Matthé Scholten

According to the “discrimination argument,” it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe two distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread “joint” approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy‐based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence‐ and autonomy‐based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS.

This study explores how qualitative health researchers navigate the demands of medical research ethics committees in Germany where qualitative research is subject to approval only when it is conducted in medical contexts. We present the results of a grounded theory study to investigate qualitative health researchers’ experiences with procedural ethics and the strategies they adopt to navigate its demands. Our analysis revealed six dimensions of experience and three strategies adopted by researchers to navigate the demands of medical research ethics committees. All participants agreed that research ethics is of high importance in qualitative health research, but strategies to navigate the demands of medical research ethics committees ranged from avoiding, and adapting, to transforming the procedures of ethics review. Based on our findings, we provide recommendations for improving the ethics review of qualitative health research.

The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as “procedural ethics” and the identification and handling of ethical issues by researchers during the research process as “ethics in practice.” While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.

Background Self-binding directives (SBDs) are psychiatric advance directives that include the possibility for service users to consent in advance to compulsory care in future mental health crises. Legal provisions for SBDs exist in the Netherlands since 2008 and were updated in 2020. While ethicists and legal scholars have identified several benefits and risks of SBDs, few data on stakeholder perspectives on SBDs are available. Aims The aim of the study was to identify opportunities and challenges of SBDs perceived by stakeholders who have personal or professional experience with legally enforceable SBDs. Methods Data collection was carried out in the Netherlands from February 2020 to October 2021 by means of semi-structured interviews. Participants were selected through purposive sampling and snowball methods. Interviews were conducted with mental health service users (n = 7), professionals (n = 13), and an expert on SBD policy (n = 1), resulting in a total number of 21 interviews. The data were analyzed thematically. Results Perceived benefits of SBDs included increased autonomy, improvement of the therapeutic relationship, possibility of early intervention and prevention of harm, prevention of compulsory care, reduction of the duration of compulsory care and recovery, mitigation of negative experiences around compulsory care, and guidance for professionals in providing compulsory care. Perceived risks included infeasibility of SBD instructions, difficulty in decision-making around SBD activation, limited accessibility of SBDs, disappointment of service users due to non-compliance with SBDs, and limited evaluation and updating of SBD content. Barriers to SBD completion included lack of knowledge of SBDs among professionals, lack of motivation or insight among service users, and lack of professional support for SBD completion. Facilitators of SBD completion and activation included support for SBD completion, involvement of relatives and peer experts, specification of SBD content, and evaluation of compulsory care and SBD content. The new legal framework was regarded as having both positive and negative effects on SBD implementation. Conclusions Stakeholders who have personal or professional experience with legally enforceable SBDs perceive SBDs as having important benefits and tend not to articulate the fundamental ethical concerns about SBDs which can be found in the ethics and legal literature. Instead, they perceive ethical and practical challenges that can be addressed through the implementation of suitable safeguards.

In this paper, I show that Kant’s solution to the third antinomy is a reply sui generis to the consequence argument. If sound, the consequence argument yields that we are not morally responsible for our actions because our actions are not up to us. After expounding the modal version of the consequence argument advanced by Peter van Inwagen, I show that Kant accepts a key inference rule of the argument as well as a requirement of alternate possibilities for moral blame. Kant must therefore reject one of the premises of the consequence argument to be able to deny its conclusion. Whereas Kantian altered-past compatibilism denies the premise of the consequence argument which states the fixity of the past, Kantian altered-law compatibilism denies the premise that states the fixity of the laws of nature. My analysis shows that Kantian altered-past and altered-law compatibilism are logically consistent, yet it also reveals that they depend on strong metaphysical premises. It must be investigated whether these premises withstand textual scrutiny and whether they are credible in their own right. By way of conclusion, I draw the outlines of this investigation.

