BackgroundFor many decades, the debate on children’s competence to give informed consent in medical settings concentrated on ethical and legal aspects, with little empirical underpinnings. Recently, data from empirical research became available to advance the discussion. It was shown that children’s competence to consent to clinical research could be accurately assessed by the modified MacArthur Competence Assessment Tool for Clinical Research. Age limits for children to be deemed competent to decide on research participation have been studied: generally children of 11.2 (...) years and above were decision-making competent, while children of 9.6 years and younger were not. Age was pointed out to be the key determining factor in children’s competence. In this article we reflect on policy implications of these findings, considering legal, ethical, developmental and clinical perspectives.DiscussionAlthough assessment of children’s competence has a normative character, ethics, law and clinical practice can benefit from research data. The findings may help to do justice to the capacities children possess and challenges they may face when deciding about treatment and research options. We discuss advantages and drawbacks of standardized competence assessment in children on a case-by-case basis compared to application of a fixed age limit, and conclude that a selective implementation of case-by-case competence assessment in specific populations is preferable. We recommend the implementation of age limits based on empirical evidence. Furthermore, we elaborate on a suitable model for informed consent involving children and parents that would do justice to developmental aspects of children and the specific characteristics of the parent-child dyad.SummaryPrevious research outcomes showed that children’s medical decision-making capacities could be operationalized into a standardized assessment instrument. Recommendations for policies include a dual consent procedure, including both child as well as parents, for children from the age of 12 until they reach majority. For children between 10 and 12 years of age, and in case of children older than 12 years in special research populations of mentally compromised patients, we suggest a case-by-case assessment of children’s competence to consent. Since such a dual consent procedure is fundamentally different from a procedure of parental permission and child assent, and would imply a considerable shift regarding some current legislations, practical implications are elaborated. (shrink)
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. (shrink)
A link between mental disorder and freedom is clearly present in the introduction of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It mentions “an important loss of freedom” as one of the possible defining features of mental disorder. Meanwhile, it remains unclear how “an important loss of freedom” should be understood. In order to get a clearer view on the relationship between mental disorder and (a loss of) freedom, in this article, I will explore (...) the link between mental disorder and free will. I examine two domains in which a connection between mental disorder and free will is present: the philosophy of free will and forensic psychiatry. As it turns out, philosophers of free will frequently refer to mental disorders as conditions that compromise free will and reduce moral responsibility. In addition, in forensic psychiatry, the rationale for the assessment of criminal responsibility is often explained by referring to the fact that mental disorders can compromise free will. Yet, in both domains, it remains unclear in what way free will is compromised by mental disorders. Based on the philosophical debate, I discuss three senses of free will and explore their relevance to mental disorders. I conclude that in order to further clarify the relationship between free will and mental disorder, the accounts of people who have actually experienced the impact of a mental disorder should be included in future research. (shrink)
Neurolaw is a new, rapidly developing area of interdisciplinary research on the meaning and implications of neuroscience for the law and legal practices. In this article three recently published volumes in this field will be reviewed.
The medical assessments of criminal responsibility and competence to consent to treatment are performed, developed and debated in distinct domains. In this paper I try to connect these domains by exploring the similarities and differences between both assessments. In my view, in both assessments a decision-making process is evaluated in relation to the possible influence of a mental disorder on this process. I will argue that, in spite of the relevance of the differences, both practices could benefit from the recognition (...) of this similarity. For cooperative research could be developed directed at elucidating exactly how various mental disturbances can affect decision-making processes. (shrink)
Competence is central to informed consent and, therefore, to medical practice. In this context, competence is regarded as synonymous with decision-making capacity. There is wide consensus that competence should be approached conceptually by identifying the abilities needed for decision-making capacity. Incompetence, then, is understood as a condition in which certain abilities relevant to decision-making capacity are lacking. This approach has been helpful both in theory and practice. There is, however, another approach to incompetence, namely to relate it to mental disorder. (...) This approach has been followed in recent research that has shown, for instance, that in anorexia nervosa a person's values may be changed, resulting in ‘pathological’ values. We explore some advantages and disadvantages of both abilities-based and pathology-based approaches. We argue that both can be valuable for further clarification of the concept of competence and improving clinical practice. Given the current predominance of the abilities-based approach, we make a plea for a greater focus on pathology-based practice and research. (shrink)
