When a patient fails to follow the advice or prescription of a physician, she is termed to be "noncompliant" by the medical community. The medical community’s response to and understanding of patient noncompliance fails to acknowledge noncompliance as either a relational failure between physician and patient or as a patient choice. I offer an analysis of Immanuel Kant and Emmanuel Levinas that refocuses the issue of noncompliance by examining the physician role, the doctor–patient relationship, and the nature (...) of responsibility. (shrink)

Nonadherence to treatment continues to be one of psychiatry's greatest challenges. To improve adherence and thus improve the care of patients, clinicians and patients' family members sometimes resort to hiding medication in food or drink, a practice referred to as covert/ surreptitious medication. The practice of covert drug administration in food and beverages is well known in the treatment of psychiatrically ill world-wide but no prevalence rates exist. Covert medication may seem like a minor matter, but it touches on legal (...) and ethical issues of a patient's competence, autonomy, and insight. Medicating patients without their knowledge is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of care giving. The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent. Ethically, covert/surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Covert medication contravenes contemporary ethical practice. Legally, treatment without consent is permissible only where common law or statute provides such authority. The practice of covert administration of medication is not specifically covered in the mental health legislation in developing countries. Many of the current dilemmas in this area have come to public attention because of two important developments in medical ethics and the law - the increasing importance accorded to respect for autonomy and loss of the parens patriae jurisdiction of the courts [parens patriae means 'parent of the country'; it permitted a court to consent or refuse treatment on behalf of an 'incapacity', or alternatively to appoint a guardian with such powers]. (shrink)

Evolutionary game theory and public goods games offer an important framework to understand cooperation during pandemics. From this perspective, the COVID-19 situation can be conceptualized as a dilemma where people who neglect safety precautions act as free riders, because they get to enjoy the benefits of decreased health risk from others’ compliance with policies despite not contributing to or even undermining public safety themselves. At the same time, humans appear to carry a suite of evolved psychological mechanisms aimed at curbing (...) free riding in order to ensure the continued provision of public goods, which can be leveraged to develop more effective measures to promote compliance with regulations. We also highlight factors beyond free riding that reduce compliance rates, such as the emergence of conspiratorial thinking, which seriously undermine the effectiveness of measures to suppress free riding. Together, the current paper outlines the social dynamics that occur in public goods dilemmas involving the spread of infectious disease, highlights the utility and limits of evolutionary game-theoretic approaches for COVID-19 management, and suggests novel directions based on emerging challenges to cooperation. (shrink)

Participants in AIDS research may justify noncompliance with protocols by a “coercion defense.” While this defense may not be philosophically successful, a prudent social policy can enhance compliance by encouraging community participation and providing greater access to non‐validated therapies.

From a medical perspective, patients who do not comply with the doctor's orders are usually seen as deviant and deviance requires correction. But many chronically ill people view their behavior differently, as a matter of self‐regulation. In this light noncompliance supports people's desires for independence and autonomy, desires that align closely with the therapeutic goals of caregivers.

Journal of Political Philosophy, EarlyView.

Patient noncompliance with physician prescriptions, especially in nonsymptomatic chronic diseases, is frequently characterized in the literature as harmful and economically costly (Miller 1997).1 Nancy Houston Miller views patient noncompliance as harmful because noncompliance can result in continued or new health problems leading to hospital admissions. Further, she places the annual monetary cost of noncompliance at $100 billion.Patient noncompliance with prescribed treatment is considered the least understood form of health behavior (Coons 2001). Despite the plethora of (...) attention in journal articles, the issue of noncompliance remains unresolved even in terms of understanding the main correlates to .. (shrink)

Does it count against a normative theory in political philosophy that it is in some important sense infeasible, that its prescriptions are unlikely to be complied with? Though a positive answer seems plausible, it has proved hard to defend against the claim that this is not how normative theories work - noncompliance shows a problem with the noncomplying agents, not with the normative theory. I think that this line of thought - this defense of Utopianism - wins the battle (...) but loses the war. It’s right about what does and what does not refute a normative theory. It’s wrong in misidentifying the problem. The right way to think about the feasibility worry is as essentially involving multiple agents, and how expected noncompliance by one agent may refute a normative claim addressed at another. Thus understood, feasibility problems may very well refute a theory in political philosophy. In this paper I develop this understanding of the feasibility worry, tie it to more general discussions in normative ethics, and in political philosophy. (shrink)

Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. This account (...) is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested. (shrink)

