ABSTRACTThis paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a ‘dual role’ dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has to be (...) balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register‐based epidemiology, lack of consent may be counter‐balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders. (shrink)

The vision of legendary criminologist Cesare Lombroso to use scientific theories of individual causes of crime as a basis for screening and prevention programmes targeting individuals at risk for future criminal behaviour has resurfaced, following advances in genetics, neuroscience and psychiatric epidemiology. This article analyses this idea and maps its ethical implications from a public health ethical standpoint. Twenty-seven variants of the new Lombrosian vision of forensic screening and prevention are distinguished, and some scientific and technical limitations are noted. Some (...) lures, biases and structural factors, making the application of the Lombrosian idea likely in spite of weak evidence are pointed out and noted as a specific type of ethical aspect. Many classic and complex ethical challenges for health screening programmes are shown to apply to the identified variants and the choice between them, albeit with peculiar and often provoking variations. These variations are shown to actualize an underlying theoretical conundrum in need of further study, pertaining to the relationship between public health ethics and the ethics and values of criminal law policy. (shrink)

This paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a 'dual role' dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has to be (...) balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register-based epidemiology, lack of consent may be counter-balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.3 (2002) 287-288 [Access article in PDF] Investigating Depersonalization Filip Radovic and Susanna Radovic The comments offered by Morris and Modigh in this issue give us an opportunity to clarify some of the views and topics discussed in our paper.One of Morris' objections is that we on some occasions characterize depersonalization complaints in a way that indicate delusion. Although one of the (...) criteria of depersonalization syndrome is intact reality testing (APA 2000), it is nevertheless the case that patients with depersonalization complaints may at the same time be delusional, a fact that Modigh also points out: "The border between unreality feelings with largely intact reality-testing ability and psychotic disorders with grossly disturbed reality-testing is, however, not absolute and patients with psychotic disorders may of course experience feelings of unreality or depersonalization."Morris is also critical of the idea that feelings of unreality in the quasi-sensory sense (or in sense [a3]) may tempt patients to doubt the reality of the items experienced as unreal. We suggest that the experience of the self or the world as unreal may actually give rise to an impulse to believe that the self or the world does not exist. This, however, need not imply that a person who has such a belief is delusional. For example, consider the following cases, which include patients with intense unreality feelings but who exhibit largely intact reality testing. One of Sierra and Berrios' (2000) patients says: "I have to touch myself to make sure that I have a body and a real existence." Lindqvist (1966, p. 171) describes two cases of the "mirror syndrome," which he recognizes as a typical behavior seen in cases of severe depersonalization. The patients want to confirm that they are real by looking in a mirror. Such cases strongly indicate that a person with otherwise intact reality testing can be so overwhelmed by feelings of unreality that he or she can come to doubt his or her own existence. The reason we do not want to call this state delusional is that the patient constantly tries to compare the experience of reality with some other mark of reality (e.g., by using a mirror), thus indicating that, on a higher cognitive level, he or she still understands that his or her belief may be incorrect. The image in the mirror works as an assurance that the fear of not existing is, after all, just a fear.Merleau-Ponty's (1962) description of Stratton's inverting spectacles experiment is indeed relevant to our analysis. The experiment seems to indicate that the feeling of unreality corresponds to the degree of unfamiliarity with seeing the world upside down. Stratton's subjects report that after a couple of days objects still appear inverted but less unreal than they did before. This seems to suggest that unreal in this circumstance approximates not normal. An inverted world is after some time accepted as normal. (See also note 3 in our paper.)Let us conclude with a few comments on an important methodological issue. Our methodological [End Page 287] approach is not equivalent with a classical ordinary language approach because our main concern is language use in psychiatric contexts. A classical ordinary language analysis aims to explicate how terms actually are used in everyday language; our primary concern is to try to understand the phenomenology underlying descriptions of felt unreality given by patients suffering from depersonalization. However, we do start by looking at the terms from an everyday angle, but this only gives us a coarse approximation of what the depersonalization patient may mean by such expressions. The strange and unpleasant phenomenology of the condition in combination with the variety of characteristic expressions make it likely that the role of unreal in connection with depersonalization complaints is quite different from its use in everyday language. When a person undergoes a depersonalization episode for the first time, he or she encounters a quite new and perhaps unexpected phenomenological reality. When the person attempts to describe these perplexing feelings he or she, naturally, uses terms found in everyday language, but the changed... (shrink)

The paper offers a conceptual and phenomenological analysis of the language of depersonalization. The depersonalization syndrome or disorder has no known common pathogenesis and shows no characteristic behavioral manifestations. A conceptual analysis of the key terms in the subjective complaints would therefore have consequences for clinical research into the phenomenon of depersonalization.

