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)

Fertility treatment enables involuntary childless people to have genetically related children, something that, for many, is a valuable life project. In this paper, I respond to two sets of objections that have been raised against expanding state-funded fertility treatment provision for existing treatments, such as in vitro fertilisation (IVF), and against funding new treatments, such as uterine transplantation (UTx). Following McTernan, I refer to the first set of objections as the ‘one good among many’ objection. It purports that it is (...) unjustifiable for the state to prioritise the funding of the life project of becoming a parent through fertility treatment provision over the funding of other life projects that people might have. Following Lotz, I refer to the second set of objections as the ‘norm-legitimation’ objection. It maintains that the provision of costly forms of fertility treatment, such as UTx, would legitimise problematic social norms concerning genetic relatedness, reproduction and parenting, and that states should not engage in such a legitimation. In response to these objections, I defend the view that (reproductive) preferences ought to be taken more seriously when discussing fertility treatment provision and parental projects, and that not doing so can be costly, especially for women. The approach defended in this paper seeks to avoid disregarding and policing preferences and to reconcile their fulfilment with political projects aimed at improving the material and social conditions of sub-fertile people: people who, for social or biological reasons (or an intersection of the two), are unable to reproduce unassisted. (shrink)

Opioid treatment agreements are written agreements between physicians and patients enumerating the risks associated with opioid medications along with the requirements that patients must meet to receive these medications on an ongoing basis. The choice to use such agreements goes beyond the standard informed consent process, and has a distinctive symbolic significance. Specifically, it suggests that physicians regard it as important to hold their patients accountable for adhering to various protocols regarding the use of their opioid medications. After laying out (...) a taxonomy of accountability relationships between physicians and patients, I argue that opioid treatment agreements are only justifiable for physicians to use in their provision of care if they improve public health outcomes, which has yet to be demonstrated. (shrink)

This paper proposes that the question “What should I believe?” is to be answered in the same way as the question “What should I do?,” a view I call Equal Treatment. After clarifying the relevant sense of “should,” I point out advantages that Equal Treatment has over both simple and subtle evidentialist alternatives, including versions that distinguish what one should believe from what one should get oneself to believe. I then discuss views on which there is a distinctively epistemic sense (...) of should. Next I reply to an objection which alleges that non-evidential considerations cannot serve as reasons for which one believes. I then situate Equal Treatment in a broader theoretical framework, discussing connections to rationality, justification, knowledge, and theoretical vs. practical reasoning. Finally, I show how Equal Treatment has important implications for a wide variety of issues, including the status of religious belief, philosophical skepticism, racial profiling and gender stereotyping, and certain issues in psychology, such as depressive realism and positive illusions. (shrink)

Does the implementation of treatment schemes as an integrated element in the sentencing of offenders violate a retributivist view of punishment? Traditional rehabilitationism has often been held to conflict with retributive justice. However, in this chapter it is argued that: 1) treatment schemes can be designed in a way that is fully consistent with retributive proportionality constraints; 2) treatment schemes cannot plausibly be rejected by retributivists as a type of punishment that should be banned in principle; 3) there may be (...) circumstances under which the retributivist should accept treatment schemes even if criminals are being disproportionately punished. (shrink)