According to what we propose to call “the competence model,” competence is a necessary condition for valid informed consent. If a person is not competent to make a treatment decision, the decision must be made by a substitute decision-maker on her behalf. Recent reports of various United Nations human rights bodies claim that article 12 of the Convention on the Rights of Persons with Disabilities involves a wholesale rejection of this model, regardless of whether the model is based on a status, outcome, or functional approach to competence. The alleged rationale of this rejection is that denying persons the right to make their own treatment decisions based on an assessment of competence necessarily discriminates against persons with mental disorders. Based on a philosophical account of the nature of discrimination, we argue that a version of the competence model that combines supported decision-making with a functional approach to competence does not discriminate against persons with mental disorders. Furthermore, we argue that status- and outcome-based versions of the competence model are discriminatory.

In this paper, I demonstrate that Kant's commitment to an asymmetry between the control conditions for praise and blame is explained by his endorsement of the principle Ought Implies Can (OIC). I argue that Kant accepts only a relatively weak version of OIC and that he is hence committed only to a relatively weak requirement of alternate possibilities for moral blame. This suggests that whether we are transcendentally free is irrelevant to questions about moral permissibility and moral blameworthiness.

Definition of the problem The reform of German guardianship law coming into force in 2023 will remove the term “well-being” from the law. This is intended to emphasise that the legal guardian should be guided by the subjective wishes of the person rather than by an objective understanding of well-being. This article analyses the understanding of well-being underlying the reformed guardianship law in comparison to common conceptions of well-being in philosophy and medical ethics, aiming to promote interdisciplinary understanding between ethics and law. Arguments The justification for the reform emphasises that the law is based on a subjective understanding of well-being. However, this understanding does not correspond to philosophical subjective theories of well-being, according to which only things that a person desires can contribute to her well-being. In contrast, the guardianship law assumes that the fulfilment of certain wishes can lead to objective harm to the person and thus impair her well-being. Negative consequences for the objective well-being of a person are only relevant insofar as they indicate a limit to following current wishes that are based on a natural will and are not an expression of self-determination. Conclusion While the term “well-being” is removed from reformed guardianship law, the law implicitly contains an understanding of well-being comparable to a hybrid conception of well-being from a medical ethics perspective. According to this conception, fulfilment of a person’s wishes generally contributes to her well-being, although certain objective criteria are also taken into consideration.

Definition of the problem The reform of German guardianship law coming into force in 2023 will remove the term “well-being” from the law. This is intended to emphasise that the legal guardian should be guided by the subjective wishes of the person rather than by an objective understanding of well-being. This article analyses the understanding of well-being underlying the reformed guardianship law in comparison to common conceptions of well-being in philosophy and medical ethics, aiming to promote interdisciplinary understanding between ethics and law. Arguments The justification for the reform emphasises that the law is based on a subjective understanding of well-being. However, this understanding does not correspond to philosophical subjective theories of well-being, according to which only things that a person desires can contribute to her well-being. In contrast, the guardianship law assumes that the fulfilment of certain wishes can lead to objective harm to the person and thus impair her well-being. Negative consequences for the objective well-being of a person are only relevant insofar as they indicate a limit to following current wishes that are based on a natural will and are not an expression of self-determination. Conclusion While the term “well-being” is removed from reformed guardianship law, the law implicitly contains an understanding of well-being comparable to a hybrid conception of well-being from a medical ethics perspective. According to this conception, fulfilment of a person’s wishes generally contributes to her well-being, although certain objective criteria are also taken into consideration.