In some criminal cases a forensic psychiatrist is asked to make an assessment of the state of mind of the defendant at the time of the legally relevant act. A considerable number of people seem to hold that the basis for this assessment is that free will is required for legal responsibility, and that mental disorders can compromise free will. In fact, because of the alleged relationship between the forensic assessment and free will, researchers in forensic psychiatry also consider the (...) complicated metaphysical discussions on free will relevant to the assessment. At the same time, there is concern about the lack of advancement with respect to clarifying the nature of the forensic assessment. In this paper I argue that, even if free will is considered relevant, there may be no need for forensic researchers to engage into metaphysical discussions on free will in order to make significant progress. I will do so, drawing a parallel between the assessment of criminal responsibility on the one hand, and the medical practice of obtaining informed consent on the other. I argue that also with respect to informed consent, free will is considered relevant, or even crucial. This is the parallel. Yet, researchers on informed consent have not entered into metaphysical debates on free will. Meanwhile, research on informed consent has made significant progress. Based on the parallel with respect to free will, and the differences with respect to research, I conclude that researchers on forensic assessment may not have to engage into metaphysical discussions on free will in order to advance our understanding of this psychiatric practice. (shrink)
Obsessive-compulsive disorder (OCD) is considered to be one of the more common serious mental disorders, with a prevalence rate of about 1% (Heyman et al. 2006). It is characterized by obsessions, or compulsions, or both. According to the DSM-IV (American Psychiatric Association 1994), obsessions are “recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.” Compulsions, on the other hand, are repetitive behaviors (e.g., (...) hand washing, ordering, checking) or “mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied .. (shrink)
The forensic psychiatrist’s task is often considered to be tightly connected to the concept of free will. Yet, there is also a lack of clarity about the role of the concept of free will in forensic psychiatry. Recently, Morse has argued that forensic psychiatrists should not mention free will in their reports or testimonies, and, moreover, that they should not even think about free will. Starting from a discussion on Morse’s claims, I will develop my own view on how forensic (...) psychiatrists are confronted with the issue of free will and how they should deal with this concept and the confusion surrounding it. I conclude that psychiatrists should at least feel free to think about free will and that the conceptual challenges connected to the issues of free will and accountability could rather encourage than deter forensic psychiatrists to think about them. (shrink)
Worrying is the central feature of generalized anxiety disorder . Many people worry from time to time, but in GAD the worrying is prolonged and difficult to control. Worrying is a specific way of coping with perceived threats and feared situations. Meanwhile, it is not considered to be a helpful coping strategy, and the phenomenological account developed in this paper aims to show why. It builds on several phenomenological notions and in particular on Michael Wheeler's application of these notions to (...) artificial intelligence and the cognitive sciences. Wheeler emphasizes the value of 'online intelligence' as contrasted to 'offline intelligence'. I discuss and apply these concepts with respect to worrying as it occurs in GAD, suggesting that GAD patients overrate the value of detached contemplation , while underrating their embodied-embedded adaptive skills . I argue that this phenomenological account does not only help explaining why worrying is used as a coping strategy, but also why cognitive behavioral therapy is successful in treating GAD. (shrink)
Wegner’s argument on the illusory nature of conscious will, as developed in The Illusion of Conscious Will (2002) and other publications, has had major impact. Based on empirical data, he develops a theory of apparent mental causation in order to explain the occurrence of the illusion of conscious will. Part of the evidence for his argument is derived from a specific interpretation of the phenomenon of auditory verbal hallucinations as they may occur in schizophrenia. The aim of this paper is (...) to evaluate the validity of the evidence on auditory verbal hallucinations as employed by Wegner. I conclude that auditory hallucinations do not provide solid evidence for Wegner’s theory. Moreover, the phenomena in schizophrenia provide, in fact, an argument against part of Wegner’s theory of apparent mental causation. (shrink)
From 1959 until 1969, Heidegger lectured to psychiatrists and psychiatry students at the University of Zurich Psychiatric Clinic and in Zollikon. The transcriptions of these lectures were published as the Zollikon Seminars. In these seminars Heidegger is highly critical of psychoanalysis, because of its causal and objectifying approach to the human being. In general, Heidegger considers it an objectification or even an elimination of the human being to approach a patient from a causal perspective. In our view Heidegger has overlooked (...) the peculiar nature and complexity of psychotherapy and psychiatry, namely that psychiatry is not just a discipline that combines a hermeneutical approach and a natural science approach on a theoretical level, but it also deals with psychopathology in practice. We argue, also referring to Strawson and Gadamer, that in psychiatric practice causal explanation and hermeneutic understanding are no mutually exclusive approaches. We conclude that the encounter of philosophy and psychiatry in matters of causality and motivation could be particularly fruitful when the practical situation is addressed, recognizing the special character of psychopathology. (shrink)
Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)
Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)
