Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries

BackgroundSelf-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.AimsThis article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders’ views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom.MethodComparisons between the empirical findings were drawn using a structured expert consensus process.ResultsFindings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals’ confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.ConclusionsStakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.<br/

Advance Research Directives in Germany: A Proposal for a Disclosure Standard

The fourth amendment to the German Medicinal Products Act (Arzneimittelgesetz) states that nontherapeutic research in incompetent populations is permissible under the condition that potential research participants expressly declare their wish to participate in scientific research in an advance research directive. This article explores the implementation of advance research directives in Germany against the background of the international legal and ethical framework for biomedical research. In particular, it addresses a practical problem that arises from the disclosure requirement for advance research directives. We show that, if the disclosure standard for advance research directives is set at a token level, nontherapeutic research in incompetent populations becomes practically impossible. To resolve this issue, we suggest the disclosure standard be set at a type level

UvA-DARE (Digital Academic Repository) Schizophrenia and Moral Responsibility: A Kantian Essay Schizophrenia and Moral Responsibility: A Kantian Essay

Link to publication General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Abstract In this paper, I give a Kantian answer to the question whether and why it would be inappropriate to blame people suffering from mental disorders that fall within the schizophrenia spectrum. I answer this question by reconstructing Kant&apos;s account of mental disorder, in particular his explanation of psychotic symptoms. Kant explains these symptoms in terms of various types of cognitive impairment. I show that this explanation is plausible and discuss Kant&apos;s claim that the unifying feature of the symptoms is the patient&apos;s inability to enter into an exchange of reasons with others. After developing a Kantian Quality of Will Thesis, I analyze some real life cases. Firstly, I argue that delusional patients who are unable to enter into an exchange of epistemic reasons are exempted from doxastic rather than moral responsibility. They are part of the moral community and exonerated from moral blame only if their actions do not express a lack of good will. Secondly, I argue that disorganized patients who are unable to form intentions and to make plans are exempted from moral responsibility because they do not satisfy the conditions for agency

Blaming friends

The aim of this paper is to shed light on the complex relations between friendship and blame. In the first part, I show that to be friends is to have certain evaluative, emotional and behavioral dispositions toward each other, and distinguish between two kinds of norms of friendship, namely friendship-based obligations and friendship-constituting rules. Friendship-based obligations tag actions of friends as obligatory, permissible or wrong, whereas friendship-constituting rules specify conditions that, if met, make it so that two persons stand in a particular type of relationship defined by various friendship-based obligations. I argue that whereas friendship-based obligations apply to actions under direct voluntary control, friendship-constituting rules apply to emotional and evaluative attitudes. The second part develops an account of friendship blame by comparing Scanlon's account of blame with Wallace's Strawsonian account of blame. I demonstrate that Scanlon's account picks out responses that become appropriate when friends' attitudes are not in agreement with friendship-constituting rules, whereas Wallace's account picks out responses that become appropriate when friends violate friendship-based obligations. Arguing that the responses picked out by Scanlon's account do not amount to blame, I show that, when combined, the views give an illuminating picture of possible reactions to friends who fall short of the standards of friendship

Soll die UN-Behindertenrechtskonvention in der psychiatrischen Praxis umgesetzt werden? Eine aktuelle Debatte in Großbritannien

Significant progress has been made in understanding the genetic basis of autosomal dominant polycystic kidney disease (ADPKD), quantifying disease manifestations in children, exploring very-early onset ADPKD as well as pharmacological delay of disease progression in adults. At least 20% of children with ADPKD have relevant, yet mainly asymptomatic disease manifestations such as hypertension or proteinuria (in line with findings in adults with ADPKD, where hypertension and cardiovascular damage precede decline in kidney function). We propose an algorithm for work-up and management based on current recommendations that integrates the need to screen regularly for hypertension and proteinuria in offspring of affected parents with different options regarding diagnostic testing, which need to be discussed with the family with regard to ethical and practical aspects. Indications and scope of genetic testing are discussed. Pharmacological management includes renin-angiotensin system blockade as first-line therapy for hypertension and proteinuria. The vasopressin receptor antagonist tolvaptan is licensed for delaying disease progression in adults with ADPKD who are likely to experience kidney failure. A clinical trial in children is currently ongoing; however, valid prediction models to identify children likely to suffer kidney failure are lacking. Non-pharmacological interventions in this population also deserve further study

Self-binding directives under the new Dutch Law on Compulsory Mental Health Care: An analysis of the legal framework and a proposal for reform

Self-binding directives (SBDs) are a special type of psychiatric advance directive by means of which mental health service users can give advance consent to compulsory hospital admission or treatment during a future mental health crisis. SBDs are legally binding in the Netherlands since 2008. On the 1st of January 2020, the Dutch Law on Special Admissions to Psychiatric Hospitals (Wet bijzondere opnemingen in psychiatrische ziekenhuizen; Bopz) was replaced by the new Law on Compulsory Mental Health Care (Wet verplichte geestelijke gezondheidszorg; Wvggz). This replacement brought with it various changes in the legal arrangement for SBDs. In this article, we expound the changes in the legal arrangement and assess the implications of these changes for the practical feasibility of SBDs. We argue that the procedures for arranging compulsory care based on an SBD in the new law are too complex and time-intensive for SBDs to yield their potential benefits. We close by proposing a workable mechanism of legal authorisation of compulsory care on the basis of an SBD

Soll die UN-Behindertenrechtskonvention in der psychiatrischen Praxis umgesetzt werden?

In einer kürzlich im $\textit {British Journal of Psychiatry}$ veröffentlichten Debatte wird diskutiert, ob Großbritannien von der UN-Behindertenrechtskonvention (UN-BRK) zurücktreten sollte (Gosney und Bartlett 2020). Die UN-BRK ist eine internationale Konvention, welche die universellen Menschenrechte für Menschen mit Behinderungen spezifiziert und von zahlreichen Ländern, darunter auch Deutschland, ratifiziert wurde. Insbesondere die Allgemeine Bemerkung des UN-Fachausschusses für die Rechte von Menschen mit Behinderungen (United Nations 2014) zum Artikel 12 der Konvention hat eine kontroverse Diskussion angeregt