_Covert treatment raises a number of ethical and practical issues in psychiatry. Viewpoints differ from the standpoint of psychiatrists, caregivers, ethicists, lawyers, neighbours, human rights activists and patients. There is little systematic research data on its use but it is quite certain that there is relatively widespread use. The veil of secrecy around the procedure is due to fear of professional censure. Whenever there is a veil of secrecy around anything, which is aided and abetted by vociferous opposition from some (...) sections of society, the result is one of two: 1) either the activity goes underground or 2) it is reluctantly discarded, although most of those who used it earlier knew it was needed. Covert treatment has the dubious distinction of suffering both such secrecy and disapproval. Covert treatment has a number of advantages and disadvantages in psychotic disorders. The advantages are that it helps solve practical clinical problems; prevents delays in starting treatment, which is associated with clinical risks and substantial costs; prevents risk of self-destructive behaviour and/or physical assault by patient; prevents relapse; and prevents demoralization of staff. The disadvantages are that it maybe used with malafide intent by caregivers with or without the complicity of psychiatrists; it may be used to force conformity in dissenters; and the clinician may land himself in legal tangles even with its legitimate use. In addition, it may prevent insight, encourage denial, promote unhealthy practices in the treating staff and prevent understanding of why noncompliance occurs in the first place. Some support its use in dementia and learning disorders but oppose it in schizophrenia. The main reason is that uncooperative patients of schizophrenia (and related psychoses) are considered to be those who refuse treatment but retain capacity; while in dementia and severe learning disorder, uncooperative patients are those who lack capacity. This paper disputes this contention by arguing that although uncooperative patients of schizophrenia (and related psychoses) apparently retain capacity, it is limited, in fact distorted, since they lack insight. It presents the concept of insight-unconsciousness in a patient of psychosis. Just as an unconscious patient has to be given covert medical/surgical treatment, similarly an insight-unconscious patient with one of the different psychoses (in the acute phase or otherwise) may also have to be given covert treatment till he regains at least partial insight. It helps control psychotic symptoms and assists the patient in regaining enough insight to realize he needs treatment. Another argument against covert treatment is that people with schizophrenia have the capacity to learn and therefore can learn that they are required to take medications, but if medications are given covertly it may well fuel their paranoia. However, it should be noted that the patient who has lack of insight cannot learn unless he regains that insight, and he may need covert treatment to facilitate this process. Covert treatment can fuel the paranoia, true, but it can also control the psychotic symptoms sufficiently so that regular treatment can be initiated. In a patient who refuses to accept that he is sick and when involuntary commitment is not an option to be considered, covert treatment is the only option, apart from physical restraint. Ultimately, a choice has to be made between a larger beneficence (control of symptoms and start of therapy) and a smaller malevolence (necessary therapy, but without the patient's knowledge and consent). A number of practical clinical scenarios are outlined wherein the psychiatrist should adopt covert treatment in the best interests of the patient. Ethical issues of autonomy, power, secrecy and malafide intent arise; each of these can be countered only by non-malfeasance (above all, do no harm) under the overarch of beneficence (even above that, dare to care). An advance directive with health care proxy that sanctions covert treatment is presented. Questions raised by the practical clinical scenarios are then answered. The conclusions are as follows: covert treatment, i.e, temporary treatment without knowledge and consent, is seldom needed or justified. But, where needed, it remains an essential weapon in the psychiatrist's armamentarium: to be used cautiously but without guilt or fear of censure. However, the psychiatrist must use it very judiciously, in the rarest of rare cases, provided: i) he is firmly convinced that it is needed for the welfare of the patient; ii) it is the only option available to tide over a crisis; iii) continuing efforts are made to try and get the patient into regular psychiatric care; iv) the psychiatrist makes it clear that its use is only as a stop-gap; v) he is always alert to the chances of malevolence inherent in such a process and keeps away from conniving or associating with anything even remotely suspicious; and vi) he takes due precautions to ensure that he does not land into legal tangles later. The need of the hour is to explore in greater detail the need and justification for covert treatment, to lay out clear and firm parameters for its legitimate use, follow it up with standard literature and, finally, to establish clinical practice guidelines by unconflicted authors. The term "covert treatment" is preferable to "surreptitious prescribing"; they should not be used synonymously, the latter term being reserved for those cases where there is malafide intent._. (shrink)

Background: The use of forced treatment and care of home-dwelling persons with dementia is a universally important topic. These patients are completely dependent on care from others to continue living at home. Aim: This study aimed to gain insights into formal decisions related to the forced treatment and care of home-dwelling persons with dementia. Design and sample: This is a cross-sectional study, based on formal decisions of forced treatment and care of home-dwelling persons with dementia in Norway between 1 January (...) 2015 and 31 December 2016. Methods: Descriptive statistical analysis. Statistically significant associations suitable for binary logistic regression were presented as odds ratios with 95% confidence intervals. Ethical considerations: Approved by The Regional Committee for Medical and Health Research Ethics, and by the Norwegian Center for Research. Results: We found 108 formal decisions of forced treatment and care of persons with dementia. Decisions of admission represented 57% of the data, other medical and safety decisions 27%, and assistance with activities of daily living 16%. In most cases, physicians were responsible for the decisions (77%), but nurses and family members were often involved. Discussion and conclusion: This study demonstrated a prevalence rate of formally documented decisions of forced treatment and care much lower than findings in previous studies. Poor documentation may constitute a risk for the safety and wellbeing of persons with dementia. Although physicians were usually responsible for the decisions, nurses and family members were often involved in the process. Family participation in forced treatment and care raises ethical dilemmas. More research on the experiences of nurses, persons with dementia and family members with forced treatment and care is needed to aid ethical, legal, and clinically challenging decision-making processes. (shrink)

