the dominant conception of competency in terms of decisional capacity. This conception is predominantly oriented towards cognitive abilities and underplays affective capacities. We confront this dominant conception with an alternative proposal of competency in terms of 'the capacity to value', which--to our opinion--more properly reflects nursing home practice concerning questions of competency. Finally we address the limitations of any concept of competency or decisional capacity in relation to the moral issues of 'good care' for demented elderly. As an alternative we draw attention to the moral perspective of the 'ethics of care'.     

The Ethics of Deprescribing in Older Adults

Deprescribing is the term used to describe the process of withdrawal of an inappropriate medication supervised by a clinician. This article presents a discussion of how the Four Principles of biomedical ethics (beneficence, non-maleficence, autonomy, and justice) that may guide medical practitioners’ prescribing practices apply to deprescribing medications in older adults. The view of deprescribing as an act creates stronger moral duties than if viewed as an omission. This may explain the fear of negative outcomes which has been reported by prescribers as a barrier to deprescribing. Respecting the autonomy of older adults is complex as they may not wish to be active in the decision-making process; they may also have reduced cognitive function and family members may therefore have to step in as surrogate decision-makers. Informed consent is intended as a process of information giving and reflection, where consent can be withdrawn at any time. However, people are rarely updated on the altered risks and benefits of their long-term medications as they age. Cessation of inappropriate medication use has a large financial benefit to the individual and the community. However, the principle of justice also dictates equal rights to treatment regardless of age.     

African communal basis for autonomy and life choices

I argue that the metaphysical capacity of autonomy is not intrinsically valuable; it is valuable only when used in relation to a community's values and instrumentally for making the proper choices that will promote one's own and the community's well‐being. I use the example of the choice to take one's life by suicide to illuminate this view. I articulate a plausible African conception of personhood as a basis for the idea of relational autonomy. I argue that this conception is better understood as a social‐moral thesis, and not a metaphysical thesis. A metaphysical thesis gives an account of the abstract nature of an atomic individual, his agency, and rational choice. The social‐moral thesis indicates that personhood and autonomy are positive and relational to the life plans, well‐being, material conditions, and the best means for achieving them that are made available and possible by harmonious living in a community. This idea of autonomy is not just having the capacity of freewill; it also involves how such freewill is used, in terms of how an individual's choices are guided by internalized communal values.     

Autonomy and the limits of cognitive enhancement

In the debates regarding the ethics of human enhancement, proponents have found it difficult to refute the concern, voiced by certain bioconservatives, that cognitive enhancement violates the autonomy of the enhanced. However, G. Owen Schaefer, Guy Kahane and Julian Savulescu have attempted not only to avoid autonomy‐based bioconservative objections, but to argue that cognition‐enhancing biomedical interventions can actually enhance autonomy. In response, this paper has two aims: firstly, to explore the limits of their argument; secondly, and more importantly, to develop a more complete understanding of autonomy and its relation to cognitive enhancement. By drawing a distinction between the capacity for autonomy and the exercise and achievement of autonomy, and by exploring the possible effects of cognitive enhancement on both competence and authenticity conditions for autonomy, the paper identifies and explains which dimensions of autonomy can and cannot, in principle, be enhanced via direct cognitive interventions. This allows us to draw conclusions regarding the limits of cognitive enhancement as a means for enhancing autonomy.     

Sick autonomy

Complex social and economic forces have placed patient autonomy at the center of medical ethics, and thereby displaced an older ethic of physician beneficence. This development arose, and is sustained, by waning trust in the traditional doctor-patient relationship. As patients have increasingly become clients and consumers, a contract basis for medical care has put the ancient covenant of care in jeopardy. Here, a philosophical approach to harmonize the apparent conflicting claims of patient autonomy and physician beneficence is offered by demonstrating that autonomy need not be understood as protecting a threatened identity. If persons are regarded as atomistic, certain defensive notions of individualistic rights-based autonomy prevail; if a relational construction of personal identity is employed instead, then respect for autonomy becomes part of a wider morality of relationship and care. By reconfiguring trust within this latter understanding of personhood, bioethics better balances its concerns over choices and actions with those of relationship and responsibility. Neither atomistic autonomy nor the ethics of responsibility can claim hegemony, for they are mutually interdependent, and a complete account of medicine's moral axis requires that they be integrated. This reorientation is crucial for reasserting the ethos of clinical medicine, whose fundamental mandate remains the care of others.     

