Authenticity has recently emerged as an important issue in discussions of mental disorder. We show, on the basis of personal accounts and empirical studies, that many people with psychological disorders are preoccupied with questions of authenticity. Most of the data considered in this paper are from studies of people with bipolar disorder and anorexia nervosa. We distinguish the various ways in which these people view the relationship between the disorder and their sense of their authentic self. We discuss the principal (...) modern ac-counts of authenticity within the analytic philosophical tradition. We argue that accounts based on autonomous, or wholehearted, endorsement of personal characteris-tics fail to provide an adequate analysis of authenticity in the context of mental disorder. Significant elements of true self accounts of authenticity are required. The concept of authenticity is a basic one that can be of particular value, in the context of self-development, to people with mental disorder and to others experiencing substantial inner conflict. (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came to the (...) concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

Most studies into the performance of socially responsible investment vehicles have focused on the performance of sustainable or socially responsible mutual funds. This research has been complemented recently by a number of studies that have examined the performance of sustainable investment indices. In both cases, the majority of studies have concluded that the returns of socially responsible investment vehicles have either underperformed, or failed to outperform, comparable market indices. Although the impact of sustainable indices to date has been limited, the (...) recent launch of sustainable indices by Dow Jones and FTSE suggests that more attention is being paid to the subject by financial markets, investors, and companies. This development raises a number of important issues which are reviewed in this article: (a) the performance of indices compared with their benchmark indices; (b) the methodologies employed in compiling the indices; and (c) the impact of the indices on companies and the investment community. The article concludes with a number of suggestions for areas that merit future research. (shrink)

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in determining the (...) relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that conceptualizing anorexia (...) nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

This research examines the possibility of developing a new corporate social responsibility (CSR) auditing system based on the analysis of current CSR literature and interviews conducted with a number of interested and knowledgeable stakeholders. This work attempts to create a framework for social responsibility auditing compatible with an existing commercially successful environmental audit system. The project is unusual in that it tackles the complex issue of CSR auditing with a scientific approach using Grounded Theory. On the evidence discovered to date (...) in the literature review and the interviews, CSR seems to be perceived by many as the social strand of sustainable development. However, there is far less agreement regarding its measurement. Both the literature review and the interview analysis indicate that developing an applied CSR auditing procedure will be a challenging task. This is principally due to the lack of formal study of this complex subject, which, despite the widespread debate it has engendered, still lacks a single and broadly accepted definition. The concepts developed from the findings of this research, together with the key factors identified in a literature review of CSR, were developed into a prospective CSR audit protocol. (shrink)

Issues in medical ethics are rarely out of the media and it is an area of ethics that has particular interest for the general public as well as the medical practitioner. This short and accessible introduction provides an invaluable tool with which to think about the ethical values that lie at the heart of medicine. Tony Hope deals with thorny moral questions, such as euthanasia and the morality of killing, and also explores political questions such as: how should health care (...) resources be distributed fairly? (shrink)

The non-identity problem arises when an intervention or behavior changes the identity of those affected. Delaying pregnancy is an example of such a behavior. The problem is whether and in what ways such changes in identity affect moral considerations. While a great deal has been written about the non-identity problem, relatively little has been written about the implications for physicians and how they should understand their duties. We argue that the non-identity problem can make a crucial moral difference in some (...) circumstances, and that it has some interesting implications for when it is or is not right for a physician to refuse to accede to a patient's request. If a physician is asked to provide an intervention (identity preserving) that makes a person worse off, then such harm provides a good reason for the physician to refuse to provide the intervention. However, in cases where different (identity-altering) interventions result in different people having a better or worse life, physicians should normally respect patient choice. (shrink)

I address the usefulness of thinking about a human right to subsistence within conceptions of human rights grounded in ordinary moral reasoning. I argue that that natural rights should be understood as rights in rem, with their dynamism constrained by the requirements of justification and their scope constrained by the distinction between perfect and imperfect duty. I then suggest that many of the most pressing demands which the moral significance of subsistence needs create are plausibly imperfect duties, and so cannot (...) correlate to a natural right to subsistence. This restricts the helpfulness of a human right to subsistence in our reasoning about what we owe to others. (shrink)