This essay explores some of the conceptual and moral issues raised by illegal actions in health care. The author first identifies several types of illegal action, concentrating on civil disobedience, conscientious objection or refusal, and evasive noncompliance. Then he sketches a framework for the moral justification of these types of illegal action. Finally, he applies the conceptual and normative frameworks to several major cases of illegal action in health care, such as "mercy killing" and some decisions not to treat (...) incompetent patients. Keywords: illegal actions, mercy killing, non-treatment of incompetent patients, civil disobedience, conscientious objection, evasive non-compliance, moral justification and disobedience, dissent in health care CiteULike Connotea Del.icio.us What's this? (shrink)

Constitutional democracies unilaterally enact the laws that regulate immigration to their territories. When are would-be migrants to a constitutional democracy morally justified in breaching such laws? Receiving states also typically enact laws that require their existing citizens to participate in the implementation of immigration restrictions. When are the individual citizens of a constitutional democracy morally justified in breaching such laws? In this article, I take up these questions concerning the justifiability of noncompliance with immigration law, focusing on the case (...) of nonviolent – or mere – noncompliance. Dissenting from Javier Hidalgo’s view, I argue that the injustice of an immigration law is insufficient to make mere noncompliance justified. Instead, I contend that only if an immigration law lacks legitimate authority are individuals justified in breaching it, since the subjects of an institution with legitimate authority are under a content-independent moral duty to comply with its rules. I further argue that a constitutional democracy’s regimes of law regulating immigration and requiring its citizens’ participation in implementing these regulations have legitimate authority. Nevertheless, when a particular immigration law is egregiously unjust, its legitimacy is defeated. (shrink)

The patient was a 19-year-old female who was transferred to this children's hospital from a community hospital in a neighboring state. She is well known to the hospital staff because she had a kidney transplanted and retransplanted several times there. Her first transplant as at age 8 and she was retransplanted most recently approximately 3 years ago. She immediately rejected her second kidney and received a third. She is currently admitted because she is again rejecting her kidney, probably due to (...) not taking her medication. The ethics consultant was called because the attending physician wanted to know if it was ethical to retransplant a patient. (shrink)

This paper examines what agents should do when others fail to comply with their responsibilities to prevent dangerous climate change. It distinguishes between six different possible responses to noncompliance. These include what I term (1) 'target modification' (watering down the extent to which we seek to prevent climate change), (2) ‘responsibility reallocation’ (reassigning responsibilities to other duty bearers), (3) ‘burden shifting I’ (allowing duty bearers to implement policies which impose unjust burdens on others, (4) 'burden shifting II’ (allowing some (...) to protect peoples rights in ways which impose otherwise unjustified burdens on the duty bearers, (5) 'compromising moral ideals' (permitting agents to compromise non-justice ideals that they are otherwise bound by); and (6) ‘promoting compliance (implementing policies and creating institutions which reduce noncompliance). It concludes by outlining a methodological framework for evaluating these options, and by setting out my tentative and provisional evaluation of which responses are the least bad. (shrink)

Constitutional democracies unilaterally enact the laws that regulate immigration to their territories. When are would-be migrants to a constitutional democracy morally justified in breaching such laws? Receiving states also typically enact laws that require their existing citizens to participate in the implementation of immigration restrictions. When are the individual citizens of a constitutional democracy morally justified in breaching such laws? In this article, I take up these questions concerning the justifiability of noncompliance with immigration law, focusing on the case (...) of nonviolent—or mere—noncompliance. Dissenting from Javier Hidalgo’s view, I argue that the injustice of an immigration law is insufficient to make mere noncompliance justified. Instead, I contend that only if an immigration law lacks legitimate authority are individuals justified in breaching it, since the subjects of an institution with legitimate authority are under a content-independent moral duty to comply with its rules. I further argue that a constitutional democracy’s regimes of law regulating immigration and requiring its citizens’ participation in implementing these regulations have legitimate authority. Nevertheless, when a particular immigration law is egregiously unjust, its legitimacy is defeated. (shrink)