During the last couple of decades, so called representationalist theories of mind have gained increased popularity. These theories describe mental states in terms of representations of external objects and states of affairs. It is also often held that the content of a subject’s thoughts and perceptions is determined by facts outside her mind, such as social relations between her and other people and causal relations between her and external objects. Some representationalists even argue that the phenomenal character of perceptual experiences (...) is determined by external factors in the sense that the truth conditions of statements like: “it looks blue” involve such facts. This entails that so called “phenomenal properties” such as colours are not properties of my experiences or even determined by such properties. This thesis has been labelled “phenomenal externalism” by e.g., Fred Dretske1 and William Lycan2. Introspection has traditionally been described as a subject’s immediate awareness of her own experiences. It has been assumed that the subject has a special and privileged access to her experiences which means that she cannot be mistaken either about the content of her beliefs and experiences or about what they feel like to her. A long lived theory about introspection is that the introspective process is similar to perception, only the objects of the introspective process are “inner” instead of “outer”. This model seems to entail that experiences also share relevant similarities with external objects, such as having intrinsic properties, properties the subject is aware of when observing the objects in question. (shrink)

Poster presentation at "Toward a Science of Consciousness, Tucson III", April 27 - May 2 1998, Tucson, Arizona.

One kind of substantial critique which has been raised by several philosophers against the so called higher order perception theory , advocated for mainly by William Lycan, concerns the combination of two important claims: that qualia are wide contents of perceptual experiences, and that the subject becomes aware of what the world is like by perceiving her own experiences of the world. In what sense could we possibly watch our own mental states if they are representations whose content and qualitative (...) character is determined by factors that are external to the mind? And, furthermore, how can we become aware of what the world is like by means of this process? Fred Dretske says that all we could become aware of by this alleged activity are activities of the nervous system. But being aware of what e.g., a certain colour is like to us, does not seem to be the same as being aware of what a particular nervous activation pattern is like to us. Barry Maund points out that it is not ruled out that the representational vehicle and the representational object share some properties, nor that it is in virtue of having certain properties that a mental state has the content it does. If it were the case that the properties of the representational states showed some iconic resemblance relation to that which they represent, there could perhaps be some point in watching them. But again, we have little reason for thinking that this is the case. It seems improbable that an experience of red would be red, i.e., that the representational vehicle would have these properties. The important issue is: what features could the representational vehicle possibly have that would make it suitable as an object for inner sense and, in turn, would enable us to become aware of what it is like for us to perceive external objects by “looking” at the representation of these objects? I will explore these questions in this paper. (shrink)

Fatigue and increased fatigability occur as symptoms in almost every medical and psychiatric condition, as well as being common reactions to non pathological physical and psychological strain and stress. We will attempt to clarify the semantics of the terms "fatigue" and "fatigability", and we will put forward the hypothesis that the special kind of mental fatigability which characterises many cases of mild to moderate dysfunction of the brain is functional in a sense that it represents an overload of pathological information (...) (from the injured area) to higher cognitive mechanisms which may themselves be anatomically and physiologically intact. (shrink)

Forensic mental health services (FMHS) involve restricting certain individual rights to uphold or promote other ethical values – the restriction of liberty in various forms is justified with reference to health and safety of the individual and the community. The tension that arises from this has been construed as a hallmark of the practice and an ever-present quandary for practitioners. Stating this ethical dilemma upfront is a common point of departure for many texts discussing FMHS. But do we run the (...) risk of missing something important if setting the ethical scene rather than exploring it? This paper draws on interviews with three types of interested parties in mental health law proceedings – patients, psychiatrists and public defenders, and seeks to tease out what values are enacted when they describe and discuss experiences of FMHS and court proceedings. In doing so, we find emphasized values such as acceptance, telling it like it is, atonement, normality, and ensuring the future. We find that well-delineated and separate values are not necessarily the basis for decisions. We also find potential for explanation and guidance in bringing ethical discourse closer to everyday practice. (shrink)

