This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment, they may still be less competent than they were when they signed the Ulysses Contract. As such, even if competent at time (...) 1 and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people’s most meaningful concerns. Third, on the approach defended, the restrictions to people’s liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis, this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary. (shrink)

‘Ulysses contracts’ are an instrument through which a psychiatric patient may prearrange involuntary commitments to be put into effect if the patient satisfies certain diagnostic criteria in the future. Proposals for Ulysses contracts typically impose numerous safeguards. This paper argues against the intuitively plausible safeguard which permits only presently remitted patients to contract. Instead of requiring a patient's remission, it is argued that the appropriate safeguard is the patient's ability, whether remitted or not, to offer good reasons (...) for wishing to contract. In short, what matters is not an executive's character, but an executive's reasons, and a bad executive may have good reasons. Attempts to deny the accessibility of good reasons in unremitted patients are rejected on the ground that psychiatric diagnosis requires psychiatrists to be able to distinguish between good and bad reasons in both remitted and unremitted patients. If psychiatrists cannot do that, psychiatric diagnosis is impossible. (shrink)

Introduction Compulsory care is controversial, since respect for the patient’s autonomy is a standard requirement in health care. Many psychiatrists have experienced that patients with borderline personality syndrome sometimes demand compulsory care for themselves in order not to exert self-harm—like Ulysses contracts. The aim of this study was to examine the possible existence and extent of borderline personality syndrome-patient demands for Ulysses contracts regarding compulsory care in acute psychiatry, and how external influences and demands could affect the caregivers’ (...) decisions about compulsory care. Method An anonymous questionnaire, with three questions with fixed answers, was distributed to 42 licensed medical doctors on call at the psychiatric emergency unit in the city of Stockholm. Thirty-three questionnaires were answered, giving a response rate of 79%. Results Ninety-four percent of the respondents recognized the phenomenon of borderline personality syndrome patients requesting compulsory care, 21% stated that this request had affected their clinical decision, and 55% had used compulsory care for other reasons than the patient’s best interest. Discussion The results indicate that compulsory care is sometimes given in the form of Ulysses contracts for borderline personality syndrome patients. Also, compulsory care is sometimes used for other reasons than the borderline personality syndrome patient’s best interest. Psychological mechanisms affect the decisions of both patients and caregivers. More research should be done concerning to whom, why, and with what consequences compulsory care is prescribed. (shrink)

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives , it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could (...) be minimised.Ulysses contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. (shrink)

In many jurisdictions, legal frameworks afford patients the opportunity to make prospective medical decisions or to create directives that contain a special provision forfeiting their own ability to object to those decisions at a future time point, should they lose decision‐making capacity. These agreements have been described with widely varying nomenclatures, including Ulysses Contracts, Odysseus Transfers, Psychiatric Advance Directives with Ulysses Clauses, and Powers of Attorney with Special Provisions. As a consequence of this terminological heterogeneity, it is challenging (...) for healthcare providers to understand the terms and uses of these agreements and for ethicists to engage with the nuances of clinical decision‐making with such unique provisions surrounding patient autonomy. In theory, prospective self‐binding agreements may safeguard patient's “authentic” wishes from future “inauthentic” changes of mind. In practice, it is unclear what may be comprised within these agreements or how—and to what effect—they are used. The primary focus of this integrative review is to curate the existing literature describing Ulysses Contracts (and analogous decisions) used in the clinical arena, in order to empirically synthesize their shared essence and provide insights into the traditional components of these agreements when used in practice, the requirements of their consent processes, and the outcomes of their utilization. (shrink)

Pre-commitment directives or Ulysses contracts are often defended as instruments that may strengthen the autonomous self-control of episodically disordered psychiatric patients. Autonomy is understood in this context in terms of sovereignty ("governing" or "managing" oneself). After critically analyzing this idea of autonomy in the context of various forms of self-commitment and pre-commitment, we argue that what is at stake in using Ulysses contracts in psychiatry is not autonomy as sovereignty, but autonomy as authenticity. Pre-commitment directives do not (...) function to protect autonomous self-control. They serve in upholding the guidance that is provided by one's deepest identity conferring concerns. We elucidate this concept of autonomy as authenticity, by showing how Ulysses contracts protect the possibility of being "a self.". (shrink)