David Hume famously states, in his A Treatise of Human Nature, “that ’tis only from the selfishness and confin’d generosity of men, along with the scanty provision nature has made for his wants, that justice derives its origin”.1 This is Hume’s summary of the conditions under which the very idea of rules of justice makes practical sense, and he effectively repeats it in the Enquiry Concerning the Principles of Morals.2 To put it briefly at the outset, Hume’s point is simply (...) this: if there was either a superabundance or drastic scarcity of resources, or if everyone were either completely and unfailingly virtuous or completely and unfailingly wicked, we would not need rules. (shrink)

To reduce the spread of the human immunodeficiency virus (HIV), Granich et al. 1 ( 2009 ) have proposed a new strategy for universal voluntary HIV testing immediately followed by antiretroviral therapy. Although this proposal is likely to benefit the partners of those affected and thus promote public health, it is by no means clear that it benefits the infected people themselves and indeed it may be harmful. Since the proposal involves an intervention that is not clinically indicated, it falls (...) foul of the normal ethical standards of clinical medicine, which is to act in the best interests of patients. Neither is it a measure that would be imposed under the protection of public health law on people who are seen as representing such danger to others that significant restrictions in liberty are appropriate. Thus, the proposal represents a third category of public health measure. We argue that a coherent ethical framework including a robust process is appropriate to proposals of this kind and that medical research offers a useful model since some research, like this proposal, is motivated not by the interests of the individual participants but by the common good. We outline some possible elements of such an ethical framework. (shrink)

There is a long history of medical research that involves intentionally infecting healthy people in order to study diseases and their treatments. Such research—what might be called “human challenge studies”—are an important strand of much current research—for example, in the development of vaccinations. The many international and national guidelines about the proper conduct of medical research do not specifically address human challenge studies. In this paper we review the guidelines on the risk of harm that healthy volunteers may be exposed (...) to in the course of medical research. We examine the ethical arguments that are implicit or explicit in these guidelines. We then ask whether there is reason for limiting such studies on grounds independent of risk of harm. We conclude that the major ethical concern with challenge studies is that of risk of harm and that the fact that a study is a challenge study is not a wrong in itself. (shrink)

Health care systems across the world are unable to afford the best treatment for all patients in all situations. Choices have to be made. One key ethical issue that arises for health authorities is whether the principle of the “rule of rescue” should be adopted or rejected. According to this principle more funding should be available in order to save lives of identifiable, compared with unidentifiable, individuals. Six reasons for giving such priority to identifiable individuals are considered. All are rejected. (...) It is concluded that the principle of the rule of rescue should not be used in determining the allocation of health resources. (shrink)

In this paper I assess the possibility of advancing a modern conception of social justice under neo-Aristotelian lights, focussing primarily on conceptions that assert a fundamental connection between social justice and eudaimonia. After some preliminary remarks on the extent to which a neo-Aristotelian account must stay close to Aristotle’s own, I focus on Martha Nussbaum’s sophisticated neo-Aristotelian approach, which I argue implausibly overworks the aspects of Aristotle’s thought it appeals to. I then outline the shape of a deeper and more (...) general, and as yet unanswered, problem facing neo-Aristotelian accounts: how to justify the claim that the point of a just society is to assist or enable its members to flourish. (shrink)

This article argues that hope is of value in clinical ethics and that it can be important for clinicians to be sensitive to both the risks of false hope and the importance of retaining hope. However, this sensitivity requires an understanding of the complexity of hope and how it bears on different aspects of a well-functioning doctor-patient relationship. We discuss hopefulness and distinguish it from three different kinds of hope, or ‘hopes for’, and then relate these distinctions back to differing (...) accounts of autonomy. This analysis matters because it shows how an overly narrow view of the ethical obligations of a clinician to their patient, and autonomy, might lead to scenarios where patients regret the choices they make. (shrink)

ZusammenfassungEntscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.

Entscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

The “doctrine of double effect” has a pleasing ring to it. It is regarded by some as the cornerstone of any sound approach to end-of-life issues and by others as religious mumbo jumbo. Discussions about “the doctrine” often generate more heat than light. They are often conducted at cross-purposes and laced with footnotes from Leviticus.