This essay first outlines a philosophical theory of concepts and then applies it to two areas of relevance to psychiatrists, especially forensic psychiatrists. In the philosophical theory, the respective roles of verbal and non-verbal definitions are illuminated, and the importance of the phenomenon of division of semantic labour is stressed. It is pointed out that vagueness and ambiguity of a term often result when the term is used for several practical purposes at the same time. Such multi-purpose uses of terms (...) may explain both the current problems associated with the Swedish forensic-psychiatric concept of a severe mental disorder and some of the shortcomings of DSM-IV. 2009 Elsevier Ltd. All rights reserved. (shrink)

Since a couple of decades, the notion of a precautionary principle plays a central and increasingly influential role in international as well as national policy and regulation regarding the environment and the use of technology. Urging society to take action in the face of potential risks of human activities in these areas, the recent focus on climate change has further sharpened the importance of this idea. However, the idea of a precautionary principle has also been problematised and criticised by scientists, (...) scholars and policy activists, and been accused of almost every intellectual sin imaginable: unclarity, impracticality, arbitrariness and moral as well as political unsoundness. In that light, the very idea of precaution as an ideal for policy making rather comes out as a dead end. On the basis of these contrasting starting points, Christian Munthe undertakes an innovative, in-depth philosophical analysis of what the idea of a precautionary principle is and should be about. A novel theory of the ethics of imposing risks is developed and used as a foundation for defending the idea of precaution in environmental and technological policy making against its critics, while at the same time avoiding a number of identified flaws. The theory is shown to have far-reaching consequences for areas such as bio-, information- and nuclear technology, and global environmental policy in areas such as climate change. The author argues that, while the price we pay for precaution must not be too high, we have to be prepared to pay it in order to act ethically defensible. A number of practical suggestions for precautionary regulation and policy making are made on the basis of this, and some challenges to basic ethical theory as well as consumerist societies, the global political order and liberal democracy are identified. (shrink)

Societal decisions regarding the possible granting of permission for industrial and power plants, waste disposals, traffic routes and other facilities implementing modern science and technology (here simply called technology-decisions) often provoke debates regarding the risks involved. A main theme in these debates concerns the magnitudes of these risks and whether or not they are worth taking to reach some aim. This is also a main theme in traditional risk-analysis and critical discussions of risk-management. However, sometimes the fact that some people (...) do not want to be exposed to the risks in question has been suggested as an independent argument, i.e. regardless of the magnitudes of these risks. A well known phenomenon in this respect on the local and national level is what has been labelled "not in my backyard" (NIMBY), but the argument also has been used on an international level. In accordance, the view that unwanted risks are less acceptable than wanted or indifferent ones (regardless of their magnitudes) has been proposed as being highly relevant for technology-decisions. The paper explores to what extent there are good reasons for accepting such a proposal. The main part of the paper is devoted to an examination of the extent to which the view that unwanted risks are less acceptable than wanted ones can be supported by, on the one hand, welfare-based ethical theories underlying standard models for risk-analysis, such as utilitarianism, and, on the other, a moral requirement to respect the autonomy of individual persons. Also, the very concept of an unwanted risk is explored and some peculiarities are noted. It is argued that no categorical impermissibility of exposing people to unwanted risks can be supported. However, there are still good reasons for policy-makers to consider the degree to which risks are unwanted as a factor in technology-decisions that is relevant independently of the welfare-gains at stake. In particular, policy-makers should avoid paternalism in risk-management, i.e.. (shrink)

❙❙ Under den senare hälften av 1900-talet ökade möjligheterna att diagnostisera sjukdomar redan under fosterlivet. Ultra- SAMMANFATTAT ljudsdiagnostiken som började tillämpas på 1960-talet har förfinats alltmer. Idag genomgår nästan varje gravid kvinna..

This paper proposes a methodological redirection of the philosophical debate on artificial moral agency in view of increasingly pressing practical needs due to technological development. This “normative approach” suggests abandoning theoretical discussions about what conditions may hold for moral agency and to what extent these may be met by artificial entities such as AI systems and robots. Instead, the debate should focus on how and to what extent such entities should be included in human practices normally assuming moral agency and (...) responsibility of participants. The proposal is backed up by an analysis of the AMA debate, which is found to be overly caught in the opposition between so-called standard and functionalist conceptions of moral agency, conceptually confused and practically inert. Additionally, we outline some main themes of research in need of attention in light of the suggested normative approach to AMA. (shrink)