Over the past three decades, two separate federal regulatory structures have emerged, each seeking to assure separate aspects of the integrity and ethics of research conducted using federal funding. One set of regulations is described in the Public Health Service Policies on Research Misconduct and relates to research misconduct, defined as consisting of fabrication of data or results, falsification of data and results, or plagiarism, in accordance with the federal‐wide definition adopted by the Office of Science and Technology Policy. The (...) second set of regulations, set forth in the Department of Health and Human Services regulations on the protection of human subjects (known as the “Common Rule”), prescribes a set of ethical and procedural protections for research involving human subjects.These two sets of research regulations are distinguished from each other by having different foci of enforcement, priorities of protection, oversight officials, oversight procedures, seizure of evidence, standards of proof, expectations of privacy, and appeal procedures for researchers who are subject to adverse findings and penalties. These differences are significant and fundamental. They complicate the process of compliance for institutions and researchers, who are expected to adhere to both sets of standards for the same federally funded research activities in research with human subjects. Compliance is especially complicated when suspected violations of both sets of standards must be investigated and resolved concurrently. This document represents an effort to provide institutions and individuals with practical suggestions as they try to comply with both sets of regulations. (shrink)

It is a rare patient who always does everything healthcare providers advise. Sometimes no harm comes from this; sometimes good does. But occasionally, great harm comes from not listening, as when it results in patients returning time and again for costly and invasive treatments of, say, infections, valve replacements, pressure ulcers, and so forth. No class of patients arouses more anger and resentment in healthcare providers, who often put out a call to invoke some version of the three strikes rule (...) and refuse care. And if the patients are also unemployed substance abusers who live in a local park, impolite or dangerous to staff, disruptive to other patients, and have intimidating visitors, the call to say “No” is louder. Can care ever be refused? If so, when? These are the questions we take up in this article. The answers we provide were developed as part of a Paraplegics and Quadriplegics with Pressure Ulcers Project carried out at Vancouver Hospital and Health Sciences Centre. Following an established usage, we refer to patients who exhibit a cluster of the above characteristics, the dominant one of which is a reluctance to heed medical advice, as “noncompliant patients.” This term is offensive to some, but the politically correct lexicon does not provide any alternative which is as short and clear or substantially different. We use the term as a convenient way of referring to a familiar class of patients and without any imputation of blame. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Cloning without Prior Approval:A Response to Recent Disclosures of NoncomplianceRuth Macklin (bio)Editor's note: In September 1994, the Kennedy Institute of Ethics Journal published a special issue on the ethics of embryo splitting or "cloning," which included papers originally prepared for a workshop on embryo splitting sponsored by the National Advisory Board on Ethics in Reproduction (NABER) and NABER's report, Human Cloning through Embryo Splitting. The impetus for the project (...) was embryo-splitting research conducted by Drs. Jerry L. Hall, Robert J. Stillman, and others, at George Washington University and presented in October 1993 at a joint meeting of the American Fertility Society and the Canadian Fertility and Andrology Society. Media coverage at the time reported that the research had been approved by the university's formal review committees. However, it came to light in December 1994 that the researchers had not obtained approval from the university's institutional review board prior to conducting the research. Following a university investigation, the researchers were disciplined and instructed to destroy their data. The university also voluntarily forwarded the records of the incident to the Office for Protection from Research Risks at the National Institutes of Health. Dr. Hall resigned from George Washington University in September 1994.In the following postscript to her article on the ethics of embryo splitting (KIEJ, September 1994), Ruth Macklin discusses these events. The letters and memoranda that she cites were obtained from NIH through the Freedom of Information Act.My article, "Splitting Embryos on the Slippery Slope: Ethics and Public Policy" (KIEJ, September 1994), included a brief assessment of the ethics of the Hall-Stillman embryo-splitting experiment conducted at George Washington University (GWU). The article reviewed the researchers' stated purpose ("to help infertile couples by reproducing nature's ability to reproduce twins"), the features of the research itself (splitting embryos that never could become viable and with no plan to implant either the original or the split embryos), and the review procedures surrounding the experiment. I said that the researchers might be [End Page 57] faulted for not waiting until embryo research guidelines had been established at the national level; on the other hand, they surely could not fail to conform to such national guidelines when none existed.My conclusions were based on information that had been reported in the print media. Dr. Robert J. Stillman's statement that the experiment "had been approved by the university's formal review committees and peer reviewed by colleagues" was reported in the Washington Post on October 25, 1993, (Sawyer 1993). However, in light of the recent disclosure that the researchers had not obtained approval from George Washington University's IRB before proceeding with the research (Schwartz 1994), I now draw a sharply different conclusion about the ethics of the researchers' behavior.The most glaring flaw was the researchers' failure to submit a protocol to their institution's IRB in advance of embarking on the research. Following an investigation of the matter, the Office for Protection from Research Risks (OPRR) made the further determination that "the failure on the part of GWU research investigators and administrators to notify the IRB promptly about noncompliance in this research constitutes additional serious noncompliance" with research regulations (J. Thomas Puglisi, Chief of the Compliance Oversight Branch, Division of Human Subject Protections, OPRR, letter to Stephen J. Trachtenberg, President of George Washington University, 23 August 1994). Is it reasonable to suppose that these researchers were unaware of their obligations (a) to obtain prior review and approval from the IRB and (b) to notify the IRB promptly about their noncompliance? Regarding the latter item, Dr. Puglisi's letter to the President of GWU states that "the notification requirement has been a longstanding element of the GWU MPA [multiple project assurance], which should have been familiar to all members of the GWU research community." I shall concentrate on the researchers' more glaring ethical omission, failure to obtain prior review and approval from the IRB.Did either or both of these researchers contend that they were unaware of any review requirements for their research? Hall blames Stillman, Director of the Division of Reproductive Endocrinology, Fertility, and IVF Programs, for not making the requirement... (shrink)