Psychedelic treatment with psilocybin is receiving increased attention following clinical trials showing it may help treat end-of-life anxiety, depression, and several other conditions. Despite this, physicians may be reluctant to prescribe psilocybin and carry out psilocybin treatment because of the stigma surrounding psychedelics and the potential for medical malpractice liability. This paper explores whether psilocybin treatment gives rise to a risk of medical malpractice liability for physicians. Following an overview of psilocybin treatment and its regulatory regime in Canada, exploratory vignettes (...) are used to highlight the relevance and limits of malpractice claims. This paper argues that the lack of established medical standards, standardized training, and credentialing contribute to liability risks surrounding psilocybin treatment. More clinical trials, meta-studies of research analyses, and knowledge sharing will help to develop training programs and medical standards of practice to better realize psilocybin’s potential. (shrink)

There are three lines of argument in defence of coercive treatment of patients with mental disorders: arguments regarding (1) societal interests to protect others, (2) the patients' own health interests, and (3) patient autonomy. In this paper, we analyse these arguments in relation to an idealized case, where a person with a mental disorder claims not to want medical treatment for religious reasons. We also discuss who should decide what in situations where patients with mental disorders deny treatment on seemingly (...) rational grounds.We conclude that, in principle, coercive treatment cannot be defended for the sake of protecting others. While coercive actions can be acceptable in order to protect close family and others, medical treatment is not justified for such reasons but should be given only in the interest of patients. Coercive treatment may be required in order to promote the patient's health interests, but health interests have to waive if they go against the autonomous interests of the patient. We argue that non-autonomous patients can have reasons, rooted in their deeply-set values, to renounce compulsory institutional treatment, and that such reasons should be respected unless it can be assumed that their new predicaments have caused them to change their views. (shrink)

Competent patients suffering from treatment-resistant depressive disorder should be treated no different in the context of assisted dying to other patients suffering from chronic conditions that render their lives permanently not worth living to them. Jurisdictions that are considering, or that have, decriminalised assisted dying are discriminating unfairly against patients suffering from treatment-resistant depression if they exclude such patients from the class of citizens entitled to receive assistance in dying.

Adopting an instrumental approach for stakeholder management, we focus on two primary stakeholder groups to investigate the relationship between employee treatment and loan contracts with banks. We find strong evidence that fair employee treatment reduces loan price and limits the use of financial covenants. In addition, we document that relationship bank lenders price both the levels and changes in the quality of employee treatment, whereas first-time bank lenders only care about the levels of fair employee treatment. Taking a contingency perspective, (...) we find that industry competition and firm asset intangibility moderate the relationship between good human resource management and bank loan costs. The cost reduction effect of fair employee treatment is stronger for firms operating in a more competitive industry and having higher levels of intangible assets. (shrink)

Treatment-resistant symptoms complicate the clinical course of schizophrenia, and a large proportion of patients do not reach functional recovery. In consequence, polypharmacy is frequently used in treatment-refractory cases, addressing psychotic positive, negative and cognitive symptoms, treatment-emergent side effects caused by antipsychotics and comorbid depressive or obsessive-compulsive symptoms. To a large extent, such strategies are not covered by pharmacological guidelines which strongly suggest antipsychotic monotherapy. Add-on strategies comprise combinations of several antipsychotic agents and augmentations with mood stabilizers; moreover, antidepressants and experimental (...) substances are applied. Based on the accumulated evidence of clinical trials and meta-analyses, combinations of clozapine with certain second-generation antipsychotic agents and the augmentation of antipsychotics with antidepressants seem recommendable, while the augmentation with mood stabilizers cannot be considered superior to placebo. Forthcoming investigations will have to focus on innovative pharmacological agents, the clinical spectrum of cognitive deficits and the implementation of cognitive behavioral therapy. (shrink)