While other parts of medicine and health care seems traditionally to be primarily directed at preventing losses of bodily functions, repairing said functions in the case of such losses, or at least to provide ailment for unpleasant symptoms, sports medicine has allready from the beginning been involved with the project of enhancing bodily functions with regard to sports performance. First, when sports medicine involve itself in the traditional health care activity of prevention, therapy and ailment, the aim is often very (...) different from ordinary medical activities in that it tries to secure bodily functions far beyond what is required to reach what would normally be seen as a non-pathological state of a person. Second, sports medicine actively involves itself in the project of extending and enhancing human performance capacities through medical knowledge and technology. This raises several issues both with regard to medical ethics and the ethics of sports. For example, how should the goals of sports medicine be viewed from the perspective of rationing scarce health care resources? Should sports medicine be restricted by rules from the sports community as to which performance enhancing activities are tolerated in that sector? Or should sports medicine rather direct what is to be accepted within the world of sports? Both lines of reasoning are to be found in debates about, e.g., doping, controversial training methods and the potential use of gene technology in sports. The paper will address these issues and analyse them from a philosophical point of view. (shrink)

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We (...) demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose. (shrink)

This article is not about abortion, but rather about how one can reflect on abortion - in particular its moral and political status. My aim, however, is not to defend any particular position regarding such status, rather, I will try to say something comprehensible about how one can (and cannot) reason one's way from a stand regarding the morality of abortion to a stand on the issue of abortion policy.

The IOC and WADA have announced their ambition to develop control program in order to detect athletes' illegitimate use of genetic technology for enhancing performance. Although it is far from clear what such uses should be counted as illegitimate, as well as to what extent the idea of control programs for such things is a feasible idea, I will assume that such programs will concern so-called somatic genetic modifications that aims at altering the athlete's initial bodily biochemistry in a way (...) that may enhance performance without the presence of any medical reason for undertaking such modifications. This means that the envisioned control-program will have to make use of the method of genetic testing in order to detect the possible presence (or non-presence) of various genetic variants within the athlete. As a consequence of this, several ethical issues familiar within the field of genetic testing for health purposes are suddenly actualised within the area of doping control. These issues concern primarily how to handle and communicate the information about the athlete that is uncovered by such testing. However, due to the ways in which gene doping may be performed, in the case of atheletic control programs, issues of medical safety and the question of what hardships it is reasonable to require of athletes to endure also become paramount. As a consequence, one may ask whether or not sporting ethics will have to consider applying the rule of informed consent in connection to testing programs of the kind here discussed. (shrink)

Guest editorial to a special symposium on New Media and Risky Behavior of Children and Young People: Ethics and Policy Implications.

Medical genetic interventions can be performed in two ways. First, genetic defects may be repaired (gene therapy). Secondly, a possible future individual (an embryo or a possible combination of gametes) may be preselected because of its favourable genetic make-up (by using genetic diagnostic methods and procedures from reproductive medicine so called Preimplantation Genetic Diagnosis). The first kind of intervention means that someone gets medical treatment in the normal sense, however, the second kind does not. Rather, in that case, the potential (...) patient is exchanged for another individual who is in no need of treatment. The paper explores to what extent arguments for and against these kinds of genetic intervention apply equally to all of them. For example, may the benefits that can be achieved through gene therapy be equally well achieved through genetic preselection? Are fears of a resurrection of eugenic practices through gene technology more warranted regarding therapeutic interventions than regarding preselective ones (or vice versa)? Since genetic preselection is an intervention at the germ-line level and is presently clinically applied: How is it possible to motivate that clinical application of germ-line gene therapy is not similarily permitted? (shrink)

While health care goals are usually formulated in terms of the securing of good health for the population, the goal of public health is to an increasing extent, at least in Western countries, being formulated in terms of the provision of societal preconditions for securing of good health. This goal may be attained although no one enjoys good health as a result, namely if people choose not to make use of the preconditions provided. However, reaching this goal may still seem (...) desirable in that it promotes the autonomy of people with regard to health-related choices. In this presentation, I address the questions: 1) whether or not the promotion of autonomy may be supported as goal of public health on the basis of ethical theories dealing with autonomy, 2) whether this support is equally strong regardless of the economic, social and cultural conditions of different countries. I will argue that the first question may be answered affirmatively only if certain important revisions are made in the ethical theories in questions but that these revisions at the same time raise a number of very complicated issues in theory as well as in practice. Regarding the second question, I will claim that in so far as the goal of promoting autonomy may be morally justified, there are a number of reasons supporting the suggestion that this justification is much stronger in societal settings where reasonably high health and welfare levels are allready secured. (shrink)

This book involves an in-depth analysis of the ethical, political and philosophical issues related to health-oriented screening programs.