Estimating the effect of a randomized treatment and the effect that is transmitted through a mediator is often complicated by treatment noncompliance. In literature, an instrumental variable (IV)-based method has been developed to study causal mediation effects in the presence of treatment noncompliance. Existing studies based on the IV-based method focus on identifying the mediated portion of the intention-to-treat effect, which relies on several identification assumptions. However, little attention has been given to assessing the sensitivity of the identification (...) assumptions or mitigating the impact of violating these assumptions. This study proposes a two-stage joint modeling method for conducting causal mediation analysis in the presence of treatment noncompliance, in which modeling assumptions can be employed to decrease the sensitivity to violation of some identification assumptions. The use of a joint modeling method is also conducive to conducting sensitivity analyses to the violation of identification assumptions. We demonstrate our approach using the Jobs II data, in which the effect of job training on job seekers’ mental health is examined. (shrink)

Randomized control trials (RCTs) are the gold standard for estimating causal effects, but often use samples that are non-representative of the actual population of interest. We propose a reweighting method for estimating population average treatment effects in settings with noncompliance. Simulations show the proposed compliance-adjusted population estimator outperforms its unadjusted counterpart when compliance is relatively low and can be predicted by observed covariates. We apply the method to evaluate the effect of Medicaid coverage on health care use for a (...) target population of adults who may benefit from expansions to the Medicaid program. We draw RCT data from the Oregon Health Insurance Experiment, where less than one-third of those randomly selected to receive Medicaid benefits actually enrolled. (shrink)

This study investigates how tone at the top, implemented by top management, and tone at the bottom, in an employee’s immediate work environment, determine noncompliance. We focus on the disallowed actions of employees that improve their own and, in turn, the company’s performance, referred to as performance-improving noncompliant behavior. We conduct a survey of German sales employees to investigate specifically how, on the one hand, corporate rules and performance pressure, both implemented by top management, and, on the other hand, (...) others’ PINC expectations and others’ PINC behavior, both arising from the employee’s immediate work environment, influence PINC behavior. When considered in isolation, we find that corporate rules, as top management’s main instrument to guide employee behavior, decrease employee PINC behavior. However, this effect is negatively influenced by the employees’ immediate work environment when employees are expected to engage in PINC or when others engage in PINC. In contrast, even though top management places great performance pressure on employees, that by itself does not increase PINC behavior. Overall, our study informs practitioners and researchers about whether and how the four determinants increase or decrease employees’ PINC behavior, which is important to comprehend triggers and to counteract such misconduct. (shrink)

We develop the concept of a volitional disability as an aid in understanding those patients who behave in ways that are harmful to themselves in spite of their desire to do otherwise. Using this concept enables us to describe their behavior as intentional but ‘unvoluntary’. We demonstrate the clinical reality of such behavior by giving clinical examples of the behavior of those with phobic, compulsive, and addictive disorders. We then attempt to show how some kinds of self-harming behavior of noncompliant (...) patients are similar to phobic and compulsive behavior. We propose use of the concept of volitional disability to make it easier for physicians to work with these noncompliant patients and thus to improve their ability to provide better care for them. (shrink)

The current paper provides an overview of treatment noncompliance at various points in the treatment pathway, especially with respect to treatment for Pelvic-floor Dysfunction. The effects of noncompliance on healthcare are considered, and examples of supporting patients psychologically to increase compliance are discussed. An outline of a method to identify costs of non-compliance, and where such costs most intensely impact the healthcare system, is provided. It is suggested that psychological support is effective in terms of increased compliance and (...) improved healthcare economics. The model is presented for PFD, but the principles developed can be generalised to many aspects of healthcare. (shrink)

