In the face of environmental crises such as climate change, pollution and biodiversity loss—which all adversely impact on health—Gils-Schmidt and Salloch explore whether physicians can be justified in taking climate issues into account in clinical care.1 While their approach centres on the ‘climate-sensitive’ decisions, physicians can carry out on the micro-level of clinical decision-making, they encourage further discussions on how climate-related issues can be included across different levels of decision-making in healthcare. We propose a list of tasks and a model (...) to assist with navigating the range of factors and structural elements an environmentally sensitive ethics must address. Stephen Gardiner’s notion of a perfect moral storm is central to understanding these issues.2 Gardiner describes how a perfect moral storm occurs in the centre of three overlapping conditions for human action and policymaking in the face of climate change. This storm is driven by: (1) a lack of interest among current generations to meet global needs and accommodate the well-being of future generations, (2) a lack of ecological concerns for other parts of nature than humans and (3) weak ethical and political theories and institutions shaping policy decisions on issues with severe implications across borders and generations. Moreover, these conditions are embedded in the existing, complex world of ethically unjustified power imbalances and social injustice. The growing awareness of healthcare’s climate footprint has amplified and accelerated global, grassroots action to make healthcare more environmentally friendly. This includes incorporating environmental impacts into quality improvement methodologies, building communities of practice to explore how to make …. (shrink)

Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these (...) philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities. (shrink)

Translational ethics (TE) has been developed into a specific approach, which revolves around the argument that strategies for bridging the theory‐practice gap in bioethics must themselves be justified on ethical terms. This version of TE incorporates normative, empirical and foundational ethics research and continues to develop through application and in the face of new ethical challenges. Here, I explore the idea that the academic field of bioethics has not yet sufficiently analysed its own philosophical foundation for how it can, and (...) should, be practically relevant; neither has it comprehensively discussed the limitations on what impacts bioethicists should pursue. As a result, there has not been adequate training on how to suitably and appropriately impact real‐world practices. Moreover, bioethical perspectives are often competing with other strong interests, for example, economic and political, which may weaken their impact on policy‐making. The TE approach I propose can not only facilitate practical impacts of academic bioethics by being better informed by real‐world ethical issues but it also supports targeted and ethical justifications of the actual impact of academic work in real‐world contexts. In this paper, I clarify the premises for this TE approach, identify further challenges and sketch out potential solutions for the implementation of this methodological framework. (shrink)

Clinical ethical support services (CESS) represent a multifaceted field of aims, consultancy models, and methodologies. Nevertheless, the overall aim of CESS can be summed up as contributing to healthcare of high ethical standards by improving ethically competent decision-making in clinical healthcare. In order to support clinical care adequately, CESS must pay systematic attention to all real-life ethical issues, including those which do not fall within the ‘favourite’ ethical issues of the day. In this paper we attempt to capture a comprehensive (...) overview of categories of ethical tensions in clinical care. We present an analytical exposition of ethical structural features in judgement-based clinical care predicated on the assumption of the moral equality of human beings and the assessment of where healthcare contexts pose a challenge to achieving moral equality. The account and the emerging overview is worked out so that it can be easily contextualized with regards to national healthcare systems and specific branches of healthcare, as well as local healthcare institutions. By considering how the account and the overview can be applied to i) improve the ethical competence of healthcare personnel and consultants by broadening their sensitivity to ethical tensions, ii) identify neglected areas for ethical research, and iii) clarify the ethical responsibility of healthcare institutions' leadership, as well as specifying required institutionalized administration, we conclude that the proposed account should be considered useful for CESS. (shrink)

Volume 20, Issue 4, May 2020, Page 71-73.

There is a growing interest in comparison of international health care data with the hope that such studies will enable individual systems to learn from other systems. Such comparisons, however, presuppose that there exist common criteria for evaluating health care systems. The main thesis of this paper is that these comparative studies are misleading because they employ inappropriate operationalizations of these criteria because the operarionalizations are based upon mistaken global conceptualizations of the criteria in question. The essay provides a methodological (...) critique of what has been done and sets a new agenda for future research. (shrink)