Rationale Treatment guidelines recommend a more conservative surgical approach than mastectomy for early stage breast cancer and a stronger emphasis on adjuvant therapy. Registry data at South Australian teaching hospitals have been used to monitor survivals and treatment in relation to these guidelines.Aims and objectives To use registry data to: (1) investigate trends in survival and treatment; and (2) compare treatment with guidelines.Methods Registry data from three teaching hospitals were used to analyse trends in primary courses of treatment of breast (...) cancers during 1977–2003 (n = 4671), using univariate analyses and multiple logistic regression. Disease-specific survivals were analysed using Kaplan–Meier product limit estimates and multivariable Cox proportional hazards regression.Results The 5-year survival was 79.9%, but with a secular increase, reaching 83.6% in 1997–2003. The relative risk of death (95% confidence limits) was 0.74 (0.62, 0.88) for 1997–2003, compared with previous diagnoses, after adjusting for tumour node metastasis stage, grade, age and place of residence. Treatment changes included an increase in conservative surgery (as opposed to mastectomy) from 51.7% in 1977–1990 to 76.8% in 1997–2003 for stage I (P < 0.001) and from 31.1% to 52.2% across these periods for stage II (P < 0.001). Adjuvant radiotherapy also became more common (P < 0.001), with 20.6% of patients receiving this treatment in 1977–1990 compared with 60.7% in 1997–2003. Radiotherapy generally was more prevalent when conservative surgery was provided, although also relatively common in mastectomy patients when tumour diameters exceeded 50 mm or when there were four or more involved nodes. The proportion of patients receiving chemotherapy increased (P < 0.001), from 19.6% in 1977–1990 to 36.9% in 1997–2003, and the proportion having hormone therapy also increased (P < 0.001), from 34.3% to 59.4% between these periods.Conclusions Survivals appear to be increasing and treatment trends are broadly consistent with guideline directions, and the earlier research on which these recommendations were based. (shrink)

How should the state respond to people who commit low‐level criminal offenses that stem from an untreated substance‐use disorder? The issue has taken on a heightened importance amidst an ongoing national addiction crisis that has destabilized many U.S. communities and led to a myriad of harms. I offer a qualified defense for the use of legal mandates that require participation in drug treatment in lieu of jail time as one possible tool for reducing the public harms associated with chronic addiction. (...) I argue that mandated treatment is effective, though less effective than many proponents argue. Beyond the effectiveness question, opponents contend that mandated treatment exacerbates structural inequalities, including the overpolicing of marginalized communities and underinvestment in voluntary treatment. Drawing on an egalitarian theory of justice, I argue that these structural inequalities present a compelling reason to constrain the use of mandates, but that they should be counterbalanced by a mixture of paternalistic and public safety concerns that make mandates one of several instruments in drug policy for addressing the pervasive harms from severe substance‐use disorders. (shrink)

Patients with severe mental illness are more likely to develop kidney disease and its complications compared to patients without severe mental illness. Once patients with mental illness develop end-stage kidney disease, supporting adherence is important but can be difficult in moments of acute psychosis when the patient objects to dialysis, particularly when considering the lack of dialysis-compatible psychiatric hospitals. In this case, a woman with a history of bipolar disease and end-stage kidney disease has a manic episode after discontinuing her (...) antipsychotic medications and refuses dialysis owing to paranoid delusions. We argue that, due to the potential imminent harm to the patient in refusing dialysis when incapacitated due to severe mental illness, it is reasonable to pursue treatment over objection while waiting for return to capacity unless the surrogate decision maker does not believe it would be in line with the patient’s values and beliefs. If there is no return to capacity after an agreed trial period and dialysis cannot be safely pursued outside of the hospital, the provider may ethically withdraw dialysis even contrary to the surrogate decision maker when continuing treatment may be limited by resources and overshadowed by harm to the patient. In this article, we will discuss how Rubin and Prager’s criteria in deciding to treat over patient objection were used and their limitations in being able to quantifiably weigh each principle, as well as the ethical justifiability of withdrawal of dialysis should the patient continue to be decapacitated and unwilling to cooperate with dialysis. (shrink)

Recent developments in genomic technology, especially those enabling gene editing, promise to put an end to hitherto intractable medical problems and to usher us into the age of personalized medicine. These technologies, however, raise a number of serious ethical challenges. Given the global impact of this technology, recent international regulations emphasize the need for intercultural dialogue on these ethical issues. This paper concentrates on Islamic perspectives on human genetic modification. It examines Islamic juristic discourses on the issue of genetic modification (...) and highlights the different layers within these discourses. The paper identifies the main positions regarding human genetic modification along with the underlying arguments for each of them. In general, these positions are articulated in light of the nature as well as the intended objectives of the different procedures. The paper devotes special attention to the treatment-enhancement distinction and argues that within Islamic discourses this distinction is quite nuanced. The paper points out important substantive and methodological gaps and emphasizes the evolving nature of Islamic discourses on this issue. (shrink)

It has recently been proposed to incorporate the use of a “Patient Preference Predictor” (PPP) into the process of making treatment decisions for incapacitated patients. A PPP would predict which treatment option a given incapacitated patient would most likely prefer, based on the individual’s characteristics and information on what treatment preferences are correlated with these characteristics. Including a PPP in the shared decision-making process between clinicians and surrogates has the potential to better realize important ethical goals for making treatment decisions (...) for incapacitated patients. However, developing and implementing a PPP poses significant practical challenges. The present paper discusses these practical challenges and considers ways to address them. (shrink)