A new landscape of prenatal testing is presently developing, including new techniques for risk-reducing, non-invasive sampling of foetal DNA and drastically enhanced possibilities of what may be rapidly and precisely analysed, surrounded by a growing commercial genetic testing industry and a general trend of individualization in healthcare policies. This article applies a set of established ethical notions from past debates on PNT for analysing PNT screening-programmes in this new situation. While some basic challenges of PNT stay untouched, the new development (...) supports a radical individualization of how PNT screening is organized. This reformation is, at the same time, difficult to reconcile with responsible spending of resources in a publicly funded healthcare context. Thus, while the ethical imperative of individualization holds and applies to PNT, the new landscape of PNT provides reasons to start rolling back the type of mass-screening programmes currently established in many countries. Instead, more limited offers are suggested, based on considerations of severity of conditions and optimized to simultaneously serve reproductive autonomy and public health within an acceptable frame of priorities. The new landscape of PNT furthermore underscores the ethical importance of supporting and including people with disabilities. For the very same reason, no ban on what may be analysed using PNT in the new landscape should be applied, although private offers must, of course, conform to strict requirements of respecting reproductive autonomy and what that means in terms of counselling. (shrink)

This paper presents a systematic account of ethical issues actualised in different areas, as well as at different levels and stages of health care, by introducing organisational and other procedures that embody a shift towards person centred care and shared decision-making (PCC/SDM). The analysis builds on general ethical theory and earlier work on aspects of PCC/SDM relevant from an ethics perspective. This account leads up to a number of theoretical as well as empirical and practice oriented issues that, in view (...) of broad advancements towards PCC/SDM, need to be considered by health care ethics researchers. Given a PCC/SDM-based reorientation of health care practice, such ethics research is essential from a quality assurance perspective. (shrink)

We address the moral importance of fish, invertebrates such as crustaceans, snails and insects, and other animals about which there is qualified scientific uncertainty about their sentience. We argue that, on a sentientist basis, one can at least say that how such animals fare make ethically significant claims on our character. It is a requirement of a morally decent (or virtuous) person that she at least pays attention to and is cautious regarding the possibly morally relevant aspects of such animals. (...) This involves having a moral stance, in the sense of patterns of perception, such that one notices such animals as being morally relevant in various situations. For the person who does not already consider these animals in this way, this could be a big change in moral psychology, and can be assumed to have behavioural consequences, albeit indeterminate. Character has been largely neglected in the literature, which focuses on act-centred approaches (i.e. that the evidence on sentience supports, or does not support, taking some specific action). We see our character-centred approach as complementary to, not superior to, act-centred approaches. Our approach has the advantage of allowing us to make ethically interesting and practically relevant claims about a wider range of cases, but it has the drawback of providing less specific action guidance. (shrink)

While promoting population health has been the classic goal of public health practice and policy, in recent decades, new objectives in terms of autonomy and equality have been introduced. These different goals are analysed, and it is demonstrated how they may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in (...) different contexts. A basic conflict of perspective is handled by integrating the ideas of public health striving for health-related autonomy and equality, resulting in a prioritarian oriented population approach to health-related autonomy. This integrated goal is demonstrated to constrain itself in several ways attractive from the point of view of the classic goal, but several serious problems remain. For this reason, a model where all of the three goals are integrated into one coherent structure where they can be assigned varying degrees of importance relative to the level of population health is described. It is argued that this model avoids the problems set out earlier, and is actually normatively preferable to the classic goal alone. It is furthermore argued that the model may be employed as a useful tool for descriptive ethics, as well as a vehicle for international harmonisation of public health policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of public health resources are noted, as are a battery of questions for further research. (shrink)

So-called ‘existential risks’ present virtually unlimited reasons for probing them and responses to them further. The ensuing normative pull to respond to such risks thus seems to present us with r...