This paper attempts to determine the best way to understand-and, thus, treat—patients who claim to hold certain health—related values and goals yet consistently act in ways that undermine and work against those values and goals. Since at least the 1970s, this phenomenon has been known in the medical community as patient noncompliance. This can come in the form of failure to take medication as prescribed, as well as failure to adhere to any number of doctors' orders, including recommendations to (...) modify diet, exercise, quit smoking, and so forth. Such cases are a source of great frustration for health care professionals because these patients present in their clinics with a health problem... (shrink)

We develop the concept of a volitional disability as an aid in understanding those patients who behave in ways that are harmful to themselves in spite of their desire to do otherwise. Using this concept enables us to describe their behavior as intentional but ‘unvoluntary’. We demonstrate the clinical reality of such behavior by giving clinical examples of the behavior of those with phobic, compulsive, and addictive disorders. We then attempt to show how some kinds of self-harming behavior of noncompliant (...) patients are similar to phobic and compulsive behavior. We propose use of the concept of volitional disability to make it easier for physicians to work with these noncompliant patients and thus to improve their ability to provide better care for them. Keywords: alcoholism, volitional disability, physician attitudes, addictive, disorders, compulsions, phobias, noncompliance CiteULike Connotea Del.icio.us What's this? (shrink)

Bioethics, Volume 36, Issue 3, Page 283-289, March 2022.

Prior research has investigated the influence of decision maker characteristics on decision choice. This research examines the effect two personality traits of taxpayers, attitude towards risk and ethical standards, on intentional noncompliance. A taxpayer who is more (less) ethical will have lower (greater) intentional noncompliance, while a taxpayer who is more (less) risk averse will have lower (greater) intentional noncompliance. However, this study also found significant correlation between risk attitudes and ethical standards. This is because tax evasion (...) is not just a gamble which can be explained by merely considering the risk variable. To understand tax evasive behavior better requires incorporation of noneconomic factors in the analysis, such as ethical standards, although risk attitudes may be an important explanatory factor. The current research suggests that individuals with lower ethical standards will have more intentional noncompliance. However, since ethical standards are correlated with attitude toward risk, the Internal Revenue Service (IRS) can partially overcome the influence of ethics by making the tax audit environment more uncertain. Thus, the research results justify the decision of the IRS not to release all its audit parameters because it makes the audit environment less uncertain. (shrink)

Just institutions have claims on us. There are two reasons for thinking that such claims are warranted. First, one may believe that we are under a natural duty of justice to support and further just institutions. If one believes that it matters whether institutions are just, one also has a reason, almost as a matter of consistency, to support and further just institutions. Second, one may believe that by enjoying the benefits brought about by cooperation through just institutions, one incurs (...) an obligation to support these institutions. Those who accept and enjoy the benefits brought about by cooperation through a just scheme are under an obligation of fairness to reciprocate. But what happens to these reasons to support and comply with an institution if the scheme of cooperation is less than fully just? There is hardly a real-world institution, policy, or scheme of social cooperation that would qualify as fully just. However, questions about obligations of fairness and duties of justice under conditions of injustice have hitherto suffered relative neglect. I shall outline an overall framework for thinking about these questions by asking what the victims of injustice owe to moderately unjust institutions. (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)