Proponents of gender transition procedures argue that parents have a moral obligation to support and facilitate a child or adolescent in the decision to transition medically. In this paper, we challenge this idea. We contend that parents of children and adolescents have a moral obligation to oppose medical transition. To argue for this claim, we present and draw conclusions from a series of cases that are similar in their morally relevant details to cases involving medical transition for children and adolescents. (...) Given such similarity, we contend that, on pain of irrationality, one must issue the same judgments across the board. If one does not make the same judgments about the cases, then the onus is on the defender of medical transition for children and adolescents to highlight a morally significant asymmetry. We argue that no such asymmetry exists. (shrink)

Apotex Pty Ltd v Sanofi-Aventis Australia Pty Ltd [2013] 304 ALR 1At the heart of some disputes regarding medical treatment is the conceptual difficulty of finding the appropriate legal framework. The diagnosis and treatment of medical conditions are clearly subject to professional standards and thus sit within the negligence framework, but what of those who develop and provide that diagnosis and treatment? Do innovative approaches give rise to a patentable interest and can the intellectual property in a method of treatment (...) be protected under existing patent law? This question was recently addressed by the High Court in Apotex Pty Ltd v Sanofi-Aventis Australia Pty Ltd [2013] 304 ALR 1.The technical arguments are clearly set out in the judgment and do not warrant repetition. For present purposes it is sufficient to highlight the central legal question, which was whether a method of medical treatment could be a “manner of manufacture” and therefore patentable.The DecisionThe High Court .. (shrink)

Ayahuasca, an ancient Amazonian psychedelic tea traditionally used ceremonially among indigenous peoples, has recently become known as a possible treatment for a wide range of disorders. The awareness of this sacred medicine has grown exponentially over the past decade, attracting westerners from a wide variety of backgrounds, hoping to find treatment for a myriad of emotional and physical illnesses, as well as spiritual needs. In the wake of the commercialization and westernization of the use of ayahuasca, and the subsequent proliferation (...) of ayahuasca treatment centers, this paper examines the benefits and possible risks of this form of therapy in an effort to create a safety protocol for Westerners in this context. The most practical approach to increasing safety for Westerners attending these Amazonian treatment centers is to educate the seeker prior to treatment and to provide access to specialized therapeutic aftercare services. (shrink)

The explanatory/pragmatic-trial distinction enjoys a burgeoning philosophical and medical literature and a significant contingent of support among philosophers and healthcare stakeholders as an important way to assess the design and results of randomized controlled trials. A major motivation has been the need to provide relevant, generalizable data to drive healthcare decisions. While talk of pragmatic and explanatory trials could be seen as convenient shorthand, the distinction can also be seen as harboring deeper issues related to inferential strategies used to evaluate (...) causal claims regarding medical treatments. A comprehensive, critical analysis of the distinction and underlying epistemological framework upon which the distinction is based, particularly with respect to treatment effectiveness, has yet to be forthcoming. I provide this, analyzing the distinction’s relationship to generalizability and cognate distinctions between ideal conditions and real-world practice, internal and external validity, and efficacy and effectiveness. I also analyze recent philosophical work that relies on the explanatory/pragmatic-trial distinction and that advocates for more pragmatic trials. I conclude that as an organizing principle for trial-design decisions and trial evaluation, the explanatory/pragmatic-trial distinction is conceptually problematic and not as useful as its proponents seem to think. Since some pragmatic-trial features can be inimical to establishing treatment effectiveness, pragmatic-trial features should not be conflated with pragmatic trials’ avowed goals. If the distinction is to be useful, it and some associated concepts, including generalizability, should be reformulated, lest they continue to underlie a medical epistemology that could contribute to methodologically flawed and potentially unethical advice for the design and interpretation of trials. (shrink)