On the necessity to distinguishing judgment from subjective choice in the cognitive neuroscience of morality

Recently, cognitive neuroscience has shed new light on our understanding of the neural underpinning of humans' morality. These findings allow for a fundamental questioning and rethinking of the alleged dichotomy between reason and emotion, that has profoundly shaped both moral philosophy and moral psychology. Functional neuroimaging and neuropsychology studies have provided strong arguments favoring a dynamic and interdependent interaction between rational and emotional processes in the brain. Yet another fundamental issue remains largely unexplored: the dissociation between certain behaviours and the moral judgments that seem to precede them. The importance of this dissociation was highlighted in a study of psychopathic patients during which they preserved their moral judgments while frequently engaging in completely non moral behaviour. Such dissociation could result from the cognitive difference between an objective moral judgement with no personal consequence, and a subjective behavioural choice that has effective or potential personal consequences. Consequently, the results of moral dilemma experiments would differ widely depending whether they explore objective or subjective moral evaluations. That these evaluations involve two distinct neural processes should be taken into account when exploring the neural bases of human morality.     

Savior Siblings,Parenting and the Moral Valorization of Children

Philosophy has long been concerned with ‘moral status’. Discussions about the moral status of children, however, seem often to promote confusion rather than clarity. Using the creation of ‘savior siblings’ as an example, this paper provides a philosophical critique of the moral status of children and the moral relevance of parenting and the role that formative experience, regret and relational autonomy play in parental decisions. We suggest that parents make moral decisions that are guided by the moral significance they attach to children, to sick children and most importantly, to a specific sick child (theirs). This moral valorization is rarely made explicit and has generally been ignored by both philosophers and clinicians in previous critiques. Recognizing this, however, may transform not only the focus of bioethical discourse but also the policies and practices surrounding the care of children requiring bone marrow or cord blood transplantation by better understanding the values at stake behind parental decision making.     

Neural Correlates of Post-Conventional Moral Reasoning: A Voxel-Based Morphometry Study

Going back to Kohlberg, moral development research affirms that people progress through different stages of moral reasoning as cognitive abilities mature. Individuals at a lower level of moral reasoning judge moral issues mainly based on self-interest (personal interests schema) or based on adherence to laws and rules (maintaining norms schema), whereas individuals at the post-conventional level judge moral issues based on deeper principles and shared ideals. However, the extent to which moral development is reflected in structural brain architecture remains unknown. To investigate this question, we used voxel-based morphometry and examined the brain structure in a sample of 67 Master of Business Administration (MBA) students. Subjects completed the Defining Issues Test (DIT-2) which measures moral development in terms of cognitive schema preference. Results demonstrate that subjects at the post-conventional level of moral reasoning were characterized by increased gray matter volume in the ventromedial prefrontal cortex and subgenual anterior cingulate cortex, compared with subjects at a lower level of moral reasoning. Our findings support an important role for both cognitive and emotional processes in moral reasoning and provide first evidence for individual differences in brain structure according to the stages of moral reasoning first proposed by Kohlberg decades ago.     

Medical experimentation, informed consent and using people

In this paper we argue that the standard focus on problems of informed consent in debates about the ethics of human experimentation is inadequate because it fails to capture a more fundamental way in which such experiments may be wrong. Taking clinical trials as our case in point, we suggest that it is the moral offence of using people as mere means which better characterizes what is wrong with violations of personal autonomy in certain kinds of clinical trials. This account also helps bring out another important way in which the autonomy of the participants in clinical trials my be violated, even in cases where they have given informed consent to their involvement. Where relevant information about the trial is framed in such a way as to induce a patient's participation by appeal to their nonrational preferences, this is also a violation of their autonomy, and one which is distinct from a failure of informed consent. The underlying wrongness of both kinds of violations, we argue, is plausibly captured by the moral offence of using people as mere means.     

Evolutionary ethics,Darwinian ethics and ethical naturalism

The relevance of evolutionary theory to ethics goes back to Darwin but until recently discussion employed evolutionary theory to justify ethical, social and political positions. Recently, evolutionary theory has been used to explain the existence of moral systems and moral propensities and, thereby, to provide a naturalistic basis for ethics. I argue that this approach has advanced our understanding of the basis of moral systems and moral propensities but does not as yet adequately incorporate the role of cognition in its account. Cognition has the effect of decoupling to some extent — though, of course, far from fully — human moral systems from their evolutionary origins. In an adequate account, evolutionary theory will play a crucial role but so also will our evolved cognitive abilities.     