The use of four-point physical restraints has long been controversial in psychiatry. But the most common objections against these restraints hinges on the idea that they would be imposed against patients. In light of the trend towards giving patients access to Advance Directives, why not allow patients to use such legal documents to arrange for restraints being used against them? Patients might do this if they feared an inability to make competent decisions in the future. Proper oversight over the requests (...) and the restraint-use would help psychiatric patients plan for their own care. Clearly, not all patients would qualify for such an expansion of their autonomy. Many would be unable to give adequately informed consent. Still, for the patients who could consent, being able to draw up such a “Ulysses Contract” could provide an improved balance of risks and benefits. (shrink)

The use of four-point physical restraints has long been controversial in psychiatry. But the most common objections against these restraints hinges on the idea that they would be imposed against patients. In light of the trend towards giving patients access to Advance Directives, why not allow patients to use such legal documents to arrange for restraints being used against them? Patients might do this if they feared an inability to make competent decisions in the future. Proper oversight over the requests (...) and the restraint-use would help psychiatric patients plan for their own care. Clearly, not all patients would qualify for such an expansion of their autonomy. Many would be unable to give adequately informed consent. Still, for the patients who could consent, being able to draw up such a “Ulysses Contract” could provide an improved balance of risks and benefits. (shrink)

Deep brain stimulation is an invasive technique designed to stimulate certain deep brain regions for therapeutic purposes and is currently used mainly in patients with neurodegenerative disorders, such as Parkinson’s disease. However, DBS is also used increasingly for other experimental applications, such as the treatment of psychiatric disorders, weight reduction. Apart from its therapeutic potential, DBS can cause severe adverse effects, some that might also have a significant impact on the patient’s personality and autonomy by the external stimulation of (...) DBS which effects lie beyond the individual’s control and free will. The article’s purpose is to outline the procedures of DBS currently used in therapeutic and experimental applications and to discuss the ethical concerns regarding this procedure. It will address the clinical benefit-risk-ratio, the particular ethics of research in this field, and the ethical issues raised by affecting a patient’s or an individual’s personality and autonomous behaviour. Moreover, a potential ethical guideline, the Ulysses contract is discussed for the field of clinical application as well as the question of responsibility. (shrink)

The legal environment -- Regulation of nursing practice -- Nurses in legal actions -- Standards of care -- Defenses to negligence or malpractice -- Prevention of malpractice -- Nurses as witnesses -- Professional liability insurance -- Accepting or refusing an assignment/patient abandonment -- Delegation to unlicensed assistive personnel -- Patients' rights and responsibilities -- Confidential communication -- Competency and guardianship -- Informed consent -- Refusal of treatment -- Pain control -- Patient teaching and health counseling -- Medication administration -- Clients (...) with AIDS and HIV testing -- Abusive situations -- Reproductive services -- Restraints -- Emergency psychiatric admissions -- Organ and tissue donation and transplantation -- Discharge against medical advice -- The medical record and documentation standards -- Electronic health information and communications -- Interdependent nursing functions: verbal orders and telenursing -- Event reporting and compliance -- Quality and safety in nursing practice -- Forensic issues -- Employer and employee rights -- Contracts -- Corporate liability -- Employment contracts and unionization -- Employment status liability -- Staffing issues and floating -- Americans with Disabilities Act -- Employees with AIDS/HIV infection and exposure to bloodborne pathogens -- Impaired nurses -- Sexual harassment in the workplace -- Violence in the workplace -- Intentional torts -- Environmental health and safety -- Ethical decision making -- Professional boundaries and patient relationships -- Moral courage and patient advocacy -- Social media and online professionalism -- Reporting illegal, unethical, or unsafe conduct -- Maternal versus fetal rights -- Futility of care -- Advance directives and end-of-life decisions -- Assisted suicide. (shrink)

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the (...) use of coercion in patients lacking mental capacity. The committee’s recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols. (shrink)