Treatment limitation decision (TLD) is a complex process affected by comorbidities and cultural aspects. We hypothesized that presence of delirium is associated with TLD in hospitalized patients. to compare the proportion of patients with at least one TLD order between delirium and non-delirium patients, to describe factors associated with TLD orders, and to explore the association between TLD, delirium and the 90-day risk of death or hospital readmission. All patients admitted to internal medicine at a single hospital between November 2019 (...) and January 2020 had a formal delirium assessment with a neuropsychologist within 48 h of hospitalization. TLD orders, death at 90 days and readmission were recorded. 217 patients were included, of whom 119 (54.9%) had a “do not resuscitated” order, 107 (49.3%) had a “do not intubate” order and 77 (35.5%) had a “do not admit to intensive care unit” order. Age, Charlson comorbidity index, cognitive impairment, kidney failure, antidepressant or neuroleptics use, and malnutrition were associated with TLD orders. The presence of at least one TLD order was more common in patients with delirium (24/32 patients, 77.4%) than in patients without delirium (95/185 patients, 51.1%, OR = 3.3 (95%CI: 1.3-8.0); p < 0.01). This association was not significant in the adjusted model (aOR = 2.0; 95%CI: 0.7–5.6; p = 0.20). A TLD order (aHR = 1.8; 95%CI:1.1–3.0.1.0) and delirium (aHR = 1.8; 95%CI:1.1–3.1) were both associated with 90-day hospital readmission or death. Patients diagnosed with delirium within 48 h of admission have frequent treatment limitations orders, but the association faints after accounting for comorbidities. (shrink)

This book considers coercion within the healing and ethical framework of therapeutic relationships and partnerships at all levels, and addresses the universal ...

Providing therapy to deaf clients raises important ethical considerations for psychologists related to competence; multiple relationships and boundary issues; confidentiality; assessment, diagnosis, and evaluation; and communication and using interpreters. In evaluating and addressing these, psychologists must consider the American Psychological Association’s Ethics Code and other relevant issues necessary to provide ethical treatment. The current article provides background, ethical considerations, principles and standards relevant to the treatment of deaf clients, and recommendations to support psychologists, training programs, and the field. Psychologists have (...) the responsibility to guarantee that the benefits of mental health treatment are fairly and justly provided to this traditionally underserved population. (shrink)

This article addresses ethical issues in conducting randomized clinical trials with youth. Ethical considerations that occur prior to treatment, during treatment, and following treatment are reviewed. Recommendations, based on empirical evidence and clinical experience, are offered for conducting ethical treatment research with youth and future directions for carrying out research on the ethics of conducting RCTs with youth are offered.

This text seeks to analyse a dream in which Freud writes to the author. Particular attention is given to the notion of treatment and, in a memorable phrase from Hélène Cixous, ‘how to treat the dream as a dream’. Royle draws on diverse references, and focuses on a range of Freud's writings, in order to explore the relationship between psychoanalysis and literature. Particular attention is given to free association, deferred effect and the epistolary.

This book offers an in-depth analysis of the wide range of issues surrounding "passive euthanasia" and "allow-to-die" decisions. The author develops a comprehensive conceptual model that is highly useful for assessing and dealing with real-life situations. He presents an informative historical overview, an evaluation of the clinical settings in which treatment abatement takes place, and an insightful discussion of relevant legal aspects. The result is a clearly articulated ethical analysis that is medically realistic, philosophically sound, and legally viable.

Franklin Miller's thoughtful reply to our paper asks pointed questions about the role of the physician qua physician in physician-assisted death. Would making assisted dying available to treatment-resistant depressed people necessarily affect the professional integrity of healthcare professionals, as Dr Miller asserts? Dr Miller agrees with us on a number of crucial points: It is possible that some patients with treatment-resistant major depression are competent to make the decision to ask for assisted dying; it is possible that some such patients (...) could make a rational choice if they requested such assistance. He also is generally supportive of physician-assisted death, at least for ‘terminally ill’ patients. He defines a terminally ill patient as someone who has a ‘predictable short life span and will die soon regardless of medical intervention’. We disagree with his conceptualisation of ‘terminal illness’ as requiring that death occurs within 6–12 months, given the existence of illnesses like Amyotrophic lateral sclerosis (ALS) or certain prostate cancers that are commonly considered to be terminal illnesses and that are taking their predictable course sometimes over years. If, all other things being equal, an illness is going to kill a patient at some point down the track, it surely should qualify for the label ‘terminal illness’. However, we will accept his definition for the sake of the argument. Dr Miller supports the availability of assisted dying for patients likely to die from that illness within 6 months from the day their request for assisted dying has been made. He broadly holds the kind of view we aimed to sway with our analysis. Apparently, we failed. Dr Miller thinks that physician-assisted death must be consistent with professional integrity, requiring that it is consistent with ‘the proper goals of medicine and the specific duties incumbent on clinicians in acting to realize …. (shrink)