Antibiotic resistance, arising when bacteria develop defences against antibiotics, is creating a public health threat of massive proportions. This raises challenging questions for standard notions in bioethics when suitable policy is to be characterized and justified. We examine the particular proposal of expediting innovation of new antibiotics by cutting various forms of regulatory ‘red tape’ in the standard system for the clinical introduction of new drugs. We find strong principled reasons in favour of such a lowering of the ethical standards (...) of research and the clinical introduction of new antibiotic formulas. However, this support is undermined by pragmatic challenges owing to expected responses from stakeholders, creating uncertainty about which policies could actually be effectively implemented. We describe an underlying dilemma on how to rationally justify compromises between ideal ethical justification and pragmatic risks that needs to be further addressed in this light. We suggest a solution to this dilemma related to proposals of expediting antibiotic drug innovation. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

Parker’s article is a welcome attempt to address the importance of environmental sustainability in the realm of clinical ethics.1 We support the recent movement to seriously consider the environmental impact of healthcare institutions in bioethics.2 3 Still, we find two partly linked weaknesses of Parker’s analysis and guideline suggestion. These relate to a need in ‘green’ bioethics to see beyond the normal healthcare ethical focus on health-related values related to individual patients, and to primarily adopt institutional ways of framing central (...) decision problems. Traditional bioethics applies a restricted scope of values to assess clinical decisions: primarily health-related patient well-being (including life) and patient autonomy. If a decision improves (or, as in Parker’s inhaler case, maintains) a patient’s health-related well-being, this supports it. However, if a decision improves a patient’s non health-related well-being, say, winning a beauty contest or securing a job by having cosmetic surgery, it is not supported. And so on. This idea of healthcare as, in Michael Walzer’s classic terminology, a separate ‘sphere of justice’ has two interrelated limitations: it reflects a bias towards individual patients over other people, and it restricts the scope of values allowed to influence healthcare ethical judgements. These limitations appear once we see that the issue addressed by Parker can be framed either as prescription decisions taken by individual doctors against the background of …. (shrink)

In response to Koplin and Wilkinson, I argue, first, that the uncertain clinical prospects of human-pig chimera based transplantation makes the reason to spend resources for clarifying whether such practice might imply serious ethical breach due to enhanced cognitive capacities of the chimeras rather weak. T he benefits of further pursuing this avenue of research is so uncertain, so that taking even very unclear risks of serious ethical breach (thus in need of clarification for justification of the research) is not (...) worth the price in terms of spent resources, and therefore only limited resources should be spent to clarify such risk before the project is abandoned due to unacceptable risks. Second, I argue that as there are some reason to pursue this avenue further (and thus investigate the risk in question), the analogy to the notion of halting all farming of larger animals for food does not hold up. The reason is that we do not need to probe any further any comparable risk to know that such farming practices should be halted. A fundamental underlying issue to the question discussed by Koplin and Wilkinson1 in this paper is formulated when they write: > We should therefore be confident that human-pig chimeras would lack morally relevant cognitive capacities before setting out to use them as a source of transplantable human organs. This leaves open the question of how confident …. (shrink)

Antibiotic resistance is widely recognized as a major threat to public health and healthcare systems worldwide. Recent research suggests that pollution from antibiotics manufacturing is an important driver of resistance development. Using Sweden as an example, this article considers how industrial antibiotic pollution might be addressed by public actors who are in a position to influence the distribution and use of antibiotics in high-income countries with publicly funded health systems. We identify a number of opportunities for these actors to incentivize (...) industry to increase sustainability in antibiotics production. However, we also show that each alternative would create tensions with other significant policy goals, necessitating trade-offs. Since justifiable trade-offs require ethical consideration, we identify and explore the main underlying normative issues, namely, the weighing of local versus global health interests, the weighing of present versus future health interests, and the role of individualistic constraints on the pursuit of collective goals. Based on this analysis, we conclude that the actors have weighty principled reasons for prioritizing the goal of addressing pollution, but that translating this stance into concrete policy requires accommodating significant pragmatic challenges. (shrink)

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (...) (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

The Swedish solution to the legal handling of professional conscientious refusal in healthcare is described. No legal right to conscientious refusal for any profession or class of professional tasks exists in Sweden, regardless of the religious or moral background of the objection. The background of this can be found in strong convictions about the importance of public service provision and related civic duties, and ideals about rule of law, equality and non-discrimination. Employee's requests to change work tasks are handled on (...) a case-by-case basis within the frames of labour law, ensuring full voluntariness, and also employer's privilege regarding the organisation and direction of work, and duties of public institutions to provide services. Two complicating aspects of this solution related to the inclusion of ‘alternative medical’ service providers in a national health service, and professional insistence on conscientious refusal rights to accept legalised assisted dying are discussed. The latter is found to undermine the pragmatic reasons behind recent attempts by prolife groups to challenge the Swedish solution related to legal abortion in courts. (shrink)