Public participation and survivor research in mental health are widely recognized as vital to the field. At the same time, contributions of patient collaborators can present unique challenges to determining authorship. Using an unresolved dispute around research contributions to the American Psychiatric Association’s Psychiatric Services journal, authorship and contribution are addressed. Recommendations are suggested to prevent dilemmas and achieve responsible research credit inclusion, especially among researchers with different backgrounds and asymmetric power relations. Researchers and publishers can prepare proactively (...) for conflict through consensus on authorship criteria, prior agreements around author inclusion, arrangement for third party dispute resolution, transparency in communication and contracts, notification to prospective publications of pending disputes, a contributor-guarantor model of contribution, journal editor “expressions of concern” when authorship disputes go unresolved, and expectation of conflict as generative. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Veterans Affairs National Center for Clinical EthicsJames L. Bernat (bio)The veterans health administration is the largest health care system in the United States and, indeed, is larger that the health care system of many foreign countries. In February 1991 the Department of Veterans Affairs (V.A.) in Washington, D.C. awarded a contract to the clinical ethics group at the Veterans Affairs Medical Center in White River Junction, Vermont to (...) establish the V.A. National Center for Clinical Ethics. In this article I describe the organizational context, mission, operation, and future direction of the Center, which William A. Nelson, Ph.D., and I co-direct.The Veterans Health AdministrationThe Department of Veterans Affairs operates 171 hospitals providing services ranging from primary, secondary, and tertiary medical care to psychiatric hospitals, rehabilitation centers, and nursing homes. The V.A. also provides outpatient services at all hospitals and at dozens of free-standing outpatent clinics. V.A. medical centers employ over 14,000 physicians and serve approximately 4.5 million veteran patients (Hollingsworth and Bondy 1990; Mirvis 1990).The V.A. serves an important educational function, providing training sites for medical students, postgraduate physicians, and trainees in other health-related fields. Approximately 78 percent of V.A. medical centers are affiliated with medical schools. Over one-third of all American medical students and over 40 percent of interns and residents spend a portion of their training in V.A. medical centers. More than 100,000 students in all health-related fields train in V.A. facilities annually (Hollingsworth and Bondy 1990).Research is another mission of the V.A. Many academic physicians and scientists derive their research and salary funding from V.A contracts and awards. The V.A. Research Career Development Program provides the means for many medical school faculty members to achieve successful careers as scientists and clinical investigators. Although research accounts for only slightly more than 1 percent of the V.A. medical budget, two V.A. researchers have been awarded the Nobel Prize (Hollingsworth and Bondy 1990). [End Page 385]In comparison to other medical care settings, the average V.A. patient is likely to be older, poorer, male, less well-educated, more chronically ill, and more expensive to care for. Many patients first patronize the V.A. system after they have been bankrupted by the costs of a major illness. Unlike young, healthy patients ideally favored by health maintenance organizations, these patients immediately require large expenditures for hospitalizations, medications, and other treatments. Additional burdens have been placed on V.A. facilities by a record of chronic federal underfunding over the past decade, despite expanded patient censuses at every facility.Bioethical issues arise in V.A. facilities with great frequency for several reasons. Older and poorer patients are often sicker, have fewer home-support resources, and have completed fewer advance directives for health care. Chronic operational underfunding requires explicit health care rationing systemwide. Academic physicians within the V.A. system have multiple professional duties that have the potential for conflict. Although their primary duty is to their patients, they also must serve the federal government and their medical school academic supervisors. The practice of medical care rationing pits the physician's professional duty to his patient against his duty to the system (Mirvis 1990).The V.A. has responded to these bioethical demands with several initiatives. Hospital ethics advisory committees have been developed in nearly every V.A. medical center. The V.A. National Bioethics Committee has been empaneled to encourage uniform policies across the V.A. system concerning bioethical issues. Most recently, funds were provided for the V.A. National Center for Clinical Ethics.Functions of the National Center for Clinical Ethics (NCCE)The NCCE has a fourfold mission: 1) to enhance the quality of clinical ethics programs at all 171 V.A. medical centers nationwide; 2) to staff the V.A. National Bioethics Committee; 3) to assist administrators and planners in the V.A. Central Office on policy development concerning bioethical issues; and 4) to study, organize, and coordinate clinical, educational, and research bioethics programs throughout the system.Enhancing the quality of clinical ethics programs at V.A. medical centers is largely an... (shrink)