Background: Independent decision-making is one of the basic rights of patients. However, in clinical practice, most older cancer patients’ treatment decisions are made by family members. Objective: This study attempted to analyze the treatment decision-making process and formation mechanism for older cancer patients within the special cultural context of Chinese medical practice. Method: A qualitative study was conducted. With the sample saturation principle, data collected by in-depth interviews with 17 family members and 12 patients were subjected to thematic analysis. Ethical (...) considerations: The study was approved by the ethics committees of Sun Yat-sen University. All participants provided verbal informed consent after being told their rights of confidentiality, anonymity, and voluntary participation. They had the right to refuse to answer questions and could withdraw at any time. Results: Three themes emerged: (1) complex process; (2) transformation of family decision-making power; and (3) individual compromise. Family members inevitably had different opinions during the long process of treatment decision-making for older cancer patients. The direction of this process could be regarded as an extension of the family power relationship. The patient usually compromised the decision to survive, which was made by family members. Conclusion: This study describes the treatment decision-making process of older cancer patients in the context of Chinese culture. The reasons underlying this process are related to the views on life and death and family values. An individual is a part of the family, which is often seen as the minimal interpersonal unit in Chinese society. It is significant that while emphasizing patient autonomy in the decision-making process, health professionals should also pay attention to the important roles of culture and family. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians (...) use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

This chapter argues that the conditions under the umbrella “personality disorders” actually constitute two very different kinds of theoretical entities. In particular, several core personality disorders are actually moral, and not medical, conditions. Thus, the categories that are held to represent them are really moral, and not medical, theoretical kinds. The chapter works back from the possibility of treatment to the nature of the kinds that are allegedly treated, revisiting 18th-century ideas of moral treatment along the way. The discussion closes (...) with a reflection on how the ambiguous medical status of personality disorders and their treatment today is reminiscent of the ideological tug of war that pits alienist “mad doctors” like Pinel against their lay counterparts such as Tuke as they battled over who should be in charge of treating the mad. (shrink)

This chapter argues that the conditions under the umbrella “personality disorders” actually constitute two very different kinds of theoretical entities. In particular, several core personality disorders are actually moral, and not medical, conditions. Thus, the categories that are held to represent them are really moral, and not medical, theoretical kinds. The chapter works back from the possibility of treatment to the nature of the kinds that are allegedly treated, revisiting 18th-century ideas of moral treatment along the way. The discussion closes (...) with a reflection on how the ambiguous medical status of personality disorders and their treatment today is reminiscent of the ideological tug of war that pits alienist “mad doctors” like Pinel against their lay counterparts such as Tuke as they battled over who should be in charge of treating the mad. (shrink)

The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

The question a judge has to ask in deciding whether or not life-sustaining treatment should be withdrawn is whether the continued treatment is lawful. It will be lawful if it is in the patient’s best interests. Identifying this question gives no guidance about how to approach the assessment of best interests. It merely identifies the judge’s job. The presumption in favour of the maintenance of life is part of the job that follows the identification of the question. The presumption is (...) best regarded as a presumption of law. It has long been recognised as part of the way in which the English law discharges its obligations under Article 2 of the European Convention on Human Rights (the right to life). But even if it is a ‘mere’ evidential presumption it cannot, on the facts of most cases involving applications for the withdrawal of life-sustaining treatment from patients in prolonged disorders of consciousness, be rebutted. (shrink)

Professional control in the selection of treatment options for patients is changing. In light of social and legal developments emphasising patient choice and autonomy, and restricting medical paternalism and judicial deference, this article examines how far patients and families can demand NHS treatment in England and Wales. It considers situations where the patient is an adult with capacity, an adult lacking capacity and a child. In all three cases, there is judicial support for professional autonomy, but there are also inconsistencies (...) that have potential to elevate the importance of patient and family preferences. In combination, they may be perceived by healthcare professionals as an obligation to follow patient preferences, even where doing so conflicts with other professional obligations. It is argued that a more nuanced approach to shared decision-making could help clarify the boundaries of decision-making responsibility. (shrink)

The recent push to extend physician-aid-in-dying (PAD) to psychiatric conditions has significantly altered the ethical landscape surrounding psychiatric judgments concerning treatment-refractory il...