Editor's introduction to the Journal of Applied Animal Welfare Science

Animal welfare names a science in which investigators ask the general question: What are the capacities, sensibilities, needs, and interests of animals as they relate to their welfare? The objects of study in this emerging field are exclusively animals other than humans. Numerous contexts give rise to this interest in nonhuman animal welfare: The intensification of the use of animals since World War II, particularly on the farm and in the laboratory. The development of moral philosophies that establish nonhuman animals as objects of moral consideration. The advances in science in fields that have added to our understanding of animals, such as cognitive ethology. Advances in technology that give us more direct access to human physiology and psychology and undercut the tradition of using animal models. The success of the contemporary animal rights movement in placing the issue of the treatment of animals before the public.     

Autonomy is a Right,Not a Feat: How Theoretical Misconceptions have Muddled the Debate on Dynamic Consent to Biobank Research

Should people be involved as active participants in longitudinal medical research, as opposed to remaining passive providers of data and material? We argue in this article that misconceptions of ‘autonomy’ as a kind of feat rather than a right are to blame for much of the confusion surrounding the debate of dynamic versus broad consent. Keeping in mind two foundational facts of human life, freedom and dignity, we elaborate three moral principles – those of autonomy, integrity and authority – to better see what is at stake. Respect for autonomy is to recognize the other's right to decide in matters that are important to them. Respect for integrity is to meet, in one's relationship with the other, their need to navigate the intersection between private and social life. Respect for authority is to empower the other – to help them to cultivate their responsibility as citizens. On our account, to force information onto someone who does not want it is not to respect that person's autonomy, but to violate integrity in the name of empowerment. Empowerment, not respect for autonomy, is the aim that sets patient‐centred initiatives employing a dynamic consent model apart from other consent models. Whether this is ultimately morally justified depends on whether empowerment ought to be a goal of medical research, which is questionable.     

Moral enhancement,at the peak of pharmacology and at the limit of ethics

The debate over the improvement of moral capacity or moral enhancement through pharmacology has gained momentum in the last decade as a result of advances in neuroscience. These advances have led to the discovery and allowed the alteration of patterns of human behavior, and have permitted direct interventions on the neuronal structure of behavior. In recent years, this analysis has deepened regarding the anthropological foundations of morality and the reasons that would justify the acceptance or rejection of such technology. We present a review of proposals for pharmacological interventions directed directly towards moral enhancement. In addition, we identify the ethical dilemmas that such interventions may generate, as well as the moral assessment of the authors of these studies. There is a moderate consensus on the risks of any intervention on the intimate structure of the human condition, its autonomy and identity, but there are large differences in explaining the reasons for this concern and especially in justifying such interventions. These findings show that it is necessary to investigate the moral assessment of authors and the ethical dimension within the field of pharmacology in order to identify future trends.     

The ‘Obligation’ to Screen and its Effect on Autonomy

In the United States, disease screening is offered to the public as a consumer service. It has been proposed that the act of “consumption” is a manifestation of agency and that the decision to consume is an exercise of autonomy. The enthusiasm of the American public for disease screening and the expansion in the demand for all sorts of disease screening in recent years can be viewed as an expression of such autonomy. Here, we argue that the enthusiasm for disease screening witnessed in the American public today may be more a reflection of the constraint on autonomy than its facilitation. It is our opinion that the articulation of socio-historical processes has contributed to a moral imperative which is reflected in the decision making of individuals around disease screening. We suggest medical and health professionals have a responsibility to facilitate the exercise of individual autonomy in health care decision making as an integral component of professional obligation. These professionals need to problematise healthcare activities that constrain individual autonomy.     

Autonomy, interdependence, and assisted suicide: respecting boundaries/crossing lines

Western philosophy has been powerfully influenced by a paradigm of personal agency that is linked to an individualistic conception of autonomy. This essay contrasts this conception with an alternative understanding that recognizes a social component built into the very meaning of autonomy. After reviewing feminist critiques of the dominant conception of autonomy, I develop the broad outlines of a relational view and apply this reconceptualization to a concrete situation in order to show how this altered view reconfigures understanding of the participants' relationships and each of their personal perspectives. The situation chosen, physician-assisted suicide, is intended principally to illustrate one respect in which a relational conception of autonomy reframes a controversial moral issue and reveals perspectives toward it that are likely to be obscured when autonomy is viewed through the lens of the dominant individualistic conception. My principal aim is to show that when autonomy is understood relationally, respecting others' autonomy is likely to be a far more complex issue than is apparent within the standard conception, both for those with professional responsibilities and often for personal intimates as well.     