The conclusion to be drawn from the preceding observations and theorizing should be that we must be very much aware of what has been called “technological functionalism” (Pieper, 1986:11). While functionalism as such is not bad, the moment it succumbs to mere structural technicality, the functions stop functioning: forced “adaptivity” takes the place of “adaptable” interaction.That this problem is not due to a primordial blame, to be attached to the computer, becomes clear when one compares the computerized environment to other (...) surroundings, such as, for example, the psychiatric treatment. In the psychiatric interview, as Davis (1986, 1988) has shown, the interest of the therapist is often limited to establishing a “contract” for treatment: for the therapist to function properly, there must be a therapy-defined (or therapy-definable) problem for him/her to attack, using the skills and experiences of the profession of which he/she is a representative and for which he/she has been properly trained.This function, however, may not coincide with the patient's needs: it may well be the case that the problem which originally caused the patient to approach the therapist for treatment, in the end turns out not to be the problem that both agree on as the objective of the therapeutic treatment. “Re-formulating” the patients' problem in terms suitable to the available resources and techniques is thus typically a case of adapting the human to the system: again, we're faced with technological functionalism in the shape of what has been called “forced adaptivity” (see Mey, 1986).We need to think seriously about the way we handle our computerized structures and their functions, and in particular about the design of supportive systems such as large databases, computer conferencing, or even simple electronic mail services. While adaptivity always is a case of manipulation, by which humans are tooled to the needs and strictures of the computer, adaptability, by contrast, allows such manipulation only inasmuch as those needs and strictures reflect, and are imposed by, the users' needs. The blind, mechanical force that makes us adapt ourselves to the machine should be replaced by the enlightened, humanizing force of the adaptable computer. (shrink)

Introduction -- "Every Legitimate Government is Republican": Rousseau's Debt to and Departure from Montesquieu on Republicanism -- What if There is no Legislator? Rousseau's History of the Government of Geneva -- Rousseau's Republican Citizenship: The Moral Psychology of The Social Contract -- Rousseau's negative liberty: Themes of domination and skepticism in The Social Contract -- Rousseau's Ancient Ends of Legislation: Liberty, Equality (& Fraternity) -- Property and Possession in Rousseau's Social Contract -- Political Equality Among Unequals -- On the Primacy (...) of Peoplehood: Nations and Nationalism in Rousseau's Social Contract -- Rousseau on Voting and Electoral Laws -- Rousseau and the puzzle of the Roman Republic -- Rousseau's Case against Democracy -- Rousseau's Dilemma or "Of Civil Religion" -- Entreating the Political: Politics and Theology in Rousseau's Social Contract -- Civil Religion and Political Unity: Social Contract 4.8. (shrink)

During the past ten years Integrative Social Contracts Theory (ISCT) has become part of the repertoire of specialized decision-oriented theories in the business ethics literature. The intention here is to (1)␣provide a brief overview of the structure and strengths of ISCT; (2) identify recurring themes in the extensive commentary on the theory including brief mention of how ISCT has been applied outside the business ethics literature; (3) describe where research appears to be headed; and (4) specify challenges faced by (...) those who seek to reform ISCT. Key themes in the critiquing literature relate to (a) the identification process for hypernorms; (b) justification of the recognition of hypernorms; (c) proposals for considering meso or meta norms; (d)␣clarification of the relationship between stakeholder concepts and ISCT; (e) problems with potentially unoccupied moral free space; (f) sources of ethical obligation within the ISCT framework; and (g) the potential role for concepts of stakeholder dialogue and engagement. (shrink)

Difficult moral issues in economic life, such as evaluating the impact of hostile takeovers and plant relocations or determining the obligations of business to the environment, constitute the raison d'etre of business ethics. Yet, while the ultimate resolution of such issues clearly requires detailed, normative analysis, a shortcoming of business ethics is that to date it has failed to develop an adequate normative theory.1 The failing is especially acute when it results in an inability to provide a basis for fine-grained (...) analyses of issues. Both general moral theories and stakeholder theory seem incapable of expressing the moral complexity necessary to provide practical normative guidance for many business ethics contexts. (shrink)

Extant social contracts, deriving from communities of individuals, constitute a significant source of ethical norms in business. When found consistent with general ethical theories through the application of a filtering test, these real social contracts generate prima facie duties of compliance on the part of those who expressly or impliedly consent to the terms of the social contract, and also on the part of those who take advantage of the instrumental value of the social contracts. Businesspeople typically (...) participate in multiple communities and, as a consequence, encounter conflicting ethical norms. Priority rules can be devised to resolve such conflicts. The framework of extant social contracts merges normative and theoretical research in business ethics and specifies a domain for empirical studies. (shrink)