Noncompliance exasperates health care professionals, leaves them worrying about the effective outcome of medical care, and results in noncompliant patients being labelled as 'difficult' or 'troublesome'. It is suggested that professionals who label a patient as noncompliant are following convenient paternalistic principles rather than considering the impact of a prescribed regimen on an individual patient. In this paper, the author considers autonomy and respect to be foremost in patient care. Further, compliance does not necessarily indicate that both professional and (...) patient have developed a collaborative understanding relationship. Noncompliance is described as a lack of recognition by the health care professional of the meaning of the regimen to the patient. Treatment interventions will be most successful when the patient participates in the prescription. Without acknowledgement of the patient as an equal partner, and listening to his or her narrative, care will be, at best, paternalistic. Les soignants peuvent devenir exasperes par les malades qui n'acquiescent pas à leur traitement. Cela laisse les soignants souciant des résultats de leurs soins et abouti à ce que les malades sont qualifiés de difficiles ou insoumis. On propose ici que le personnel qui traite les malades d'insoumis suit des principes paternalistes plutôt que de considérer les suites des regimes prescrits pour les particuliers. Dans cet article l'auteur considère l'autonomie et le respet comme primordiaux pour les soins. L'acqiescement ne veut pas toujours dire que malades et infirmiers/ères ont développés des rapports collaborateurs. Le refus d'acquiescer est aperçu comme un manque de reconnaissance par la personne soignante de la significance du traitement médical du malade. Les interventions réussissent le mieux quant les malades participent à leurs soins. Si l'on n'accepte pas les malades comme partenaires en écoutant leurs récits, les soins sont au plus du paternalisme. Die Ablehnung der verordneten Behandlung durch die Patienten kann das Pflege personal zur Verzweiflung bringen und den Ausgang der Behandlung in Frage stellen und führt dazu, die Patienten als schwierig oder problematisch einzustrafen. Hier wird die Ansicht vertreten, dass das Pflegepersonal, das Patienten als unkooperativ oder ablehnend bezeichnet, einem paternalistischen Prinzip folgt und nicht an die Wirkung denkt, die die verschriebene Behandlung auf einzelne Patienten hat. In diesem Artikel bezeichnet die Autorin die Selstbestimmung der Patienten und den Respekt ihnen gegenüber als das Wichtigste in der Krankenpflege. Fügsamkeit deutet nicht unbedingt auf eine Zusammenarbeit zwischen Patienten und Pflegenden hin. Zuwiderhandlung der Patienten wird als Mangel an Verständnis von Seiten des Pflegepersonals gesehen, das die Bedeutung, die die Behandlung für Patienten hat, nicht einzuschatzen weiss. Die Behandlung wird nur dann den grösstmöglichen Erfolg bringen, wenn die Patienten daran teilnehmen. Wenn Patienten nicht als gleichberechtigte Partner angesehen werden, deren Meinungen gehört und respektiert werden, ist die Pflege höchstens patemalistisch. (shrink)

This article presents an analytic critique of the predominant revisionist theoretical paradigm of just war (henceforth: revisionism). This is accomplished by means of a precise description and explanation of the practicability problem that confronts it, namely that soldiers that revisionism would deem “unjust” are bound to fail to fulfil the duties that revisionism imposes on them, because these duties are overdemanding. The article locates the origin of the practicability problem in revisionism’s overidealized conception of a soldier as an individual rational (...) agent analogous to the aggressor or defender in a case of lethal self-defense, who is capable of reflecting on the morality of his status in war and of the killing he performs and thus of recognizing his revisionist duties. Revisionism, however, ignores the following fact: Killing in war is not a natural human behavior. This is why training soldiers to kill is—and arguably always has been—a necessity for the existence of war and the killing that occurs in it. Moreover, this training involves a certain level of moral desensitization to violence whose goal is to prevent soldiers from thoroughly reflecting on the morality of the killing they engage in. Hence, war and killing can only exist if soldiers are trained in such a way that they do not reflect on whether they could be addressees of revisionist duties in the first place. This means that military training is a “constitutive condition” of soldiers and war, which is why it cannot excuse their noncompliance with revisionist duties, thus making these duties categorically overdemanding. The argument here draws on the paradigmatic example of modern US military killing conditioning (MC), but embeds it into a broader military-historical perspective that describes how soldiers have always needed to be mentally and morally influenced in order to enable war and killing. The article’s explanation of revisionism’s practicability problem has a constructive consequence for future theory-building in the ethics of war: It implies that a potentially revised ethical theory of war must necessarily analyze the institutions that allocate belligerent resources, if it aims to morally assess battlefield behavior in a practicable manner. (shrink)

Many agents have failed to comply with their responsibilities to take the action needed to avoid dangerous anthropogenic climate change. This pervasive noncompliance raises two questions of nonideal political theory. First, it raises the question of what agents should do when others do not discharge their climate responsibilities. (the Responsibility Question) In this paper I put forward four principles that we need to employ to answer the Responsibility Question (Sections II-V). I then illustrate my account, by outlining four kinds (...) of action that should be undertaken (Section VI). Pervasive noncompliance also raises a second question: Given the lack of progress in combating climate change, should existing governance structures be maintained or changed (and if they should be changed, in what ways)? (the Governance Question). The paper briefly outlines a methodology for addressing this question and outlines what a nonideal response to the existing institutional structures would be (Section VII). It does so with reference to the Paris Agreement, and in particular the creation of a "global stocktake" (Article 14, Paris Agreement) and the "facilitative dialogue" (paragraph 20 of the ‘Adoption of the Paris Agreement’). The aim, then, is to set out an account of a nonideal theory of climate justice. (shrink)