The phenomenon of twinning in early fetal development has become a popular source for doubt regarding the ascription of moral status to early embryos. In this paper, the possible moral basis for such a line of reasoning is critically analysed with sceptical results. Three different versions of the argument from twinning are considered, all of which are found to rest on confusions between the actual division of embryos involed in twinning and the property of early embryos to be divisible, be (...) based on highly questionable ethical assumptions, or to imply inconsistent claims regarding the moral importance of potentiality and/or the moral status of embryos. This is taken to expose a number of related inconsistencies in the moral basis of pro-life positions. In particular, ascribing moral significance to the property of being (in)divisible is found to be incompatible with the claim that human individuals possess unique values which could underpin an absolute moral ban on murder. (shrink)

The ideal of scientific openness — i.e. the idea that scientific information should be freely accessible to interested parties — is strongly supported throughout the scientific community. At the same time, however, this ideal does not appear to be absolute in the everyday practice of science. In order to get the credit for new scientific advances, scientists often keep information to themselves. Also, it is common practice to withhold information obtained in commissioned research when the scientist has agreed with his (...) or her employer to do so. The secrecy may be intended for ever, as in the military area, but also temporarily until a patent application has been made. The paper explores to what extent such secrecy is undesirable, as seems to be suggested by the ideal of scientific openness. Should this ideal be interpreted as having certain exceptions which make the above-mentioned practices acceptable? Are there, on closer inspection, good arguments for the ideal of scientific openness, and for officially upholding it? Possible versions of the ideal of scientific openness are explored and the issue is found to be rather complex, allowing for wide variations depending on the acting parties, beneficiaries, types of information and moral requirements involved. We conclude that the arguments usually given in favour of this ideal are weaker than what seems to be generally believed, and that, on closer inspection, they leave plenty of room for exceptions to it. These exceptions only partly cover the actual practice of withholding scientific information, and there may still be good reason to advocate, teach and enforce the ideal of scientific openness within the scientific community. (shrink)

Human consumption of pharmaceuticals often leads to environmental release of residues via urine and faeces, creating environmental and public health risks. Policy responses must consider the normative question how responsibilities for managing such risks, and costs and burdens associated with that management, should be distributed between actors. Recently, the Polluter Pays Principle (PPP) has been advanced as rationale for such distribution. While recognizing some advantages of PPP, we highlight important ethical and practical limitations with applying it in this context: PPP (...) gives ambiguous and arbitrary guidance due to difficulties in identifying the salient polluter. Moreover, when PPP does identify responsible actors, these may be unable to avoid or mitigate their contribution to the pollution, only able to avoid/mitigate it at excessive cost to themselves or others, or excusably ignorant of contributing. These limitations motivate a hybrid framework where PPP, which emphasizes holding those causing large-scale problems accountable, is balanced by the Ability to Pay Principle (APP), which emphasizes efficiently managing such problems. In this framework, improving wastewater treatment and distributing associated financial costs across water consumers or taxpayers stand out as promising responses to pharmaceutical pollution from human use. However, sound policy depends on empirical considerations requiring further study. (shrink)

In recent years a principle for responsible risk-taking called "The Precautionarity Principle" (PP) has been put forward in several policy documents regarding risk-management of technological and environmental issues. PP involves two claims: 1. An ethical claim according to which it is irresponsible to, for example, use new technologies, regdless of how large benefits these are known to bring, unless it has been proven that they will not give rise to unacceptable long term risks. 2. An administrative/political claim according to which (...) the burden of supplying the proof spoken of in claim 1 is to be laid on the supplier of the new technology. This paper deals only with claim 1, which is the real "precautionarity claim". PP has produced much enthusiasm in different political circles, where it is often held out as a landmark for a new thinking in risk-management. However, while claim 2 is clear enough, it is rather obscure how the precautionarity claim is to be understood. In particular, it is not clear to what extent (if any) this claim implies anything new for risk-analysis. This is so since the precautionarity claim does not say anything about what is to be counted as a proof, or what constitutes an unacceptable risk. The paper explores different conlicting interpretations of the precautionarity claim and demonstrates how the choice between these actualise hard ethical issues. In particular, the issue of how much damage we are allowed to cause in order to pursue safety and certainty is discussed. This issue is actualized when new technologies with known beneficiary effects cannot be proven to be "safe enough" according to some interpretations of the precautionarity claim unless investigated for a rather long period of time, during which the technology is not allowed to be used to produce the beneficiary effects it can produce. This problem is structurally similar to a well known issue in medical ethics regarding the rsponsibility of continuing a controlled clinical trial of a drug known to cure when this means that half of the patients suffers extra agony and earlier death because they get a placebo instead of the new drug.. (shrink)