Developing a ‘moral compass tool’ based on moral case deliberations: A pragmatic hermeneutic approach to clinical ethics

Although moral case deliberation (MCD) is evaluated positively as a form of clinical ethics support (CES), it has limitations. To address these limitations our research objective was to develop a thematic CES tool. In order to assess the philosophical characteristics of a CES tool based on MCDs, we drew on hermeneutic ethics and pragmatism. We distinguished four core characteristics of a CES tool: (a) focusing on an actual situation that is experienced as morally challenging by the user; (b) stimulating moral inquiry into the moral concepts, questions and routines in the lived experience of the CES tool user; (c) stimulating moral learning by exploring other perspectives; and (d) incorporating contextual details. We provide an example of a CES tool developed for moral dilemmas over client autonomy. Our article ends with some reflections on the normativity of the CES tool, other application areas and the importance of evaluation studies of CES tools.     

Beyond the 'Village' Rhetoric: Creating Healthy Communities for Children and Adolescents

In this article, we explore the intertwining of moral identity and the social and cultural context. First, we review existing research on moral identity that has considered the role of social others and the cultural environment. Then we pose questions to further research in this area and offer a 3-level framework with which to understand how the cultural world influences moral identity development. Central to this framework is an analysis of the cultural practices within which moral identities develop, as well as the institutional contexts that support these practices and the social interactions that comprise them. Finally, we illustrate the components of framework using examples of data from 2 studies-1 focused on how an inner city Muslim school worked to foster the moral identities of students and the other on the development of civic identities among urban teens in a community action program.     

A Fine Balance: Reconsidering Patient Autonomy in Light of the UN Convention on the Rights of Persons with Disabilities

The Convention on the Rights of Persons with Disabilities is increasingly seen as driving a paradigm shift in mental health law, particularly in relation to the understanding that it requires a shift from substituted to supported decisions. This article identifies two competing moral commitments implied by this shift, both of which appeal to the notion of autonomy. It is argued that because of these commitments the Convention is in tension with more general calls in the medical ethics literature for preserving patient autonomy through support. The competing commitments within the Convention also present a particular challenge in putting the support it requires into practice. A discursive control account of freedom is used to develop some practical guidelines for navigating this new moral territory.     

Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy

Most contemporary bioethicists believe that Western bioethical principles, such as the principle of autonomy, are universally binding wherever bioethics is found. According to these bioethicists, these principles may be subject to culturally-conditioned further interpretations for their application in different nations or regions, but an 'abstract content' of each principle remains unchanged, which provides 'an objective basis for moral judgment and international law'. This essay intends to demonstrate that this is not the case. Taking the principle of autonomy as an example, this essay argues that there is no such shared 'abstract content' between the Western bioethical principle of autonomy and the East Asian bioethical principle of autonomy. Other things being equal, the Western principle of autonomy demands self-determination, assumes a subjective conception of the good and promotes the value of individual independence, whilst the East Asian principle of autonomy requires family-determination, presupposes an objective conception of the good and upholds the value of harmonious dependence. They differ from each other in the most general sense and basic moral requirement.     

Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia

Most contemporary bioethicists believe that Western bioethical principles, such as the principle of autonomy, are universally binding wherever bioethics is found. According to these bioethicists, these principles may be subject to culturally-conditioned further interpretations for their application in different nations or regions, but an 'abstract content' of each principle remains unchanged, which provides 'an objective basis for moral judgment and international law'. This essay intends to demonstrate that this is not the case. Taking the principle of autonomy as an example, this essay argues that there is no such shared 'abstract content' between the Western bioethical principle of autonomy and the East Asian bioethical principle of autonomy. Other things being equal, the Western principle of autonomy demands self-determination, assumes a subjective conception of the good and promotes the value of individual independence, whilst the East Asian principle of autonomy requires family-determination, presupposes an objective conception of the good and upholds the value of harmonious dependence. They differ from each other in the most general sense and basic moral requirement.