The concept of integrity appears in many arguments and theories in business ethics and organizational behavior where it plays multiple roles. It has been shown to have desirable organizational outcomes and is held as important by the academic and practitioner alike. Yet despite its prominence there are a variety of approaches to defining and conceptualizing it and little existent theory to explain its nature. We offer integrative social contracts theory (ISCT) as a framework that can anchor integrity in ethical (...) theory and also encompass aspects of integrity such as wholeness, consistency, and authenticity. In addition we show how ISCT can resolve some of the challenges to definitions of integrity that have been raised in the literature and hence we provide some suggestions for future academic research and suggestions for the practitioner. (shrink)

The intention of the article is to offer stakeholders affected by mergers a criterion from which moral arguments may be generated for the organization of each individual case. The criterion: "Any operation causing legitimate interests to suffer vital infringement should be avoided in a merger process." A vital infringement of these interests is assumed when the merger undermines unique positive opportunities or considerable impairment in the future, impossible to overcome for the person affected without an unacceptable level of difficulty. Therefore, (...) we mainly concentrate on implicit contracts – which should be based on the principle pacta sunt servanda as well. These contracts are mandatory to run an economy that produces increasingly more knowledge-based goods. (shrink)

Difficult moral issues in economic life, such as evaluating the impact of hostile takeovers and plant relocations or determining the obligations of business to the environment, constitute the raison d'etre of business ethics. Yet, while the ultimate resolution of such issues clearly requires detailed, normative analysis, a shortcoming of business ethics is that to date it has failed to develop an adequate normative theory.1 The failing is especially acute when it results in an inability to provide a basis for fine-grained (...) analyses of issues. Both general moral theories and stakeholder theory seem incapable of expressing the moral complexity necessary to provide practical normative guidance for many business ethics contexts. (shrink)

Downsizing has become a significant public issue that has not yet been significantly studied by business ethicists. It is proposed that reasonable social and psychological contracts bound the moral free space of managers contemplating downsizing; the degree of constraint is also dependent on the organization's resource munificence. A framework for considering the extent of managerial moral free space and implications thereof for managerial practice are offered.

In this article I argue that Kant’s understanding of the universality of radical evil is best understood in the context of human sociality. Because we are inherently social beings, the nature of the human community we find ourselves in has a determinative influence on the sorts of persons we are, and the kinds of choices we can make. We always begin in evil. This does not vitiate responsibility, since through reflection we can become aware of our situation and envision ourselves (...) as members of a different community, one with different expectations, making genuine virtue possible. This understanding of radical evil helps to make sense of Kant’s high regard for the church in Religion. (shrink)

This book explores how the design, construction, and use of robotics technology may affect today's legal systems and, more particularly, matters of responsibility and agency in criminal law, contractual obligations, and torts. By distinguishing between the behaviour of robots as tools of human interaction, and robots as proper agents in the legal arena, jurists will have to address a new generation of "hard cases." General disagreement may concern immunity in criminal law (e.g., the employment of robot soldiers in battle), personal (...) accountability for certain robots in contracts (e.g., robo-traders), much as clauses of strict liability and negligence-based responsibility in extra-contractual obligations (e.g., service robots in tort law). Since robots are here to stay, the aim of the law should be to wisely govern our mutual relationships. (shrink)

Integrative social contracts theory (ISCT) uses empirical methods to develop guidelines for international business ethics. This article criticizes ISCT in terms of the way people actually think about contracts and agreements around the globe. Differences in orientations to communications context, moral reasoning, and institutional and structural conditions make the identification of authentic norms, hypernorms, and relevant communities problematic. The difficulties of the empirical methods suggest recourse to more traditional theoretical approaches for the identification of hypernorms as well as (...) a stronger test for the compatibility of authentic norms with hypernorms. (shrink)