The overall aim of this article is to discuss the organization of limit setting in healthcare in terms of legitimacy. We argue there is a strong ethical demand that such processes should be arranged to provide adversely affected people well-justified reasons to confer legitimacy to the processes despite favouring a different decision-making outcome. Two increasingly popular approaches, Accountability for Reasonableness (A4R) and Multi-Criteria Decision Analysis (MCDA), can both be applied to support legitimate decision-making processes. However, the role played by ‘fair-minded (...) people’ in the A4R framework can be shown to undermine an adequate conceptualization of legitimacy according to the ethical demand. We discuss and specify conditions enabling A4R to meet this ethical demand when being implemented in a real-world setting without having to renounce the aim of striving for ‘reasonableness’ and impartiality. The methodological approach MCDA describes how to arrange for transparent resource allocation. This approach does not encompass any normative guidance on how to shape limit settings in terms of ‘reasonableness’; it basically promotes ‘rational’ decisions. We discuss how this practical methodology can be integrated with the theoretical A4R framework to meet the ethical demand while at the same time promoting politically required impartiality of healthcare limit setting. (shrink)

Denne artikkelen tar utgangspunkt i et skille mellom samfunnsstrukturer som avgrenser legers skjønnsmessige utfoldelse på den ene siden, og profesjonens tilrettelegging for kultiveringen av erkjennelsesmessige ferdigheter på den annen. Ved å videreføre H. Grimen og A. Molanders anvendelse av S.E. Toulmins modell for praktisk resonnering i en klinisk kontekst redegjør jeg for legeskjønnets multidimensjonale, epistemiske struktur. Gjennomgangen viser hvordan skjønnsanvendelse i legerollen kan analyseres i henhold til en fagteknisk, en distributiv og en relasjonell dimensjon. Mot denne bakgrunnen diskuterer jeg så (...) spenninger som oppstår i skjæringspunktet mellom strukturering og kultivering av skjønnets ulike dimensjoner. Diskusjonen tydeliggjør at den medisinske profesjonen ikke kan betraktes som en selvtilstrekkelig premissleverandør når det gjelder å sikre adekvat kultivering av medlemmenes skjønnsutøvelse i en klinisk kontekst. Ved å synliggjøre og vektlegge de relevante profesjonseksterne bidragene i profesjonens pågående selvregulering kan befolkningens berettigete tillit til profesjonen styrkes ytterligere.Nøkkelord: strukturelt skjønn, epistemisk skjønn, profesjon, selvregulering, tillitEnglish summary: In Between Structures of Society and Profession: On Delimitation, Cultivation and Premises for Adequately Exercising Judgment in the Role as PhysicianThe point of departure of this article is a distinction between societal structures that delimit the discretion of the physician on the one hand and the profession's arrangements for the cultivation of the physician's judgment on the other. By developing H. Grimen and A. Molander's application of S.E. Toulmin's model for practical reasoning in a clinical context, the multi-dimensional epistemic structure of the physician's judgment in terms of technical, distributive, and relational judgment is accounted for. Against this backdrop, tensions emerging in the intersection between delimitation and cultivation of professional judgment in its various dimensions are discussed. The discussion clarifies that the medical profession is not a self-sufficient provider when it comes to ensuring an adequate cultivation of its members' judgment in a clinical context. It is argued that by emphasising and implementing the relevant external contributions to the profession's ongoing self-regulation, the public's justified trust in the medical profession can be strengthened. (shrink)

On Ramchandra Dattatraya Ranade, 1886-1957, educationist and Indic philosopher.

I Norge er ikke surrogati tillatt, og myndighetene fraråder norske statsborgere å benytte seg av surrogati i utlandet. I denne artikkelen fokuserer vi på kommersiell gestational surrogati og stiller spørsmålet: Bør man tillate at norske statsborgere benytter seg av surrogati i India? De etiske problemstillingene rundt surrogati er mange og sammensatte og blir spesielt utfordrende når tjenesten tilbys i et land med store kulturelle og økonomiske forskjeller både internt og i forhold til Norge. Vi baserer analysen og drøftingen av dette (...) etisk utfordrende spørsmålet på Beauchamps og Childress sin veletablerte metodiske tilnærming innen biomedisinsk etikk. Vi anvender de fire allmennmoralske prinsipper: respekt for autonomi, velgjørenhet, ikke-skade og rettferdighet på sakskomplekset for å synliggjøre spenningene involvert i dette etiske dilemmaet. Med full bevissthet om at det ikke finnes noen lettvinte og omkostningsfrie løsninger på dilemmaer generelt og dette spesielt, konkluderer vi med at interessene til de berørte parter, og spesielt surrogatmødrenes, kan bli bedre ivaretatt om surrogati tillates under omfattende reguleringer. Dersom man velger å gjøre praksisen illegal, vil man også miste mulighetene til å påvirke prosessen og sikre rettighetene til de involverte partene.Nøkkelord: surrogati, Norge–India, utnyttelse, autonomi, regulering av prosessenEnglish summary: Should Norwegian citizens be permitted to use surrogacy in India?Surrogacy is not permitted in Norway, and the government strongly advises against Norwegian citizens travelling abroad to have children through the use of the surrogacy industry. In this article, we focus on commercial gestational surrogacy and debate the question: Should Norwegian citizens be permitted to use surrogacy in India? The ethical concerns regarding surrogacy are complex and are especially challenging when the service is offered in a country with big cultural and economic differences both internal and in comparison to Norway. We base our analysis of this ethical, challenging question on Beauchamp’s and Childress’s well-established approach within biomedical ethics. We apply the four principles of respect for autonomy, beneficence, nonmaleficence and justice to shed light on the conflicts of interests in this ethical dilemma. With full awareness that there are no simple and correct solutions to dilemmas in general and on this issue, especially, our conclusion is that the interests of the involved parties, and especially those of the surrogate mothers, might be better attended to if surrogacy is allowed with extensive regulations. If this practice is made illegal, the opportunity to influence the process and secure the rights of the involved parties is lost. (shrink)

