Depression, possibilities, and competence: A phenomenological perspective

Competent decision-making is required for informed consent. In this paper, I aim, from a phenomenological perspective, to identify the specific facets of competent decision-making that may form a challenge to depressed patients. On a phenomenological account, mood and emotions are crucial to the way in which human beings encounter the world. More precisely, mood is intimately related to the options and future possibilities we perceive in the world around us. I examine how possibilities should be understood in this context, and how, in depression, decision-making might be compromised. I suggest that, based on this analysis, a specific emphasis and alertness in assessments of competence in depressed patients is called for. In fact, close attention should be paid to the range of future possibilities depressed patients are able to perceive. In addition, providing environmental cues to these patients might be one way of enhancing their decision-making capacity. The practical suggestions arrived at are open to empirical research

Autonomy as a justification for psychiatric treatments

In der psychiatrischen Praxis werden etliche medizinisch indizierte Therapien sowie auch Zwangsmaßnahmen nicht nur mit dem Argument der Symptombekämpfung und der therapeutischen Notwendigkeit, sondern auch implizit mit der Wahrung oder Wiederherstellung von Autonomie gerechtfertigt. Seit neueren Rechtsprechungen des Bundesverfassungsgerichts und des Bundesgerichtshofs und seit der vom Bundestag 2013 verabschiedeten neuen Regelung zur Durchführung von Zwangsmaßnahmen in der Psychiatrie wird eine ethische Debatte geführt, wie in der Praxis mit psychisch kranken Patienten umgegangen werden soll, die sich selbst oder andere gefährden, aber keine Behandlung wünschen. Dabei wird selten eine differenzierte Darstellung philosophischen Autonomieverständnisses vorgelegt, mit der Konsequenz, dass Potenziale einer differenzierten Auseinandersetzung für die Fragestellung nicht ausgeschöpft werden. Hierzu möchte dieser Aufsatz Anregungen liefern und differenziert in drei Formen von Selbstbestimmung mit ihren jeweiligen konstituierenden Bedingungen, die in Bezug gesetzt werden zu verschiedenen psychiatrischen Krankheitsbildern und Zwangsmaßnahmen

Depression and Decision-making Capacity for Treatment and Research:A Systematic Review

BACKGROUND: Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so particularly where psychopathology is seen as the extreme end of a dimension that includes normality. Depression is an example of such a psychiatric disorder. Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions. METHODS: A systematic review of the medical ethical and empirical literature concerning depression and DMC was conducted. Medline, EMBASE and PsycInfo databases were searched for studies of depression and consent and DMC. Empirical studies and papers containing ethical analysis were extracted and analysed. RESULTS: 17 publications were identified. The clinical ethics studies highlighted appreciation of information as the ability that can be impaired in depression, indicating that emotional factors can impact on DMC. The empirical studies reporting decision-making ability scores also highlighted impairment of appreciation but without evidence of strong impact. Measurement problems, however, looked likely. The frequency of clinical judgements of lack of DMC in people with depression varied greatly according to acuity of illness and whether judgements are structured or unstructured. CONCLUSIONS: Depression can impair DMC especially if severe. Most evidence indicates appreciation as the ability primarily impaired by depressive illness. Understanding and measuring the appreciation ability in depression remains a problem in need of further research