Standard versions of the requirement of informed consent state that patients who are offered to enter a clinical trial of a medical procedure should be informed about risks and possible benefits of this procedure (compared to available alternatives) in order to facilitate a rational decision whether or not to participate. However, in many real cases where new medical procedures are to be clinically tested for the first time the information available for such communication to prospective patients is very scarce, vague (...) and/or uncertain. This phenomenon is illustrated by the clinical introduction of new procedures in reproductive medicine, such as preimplantation genetic diagnosis (PGD). Regarding such procedures, it has ben argued that, in such cases, the quality of the available information may be too low for the obtaining of informed consent to be possible, even if it is successfully communicated. Others, instead, holds that informed consent may always be obtained regardless of the quality of the available information. Unfortunately, the standard litterature on informed consent give no clue as to which of these interpretations is correct. This issue is explored by connecting the concept of informed consent to ethical ideas of respect for autonomy and ideas of rational decision making. It is argued, first, that low quality of available information regarding the risks and possible benefits of a medical procedure may indeed make the obtaining of informed consent from patients to undergo this procedure impossible even in theory. However, it is also argued that whether or not this is the case must be relativized to the actual needs and deires of individual patients. Thus, regarding one and the same procedure, informed consent may be impossible to obtain from some patients due to the low quality of the available information regarding this procedure, but still be possible to obtain from other patients. (shrink)

We consider the implications for the ethical evaluation of research programs of two fundamental changes in the revised research ethical guideline of the Council for International Organizations of Medical Sciences. The first is the extension of scope that follows from exchanging “biomedical” for “health‐related” research, and the second is the new evaluative basis of “social value,” which implies new ethical requirements of research. We use the example of antibiotic resistance interventions to explore the need to consider the instances of what (...) we term the pragmatic risks of such interventions to evaluate the social value of certain kinds of health‐related research. These (pragmatic) risks severely threaten the social value of interventions in every area where human and social responses significantly impact on their effectiveness. Thus, the social value of health‐related research needed to demonstrate its effectiveness depends on the extent and successful management of such risks. Research designed to take into account the management of pragmatic risks also gives rise to similar types of risks, and the potential for social value in light of those risks needs to be considered in ethical reviews based on the new guidelines. We argue that, to handle this new expanded task, the international system of research ethical review addressed by the guidelines needs institutional development. (shrink)

Public health is often distinguished from heaslth care in that it is said to serve more 'collective' goals, such as 'the common good' rather than the good of individual people. However, it is not clear what this good is supposed to be (although it is supposed to be 'common'). In regular health care we see in the West a gradual expansion of traditional goals exclusively in terms of length and quality of life to goals having to do more with autonomy (...) - the ability of people to control and direct their own lives. This has lead to a number of questions regarding how such an ethical ideal of promotion of autonomy may be construed, whether or not it really is an ideal, what practical consequences it has etc. (shrink)

Effectiveness is a key criterion in assessing the justification of antibiotic resistance interventions. Depending on an intervention’s effectiveness, burdens and costs will be more or less justified, which is especially important for large scale population-level interventions with high running costs and pronounced risks to individuals in terms of wellbeing, integrity and autonomy. In this paper, we assess the case of routine hospital screening for multi-drug-resistant Gram-negative bacteria (MDRGN) from this perspective. Utilizing a comparison to screening programs for Methicillin-Resistant Staphylococcus aureus (...) (MRSA) we argue that current screening programmes for MDRGN in low endemic settings should be reconsidered, as its effectiveness is in doubt, while general downsides to screening programs remain. To accomplish justifiable antibiotic stewardship, MDRGN screening should not be viewed as a separate measure, but rather as part of a comprehensive approach. The program should be redesigned to focus on those at risk of developing symptomatic infections with MDRGN rather than merely detecting those colonised. (shrink)