The aim of this paper is to shed light on the complex relations between friendship and blame. In the first part, I show that to be friends is to have certain evaluative, emotional and behavioral dispositions toward each other, and distinguish between two kinds of norms of friendship, namely friendship-based obligations and friendship-constituting rules. Friendship-based obligations tag actions of friends as obligatory, permissible or wrong, whereas friendship-constituting rules specify conditions that, if met, make it so that two persons stand in a particular type of relationship defined by various friendship-based obligations. I argue that whereas friendship-based obligations apply to actions under direct voluntary control, friendship-constituting rules apply to emotional and evaluative attitudes. The second part develops an account of friendship blame by comparing Scanlon’s account of blame with Wallace’s Strawsonian account of blame. I demonstrate that Scanlon’s account picks out responses that become appropriate when friends’ attitudes are not in agreement with friendship-constituting rules, whereas Wallace’s account picks out responses that become appropriate when friends violate friendship-based obligations. Arguing that the responses picked out by Scanlon’s account do not amount to blame, I show that, when combined, the views give an illuminating picture of possible reactions to friends who fall short of the standards of friendship.

The aim of this paper is to situate Kant in the debate on free will. Whereas Kantians often assume that Kant's views on free will cannot be brought under any of the headings of this debate, contemporary free will theorists commonly assume that Kant is an incompatibilist of the libertarian type. I argue against both assumptions: Kant can and should be characterized as a compatibilist and more specifically as a soft determinist. After removing some persistent misconceptions about Kant's position in the free will debate, I contend that Kant affirms the truth of determinism, that he rejects the possibility of libertarian free will and that he considers the sort of freedom required for moral responsibility to be compatible with determinism.

It is a common picture that Kant is committed to an uncompromising account of moral responsibility that leaves no room for excuses. I argue that this picture is mistaken. More specifically, I reconstruct a Kantian quality of will account of excuses according to which an agent is excused for performing a morally wrong (or omitting a morally obligatory) action if and only if the action (or omission) does not manifest a lack of good will on the part of the agent. Based on this Kantian quality of will account of excuses, I explain why agents are often excused in cases that involve physical constraint, unintentional bodily movement, ignorance, coercion or necessity.

In this paper, I give a reconstruction of the so‐called Reinhold–Sidgwick objection and show that Korsgaard‐style Kantian constructivists are committed to two key premises of the underlying argument. According to the Reinhold–Sidgwick objection, the Kantian conception of autonomy entails the absurd conclusion that no one is ever morally responsible for a morally wrong action. My reconstruction of the underlying argument reveals that the objection depends on a third premise, which says that freedom is a necessary condition for moral responsibility. After mapping the common replies to the objection, I demonstrate that none of these replies is available to Kantian constructivists. But they need not be committed to the absurd conclusion that no one is ever morally blameworthy. Kantian constructivists who want to resist the Reinhold–Sidgwick objection are well advised to subject the third premise of the underlying argument to critical scrutiny.

The fourth amendment to the German Medicinal Products Act (Arzneimittelgesetz) states that nontherapeutic research in incompetent populations is permissible under the condition that potential research participants expressly declare their wish to participate in scientific research in an advance research directive. This article explores the implementation of advance research directives in Germany against the background of the international legal and ethical framework for biomedical research. In particular, it addresses a practical problem that arises from the disclosure requirement for advance research directives. We show that, if the disclosure standard for advance research directives is set at a token level, nontherapeutic research in incompetent populations becomes practically impossible. To resolve this issue, we suggest the disclosure standard be set at a type level.

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making.

In this paper, I give a Kantian answer to the question whether and why it would be inappropriate to blame people suffering from mental disorders that fall within the schizophrenia spectrum. I answer this question by reconstructing Kant’s account of mental disorder, in particular his explanation of psychotic symptoms. Kant explains these symptoms in terms of various types of cognitive impairment. I show that this explanation is plausible and discuss Kant’s claim that the unifying feature of the symptoms is the patient’s inability to enter into an exchange of reasons with others. After developing a Kantian Quality of Will Thesis, I analyze some real life cases. Firstly, I argue that delusional patients who are unable to enter into an exchange of epistemic reasons are exempted from doxastic rather than moral responsibility. They are part of the moral community and exonerated from moral blame only if their actions do not express a lack of good will. Secondly, I argue that disorganized patients who are unable to form intentions and to make plans are exempted from moral responsibility because they do not satisfy the conditions for agency