Treatment of sexual minority youth presents psychologists with a number of challenging ethical considerations. The APA Ethics Code is a valuable resource for addressing these issues, but psychologists require additional guidance in order to provide ethical treatment. This article provides relevant background, an overview of the ethical considerations of treating sexual minority youth, and recommendations to improve upon the current state of awareness and available resources. Psychologists must continually strive to improve our understanding of ethical decisions around treatment, training, and (...) research that will serve to address this vulnerable population's unmet mental health needs. (shrink)

The goal of this article is to shed light on Deep Brain Stimulation (DBS) postoperative suicidality risk factors within Treatment Resistant Depression (TRD) patients, in particular by focusing on the ethical concern of enrolling patient with history of self-estrangement, suicide attempts and impulsive–aggressive inclinations. In order to illustrate these ethical issues we report and review a clinical case associated with postoperative feelings of self-estrangement, self-harm behaviours and suicide attempt leading to the removal of DBS devices. Could prospectively identifying and excluding (...) patients with suicidality risk factors from DBS experimental trials—such as history of self-estrangement, suicide attempts and impulsive–aggressive inclinations—lead to minimizing the risk of suicidality harm? (shrink)

Our attitudes to wrongdoers, and what social and institutional practices we apply to them or engage them in, depend on whether (in our eyes) they are responsible for their wrongdoing. They also depend on whether we see them as fully or partially responsible agents more generally. Very crudely, we hold to account agents who are responsible for their conduct to account, where we treat the non-responsible. This chapter explores the relationship between treatment and accountability by critically engaging with P F (...) Strawson’s influential views on the issue. It argues that the appropriate distinction between treatment and accountability is based primarily on the content of interpersonal exploration of wrongdoing rather than the attitudes and practices that are involved in these practices. (shrink)

Treatment in medicine is a medical intervention that can be performative, intentional, emotional, hortatory, or persuasive, which assumes patient compliance. A treatment may be efficient or effective. Abortion, or euthanasia, even without request may sometimes be therapeutic options. Most treatments have undesirable side-effects. Placebos and nocebos are part of the meaning of therapeutic procedures.

Moral treatment refers to a psychological approach to treating mental disorder that arose across Europe and North America around the turn of the eighteenth century. It is mostly associated with the French physician Philippe Pinel (1745–1826) and the English Quaker philanthropist William Tuke (1732–1819). Pinel and Tuke each independently developed their own distinct models of the once popular therapy known as moral treatment. Although moral treatment is often considered to have been a successful therapy in its early years, it was (...) eventually replaced by custodial care on a mass scale and became a travesty of its earlier self. (shrink)

Futile treatment is one ethically challenging situation commonly encountered by junior doctors. By analysing an intern's story using a role virtues framework, I propose a set of three steps for junior doctors facing this problem. I claim that junior doctors ought always to investigate the rationale underlying decisions to proceed with apparently futile treatment and discuss their concerns with their seniors, even if such discussion will be difficult. I also suggest that junior doctors facing this ethical challenge ought always to (...) be willing to initiate and engage in ethical dialogue, and that in some situations further action (such as taking concerns outside the team or refusing to participate in treatment) may be morally appropriate. (shrink)

Unequal treatment of human research subjects is a significant ethical concern, because justice in research involving human subjects requires equal protection of rights and equal protection from harm and exploitation. Disputes sometimes arise concerning the issue of unequal treatment of research subjects. Allegedly unequal treatment occurs when subjects are treated differently and there is a genuine dispute concerning the appropriateness of equal treatment. Patently unequal treatment occurs when subjects are treated differently and there is not a genuine dispute about the (...) appropriateness of equal treatment. Allegedly unequal treatment will probably always occur in research with human subjects due to disagreements about fundamental questions of justice. The best way to deal with allegedly unequal treatment is to promote honest and open discussions of the issues at stake. Research regulations can help to minimize patently unequal treatment by providing rules for investigators, ethical review boards, institutions, and sponsors to follow. However, patently unequal treatment may still occur because the regulations are subject to interpretation. Federal agencies have provided interpretive guidance that can help promote consistent review and oversight of human subjects research. Additional direction may be needed on topics that are not adequately covered by current guidance or regulations. International guidelines can help promote equal treatment of human subjects around the globe. While minor variations in the treatment of research subjects should be tolerated and even welcomed, major ones (i.e. those that significantly impact human rights or welfare) should be avoided or minimized. (shrink)

Despite wide recognition of the importance of treating patients with respect and dignity, little is known about what constitutes treatment in this regard. The intensive care unit (ICU) is a unique setting that can pose specific threats to treatment with respect and dignity owing to the critical state of patients, stress and anxiety amongst patients and their family members, and the highly technical nature of the environment. In attempt to understand various stakeholders’ perspectives of treatment with respect and dignity, patients (...) and family members were interviewed, a wide range of health care professionals participated in focus groups, and third party observers took field notes of interactions in the ICU. This paper compares and contrasts the data that were generated using these different methods. Triangulating the data in this way contributes to a more complete and nuanced understanding of treatment with respect and dignity in the ICU. (shrink)

Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient’s life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.