The article discusses theoretical and practical issues one may face when applying various types of employment contracts, refers to specific legal relations governed by Labour Code standards, and raises issues that would help to solve the existing troubles. Last decades as globalization processes were gaining pace, and market economy conditions changed, labour and production organization models were undergoing transformation. The more complex people’s social relationships are, the greater is the need to regulate these relationships, i. e. to adopt legislation (...) that would create pre-conditions for addressing social interest conflicts. Thus a need has arisen for a new legal regulation because new activity models do not fit into traditional relationships governed by labour law. Along standard employment relationship, non-standard relationships occur in the market. In 2003 the Ministry of Social Security and Labour of the Republic of Lithuania issued recommendations for employers on flexible work organisation forms and indicated reasons for the organisation of flexible work forms: the nature of work and employee’s demographic and social characteristics; fulfilment of family duties; health condition; unfavourable work environment; employee’s age; studying and studies. (shrink)

The knowledge contribution of members is essential and beneficial to both the business and users of online health communities (OHCs). This study explores and tests the effects of OHC users' psychological contracts on their community identification and knowledge-sharing behavior. A total of 362 valid responses from several well-known OHCs in China are used in the data analysis. The results of the path analysis with structural equation modeling show that users' transactional psychological contracts have a negative effect on their (...) knowledge contribution both directly and indirectly by weakening their community identification. In contrast, users' relational psychological contracts can lead to increased active knowledge contributions both directly and indirectly by enhancing their community identification. Knowledge sharing self-efficacy can strengthen the relationship between relational psychological contracts and knowledge contributions, and the relationship between community identification and knowledge contributions. However, it has no significant impact on the path from transactional psychological contracts to knowledge contribution. The implications and direction of future works are presented on the basis of the results of the empirical analysis. (shrink)

Downsizing has become a significant public issue that has not yet been significantly studied by business ethicists. It is proposed that reasonable social and psychological contracts bound the moral free space of managers contemplating downsizing; the degree of constraint is also dependent on the organization's resource munificence. A framework for considering the extent of managerial moral free space and implications thereof for managerial practice are offered.

Although moral hazard is a well-known economic concept, there is a long-standing controversy over its moral implications. The language economists use to describe moral hazard is often value-laden, and implies moral judgments about the persons or actions of economic agents. This in turn leads some to question whether it is actually a scientific concept, or simply a convenient tool for criticizing certain public policies. At present, there is no consensus about the moral meaning of moral hazard, or about whether the (...) concept can be salvaged by economists. As a first step toward resolving this problem, I suggest a contracts approach to moral hazard. I use the ‘title-transfer’ theory of contract to clarify the moral content of moral hazard, thereby increasing its value to scholars in numerous disciplines. A contracts view is useful for economic policy discussions because it does not include hidden value judgments. At the same time, however, it is also valuable for ethicists because it directly explains a moral dimension of behavior under moral hazard, namely, the violation of property rights. (shrink)

Social contract theory offers a powerful method and metaphor for the study of organizational ethics. This paper considers the variant of the social contract that has arguably gained the most attention among business ethicists: integrative social contracts theory or ISCT [Donaldson and Dunfee: 1999, Ties That Bind (Harvard Business School Press, Boston)]. A core precept of ISCT - that consent to membership in an organization entails obligations to follow the norms of that organization, subject to the moral minimums of (...) basic human rights - is a reasonable and appealing notion. One potential challenge for those attempting to apply this idea, however, lies in the dynamic nature of social norms. Organizational norms evolve, often through the conscious efforts of community members and leaders. As currently formulated, ISCT offers a framework that under-appreciates the evolving nature of moral norms. In this paper, we extend ISCT by considering the circumstances under which the terms of and parties to social contracts change. We also consider a number of principles that should be considered as the terms and parties to organizational social contracts change. (shrink)

Long used as a tool for medical compliance and adhering to treatment plans, behavior contracts have made their way into the in-patient healthcare setting as a way to manage the “difficult” patient and family. The use of this tool is even being adopted by healthcare ethics consultants (HECs) in US hospitals as part of their work in navigating conflict at the bedside. Anecdotal evidence of their increasing popularity among clinical ethicists, for example, can be found at professional bioethics meetings (...) and conversations and idea-sharing among practitioners on HEC social media. While there are a handful of papers gesturing toward a bioethical critique of behavior contracts of various types, the use of behavior contracts in the context of interpersonal conflict has not been vetted by bioethicists to determine their ethical legitimacy or efficacy. In this paper, we highlight a set of ethical concerns that we believe must be addressed before continuing or widespread implementation of behavior contracts to manage the “difficult” patient or family. (shrink)