This article presents a new criticisms of reductive approaches to knowledge-‘wh’ (i.e., those approaches on which whether one stands in the knowledge-‘wh’ relation to a question is determined by whether one stands in the knowledge-‘that’ relation to some answer(s) to the question). It argues in particular that the truth of a knowledge-‘wh’ attribution like ‘Janna knows where she can buy an Italian newspaper’ depends not only on what Janna knows about the availability of Italian newspapers, but on what she believes (...) about the matter. This dependence of Janna's knowledge-‘wh’ on her (possibly false) beliefs is incompatible with the reductive approach. (shrink)

ABSTRACT In this paper, I address some of the shortcomings of established clinical ethics centring on personal autonomy and consent and what I label the Doctrine of Respecting Personal Autonomy in Healthcare. I discuss two implications of this doctrine: 1) the practice for treating patients who are considered to have borderline decision‐making competence and 2) the practice of surrogate decision‐making in general. I argue that none of these practices are currently aligned with respectful treatment of vulnerable individuals. Because of ‘structural (...) arbitrariness’ in the whole process of how we assess decision‐making competence, this area is open to disrespectful treatment of people. The practice of surrogate decision‐ making on the basis of a single person's judgment is arguably not consistent with ethical and political requirements derived from the doctrine itself. In response to the inadequacies of the doctrine, I suggest a framework for reasonableness in surrogate decision‐making which might allow practice to avoid the problems above. I conclude by suggesting an extended concept of Patient Autonomy which integrates both personal autonomy and the regulative idea of morality that is required by reasonableness in deciding for non‐competent others. (shrink)

Translational research in medicine requires researchers to identify the steps to transfer basic scientific discoveries from laboratory benches to bedside decision-making, and eventually into clinical practice. On a parallel track, philosophical work in ethics has not been obliged to identify the steps to translate theoretical conclusions into adequate practice. The medical ethicist A. Cribb suggested some years ago that it is now time to debate ‘the business of translational’ in medical ethics. Despite the very interesting and useful perspective on the (...) field of medical ethics launched by Cribb, the debate is still missing. In this paper, I take up Cribb’s invitation and discuss further analytic distinctions needed to base an ethics aiming to translate between theory and practice. (shrink)

In 2014, the editorial board of BMC Medical Ethics came together to devise sections for the journal that would give structure to the journal help ensure that authors’ research is matched to the most appropriate editors and help readers to find the research most relevant to them. The editorial board decided to take a practical approach to devising sections that dealt with the challenges of content management. After that, we started thinking more theoretically about how one could go about classifying (...) the field of medical ethics. This editorial elaborates and reflects on the practical approach that we took at the journal, then considers an alternative theoretically derived approach, and reflects on the possibilities, challenges and value of classifying the field more broadly. (shrink)

Open peer commentary on the article “Radical Constructivist Structural Design Education for Large Cohorts of Chinese Learners” by Christiane M. Herr. Upshot: In this comment, I take Herr’s proposition for a constructivist-informed pedagogy for structural design education to extract initial ideas for a framework for a constructivist pedagogy, a framework focused on the decision-making of a constructivist teacher. I enhance this initial framework with initial findings of a study I conducted with a constructivist mathematics teacher.

Progress in recombinant DNA technology and in mapping of the human genome makes it possible to diagnose genetic defects as early as 8–10 weeks after conception for an increasing number of genetic diseases. Further developments will bring wider applicability and increased sensitivity, making widespread application of this type of diagnosis possible. Logistical and ethical problems will however arise in the course of this development.

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to be met in order to ensure (...) that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework. (shrink)