OBJECTIVES: To study the resources available and resources needed for ethics teaching to medical students in UK medical schools as required by the new GMC core curriculum. DESIGN: A structured questionnaire was piloted and then circulated to deans of medical schools. SETTING: All UK medical schools. RESULTS: Eighteen out of 28 schools completed the questionnaire, the remainder either indicating that their arrangements were "under review" (4) or not responding (6). Among those responding: 1) library resources, including video and information technology (...) were found to be fairly well developed; 2) many schools had a good supply of handouts and sample cases for teaching; 3) most had a written syllabus, and 4) two-thirds examined in the subject. However, many schools indicated that there was an urgent need for: 1) full-time teachers (most ethics teaching is still by part-time and voluntary staff); funding for books and journals, and 3) additional teaching materials (including further case vignettes, handouts and sample exam questions). CONCLUSIONS: There has been a considerable overall improvement in resources for medical ethics teaching since the time of the last national survey (The Pond Report). However, provision varies widely from medical school to medical school. The particular needs identified were for full-time teachers, library resources and teaching materials. Wider use of existing organisations concerned with medical ethics could help to meet these needs. (shrink)

We describe the teaching programme in ethics, law and communication skills for clinical medical students which is being developed as part of the Oxford Practice Skills Project. These three elements of practice are approached in an integrated teaching programme which aims to address everyday clinical practice. The role of a central value of patient-centred health care in guiding the teaching is described. Although the final aim of the teaching is to improve actual practice, we have found three 'sub-aims' helpful in (...) the development of the programme. These sub-aims are: increasing students' awareness of ethical issues; enhancing their analytical thinking skills, and teaching specific knowledge. (shrink)

Some of the most important achievements in the field of empiricist ethics were made by the School of Moral Sentiment, comprising Francis Hutcheson, David Hume, and Adam Smith. This book throws new light on their consensus theory of virtue. Hope works some of their ideas into a merit theory of rights applicable to conventional rights, defends ethical cognitivism, and analyzes pleasure.

The Mental Capacity Act is an impressive piece of legislation that deserves serious ethical attention, but much of the commentary on the Act has focussed on its legal and practical implications rather than the underlying ethical concepts. This paper examines the approach that the Act takes to best interests. The Act does not provide an account of the underlying concept of best interests. Instead it lists factors that must be considered in determining best interests, and the Code of Practice to (...) the Act states that this list is incomplete. This paper argues that this general approach is correct, contrary to some accounts of best interests. The checklist includes items that are unhelpful. Furthermore, neither the Act nor its Code of Practice provides sufficient guidance to carers faced with difficult decisions concerning best interests. This paper suggests ways in which the checklist can be developed and discusses cases that could be used in an updated Code of Practice. (shrink)

It is commonly claimed, in the global justice literature, that global injustices are best characterised in terms of the violation or unfulfilment of human rights. I suggest that global justice theorists are overconfident on this point. For decolonising peoples, contemporary global injustice is likely to be characterised in terms drawn from local histories of injustice and the constellations of thick ethical concepts they contain. To make the point I describe how the Māori of New Zealand, who do not reject human (...) rights, typically make no reference to human rights in political argument. I argue that the Māori are reasonable to consider human rights talk to be ‘one thought too many’, and the considerations that make this so typically apply in other postcolonial contexts of political activity. (shrink)

Next SectionMaking threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way (...) that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong. (shrink)

This paper explores the relationship between mania, or pathologically elevated mood, and philosophical theories of well-being. A patient, Mr. M., is described who oscillated between periods when he refused medication and periods when he was willing to accept it, and whose desires and life objectives were radically different in his medicated and unmedicated states. The practical dilemmas this raised are explored in terms of the three principal philosophical theories of well-being: hedonism, the desire fulfillment theory, and objectivism. None of these (...) adequately accounted for Mr. M.'s case: hedonism, because pleasure is increased in mildly manic states; desire fulfillment theories, because these suggest that an unending cycle of treatment and nontreatment would be in Mr. M.'s best interests; and objectivism, because, in a form that would be applicable to Mr. M., that theory brings with it substantial risks of paternalism. Four further philosophical approaches are explored briefly—approaches focusing on autonomy, rationality, personal identity, and illness, respectively—but these also provide no straightforward resolution of the clinical dilemmas. It is concluded that philosophical analysis, even if it does not resolve cases like Mr. M.'s, can deepen our understanding of the issues involved in clinical decision making in psychiatry, especially the importance of sensitivity to the patient's wishes and values; and conversely, that mild mania is an important "real life" case against which philosophical theories of well-being can be tested. (shrink)