Social contract theory offers a powerful method and metaphor for the study of organizational ethics. This paper considers the variant of the social contract that has arguably gained the most attention among business ethicists: integrative social contracts theory or ISCT [Donaldson and Dunfee: 1999, Ties That Bind (Harvard Business School Press, Boston)]. A core precept of ISCT – that consent to membership in an organization entails obligations to follow the norms of that organization, subject to the moral minimums of (...) basic human rights – is a reasonable and appealing notion. One potential challenge for those attempting to apply this idea, however, lies in the dynamic nature of social norms. Organizational norms evolve, often through the conscious efforts of community members and leaders. As currently formulated, ISCT offers a framework that under-appreciates the evolving nature of moral norms. In this paper, we extend ISCT by considering the circumstances under which the terms of and parties to social contracts change. We also consider a number of principles that should be considered as the terms and parties to organizational social contracts change. (shrink)

Psychiatric treatment and diagnosis rests upon a richer conception of normativity than, for example, cognitive neuropsychology. This paper explores the role that considerations of rationality can play in defining this richer conception of normativity. It distinguishes two types of rationality and considers how each type can break down in different ways in delusional psychiatric disorders.

A pluralistic view of psychiatric classification is defended, according to which psychiatric categories take a variety of structural forms. An ordered taxonomy of these forms—non-kinds, practical kinds, fuzzy kinds, discrete kinds, and natural kinds—is presented and exemplified. It is argued that psychiatric categories cannot all be understood as pragmatically grounded, and at least some reflect naturally occurring discontinuities without thereby representing natural kinds. Even if essentialist accounts of mental disorders are generally mistaken, they are not implied whenever (...) a psychiatric category that is not pragmatically grounded is posited. (shrink)

Liao and Carbonell argue that medical devices are often not merely biased, but rather materialize oppression through the perpetuation of oppression into the present and future (Liao and Carbonell 2...

In a multilateral bargaining game where a proposer and responders can set up a “principal–agent” relationship by means of binding cash-offer contracts, we show that there is a Markov SPE with a delay in reaching an agreement. We also show that all the individually rational and efficient payoffs can be supported by SPE.

In Real Hallucinations, Matthew Ratcliffe offers a philosophical examination of the structure of human experience, its vulnerability to disruption, and how it is shaped by relations with other people. He focuses on the seemingly simple question of how we manage to distinguish among our experiences of perceiving, remembering, imagining, and thinking. To answer this question, he first develops a detailed analysis of auditory verbal hallucinations (usually defined as hearing a voice in the absence of a speaker) and thought insertion (somehow (...) experiencing one's own thoughts as someone else's). He shows how thought insertion and many of those experiences labeled as "hallucinations" consist of disturbances in a person's senseof being in one type of intentional state rather than another. Ratcliffe goes on to argue that such experiences occur against a backdrop of less pronounced but wider-ranging alterations in the structure of intentionality. In so doing, he considers forms of experience associated with trauma, schizophrenia, and profound grief. The overall position arrived at is that experience has an essentially temporal structure, involving patterns of anticipation and fulfillment that are specific to types of intentional states and serve to distinguish them phenomenologically. Disturbances of this structure can lead to various kinds of anomalous experience. Importantly, anticipation-fulfillment patterns are sustained, regulated, and disrupted by interpersonal experience and interaction. It follows that the integrity of human experience, including the most basic sense of self, is inseparable from how we relate to other people and to the social world as a whole. (shrink)

Integrative social contracts theory (ISCT) has been an influential theory in normative business ethics for well over a decade, drawing attention both as an object of criticism and as a source of inspiration. In this paper I argue that, despite this attention, the fact that it is a genuinely pluralistic theory, in the tradition of pluralistic theories of political philosophy, is often overlooked. It is in the notion of moral free space that this pluralism is most clearly expressed. This (...) oversight is unfortunate for two reasons. Firstly, it prevents the potential of ISCT, as a normative theory of business ethics, from being appreciated fully; secondly, it leads us to ignore resources that could help tackle its most problematic flaws. In this second respect, I show how some of these flaws could be addressed by paying closer attention to the similarities between ISCT and John Rawls' theory of Political Liberalism. (shrink)

This paper addresses philosophical issues concerning whether mental disorders are natural kinds and how the DSM should classify mental disorders. I argue that some mental disorders (e.g., schizophrenia, depression) are natural kinds in the sense that they are natural classes constituted by a set of stable biological mechanisms. I subsequently argue that a theoretical and causal approach to classification would provide a superior method for classifying natural kinds than the purely descriptive approach adopted by the DSM since DSM-III. My argument (...) suggests that the DSM should classify natural kinds in order to provide predictively useful (i.e., projectable) diagnostic categories and that a causal approach to classification would provide a more promising method for formulating valid diagnostic categories. (shrink)

This research documents consumers’ potential to monitor corporations’ License to Operate through their consumption responses to corporate social responsibility failures. The premise is that the type of social contracts or standards in place may determine how consumers, through their individual and collective behaviors, can play a direct role in influencing corporate behavior, when corporations fail to meet social responsibility standards. An experiment conducted with a large sample of consumers in the United States shows that consumers respond differently to a (...) company’s failure in its social responsibilities depending on whether the violated standard is a government mandate or a voluntary commitment and depending on the consumers’ own environmental consciousness. The findings highlight the potential power of individual consumers and consumer collectives in narrowing the governance gaps relative to social and environmental issues and reducing the likelihood of CSR failures. (shrink)

Integrative Social Contracts Theory is a popular framework to assist managers in making decisions on international moral dilemmas. Although the theory has been praised for its comprehensiveness and sophistication, commentators have raised concerns regarding the justification and identification of substantive hypernorms, fundamental moral principles valid across cultures. This paper introduces the deliberative test, a new method for testing the cross-cultural validity of ethical norms in ISCT. The test relies on the concept of Deliberative Capacity, arising from new developments in (...) system-level deliberative democracy research, which studies deliberation at the level of national societies and over time. Based on this recent stream of research, the deliberative test has the potential of providing better guidance for managers to decide which norms to follow in case of conflicting standards between home and host countries. (shrink)

Psychiatric researchers typically assume that the modelling of psychiatric symptoms is not influenced by psychiatric categories; symptoms are modelled and then grouped into a psychiatric category. I highlight this primarily through analysing research domain criteria. RDoC’s importance makes it worth scrutinizing, and this assessment also serves as a case study with relevance for other areas of psychiatry. RDoC takes inadequacies of existing psychiatric categories as holding back causal investigation. Consequently, RDoC aims to circumnavigate existing (...) class='Hi'>psychiatric categories by directly investigating the causal basis of symptoms. The unique methodological approach of RDoC exploits the supposed lack of influence of psychiatric categories on symptom modelling, taking psychiatric symptoms as the same regardless of which psychiatric category is employed or if no psychiatric category is employed. But this supposition is not always true. I will show how psychiatric categories can influence symptom modelling, whereby identical behaviours can be considered as different symptoms based on an individual’s psychiatric diagnosis. If the modelling of symptoms is influenced by psychiatric categories, then psychiatric categories will still play a role, a situation which RDoC researchers explicitly aim to avoid. I discuss four ways RDoC could address this issue. This issue also has important implications for factor analysis, cluster analysis, modifying psychiatric categories, and symptom based approaches. (shrink)

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are ‘drug seeking’, ‘abusing’ and ‘diverting’ prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some (...) scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient–physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient–physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient–physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients’ subjective knowledge in enhancing physicians’ self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain. (shrink)

Psychiatric classification, as exemplified by the Diagnostic and Statistical Manual of Mental Disorders, is dealing with a lack of trust and credibility—in the scientific, but also in the public realm. Regarding the latter in particular, one possible remedial measure for this crisis in trust lies in an increased integration of patients into the DSM revision process. The DSM, as a manual for clinical practice, is forced to make decisions that exceed available data and involve value-judgments. Regarding such decisions, public (...) epistemic trustworthiness requires that these value-judgments should be representative of those of the affected public, and that the public has a reason to believe such a representation to be realized. Due to the long tradition of distrust in psychiatry, such a reason can in this case best be provided by an actual integration of patients into the decision-making process, rather than by their representation through scientific experts. (shrink)