Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same (...) way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications. (shrink)

Intensive research is carried out to develop a disease-modifying drug for Alzheimer’s disease. The development of drug candidates that reduce Aß or tau in the brain seems particularly promising. However, these drugs target people at risk for AD, who must be identified before they have any, or only moderate, symptoms associated with the disease. There are different strategies that may be used to identify these individuals. Each of these strategies raises different ethical challenges. In this paper, we analyse these challenges (...) in relation to the risk stratification for AD necessary for using these drugs. We conclude that the new drugs must generate large health benefits for people at risk of developing AD to justify the ethical costs associated with current risk stratification methods, benefits much larger than current drug candidates have. This conclusion raises a new set of ethical questions that should be further discussed. No data are available. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in (...) Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care need with a starting (...) point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that (...) public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification. (shrink)

In this paper we explore the relation between health-care needs and patients’ desires within shared decision-making in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out and discuss a number of queries which seem to (...) arise due to the double focus on a patient’s need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine. (shrink)

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition‐specific severity). In this paper I argue that giving priority to the worse off in terms of condition‐specific severity does not reflect the morally relevant sense of being (...) worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity). (shrink)

How to handle orphan drugs for rare diseases is a pressing problem in current health-care. Due to the group size of patients affecting the cost of treatment, they risk being disadvantaged in relation to existing cost-effectiveness thresholds. In an article by Niklas Juth it has been argued that it is irrelevant to take indirectly operative factors like group size into account since such a compensation would risk discounting the use of cost, a relevant factor, altogether. In this article we analyze (...) Juth’s argument and observe that we already do compensate for indirectly operative factors, both outside and within cost-effectiveness evaluations, for formal equality reasons. Based on this we argue that we have reason to set cost-effectiveness thresholds to integrate equity concerns also including formal equality considerations. We find no reason not to compensate for group size to the extent we already compensate for other factors. Moreover, groups size implying a systematic disadvantage also on a global scale, i.e. taking different aspects of the health condition of patients suffering from rare diseases into account, will provide strong reason for why group size is indeed relevant to compensate for. (shrink)

In recent years, the issue of accepting a higher cost per health improvement for orphan drugs has been the subject of discussion in health care policy agencies and the academic literature. This article aims to provide an analysis of broadly egalitarian arguments for and against accepting higher costs per health improvement. More specifically, we aim to investigate which arguments one should agree upon putting aside and where further explorations are needed. We identify three kinds of arguments in the literature: considerations (...) of substantial equality, formal equality, and opportunity cost. We argue that considerations of substantial equality do not support higher costs per health improvement orphan drugs, even if such considerations are considered valid. On the contrary, arguments of formal equality may support accepting a higher cost per health improvement for orphan drugs. However, in order to do so, a number of both normative and empirical issues must be resolved; these issues are identified in the article. For instance, it must be settled to what extent the opportunity cost in terms of foregone health for other patients is acceptable in order to uphold formal equality. We conclude that certain arguments can be set aside, and future focus should be put on the unresolved normative and empirical issues related to formal equality and opportunity cost. (shrink)

In a recent extended essay, philosopher Daniel Hausman goes a long way towards dismissing severity as a morally relevant attribute in the context of priority setting in healthcare. In this response, we argue that although Hausman certainly points to real problems with how severity is often interpreted and operationalised within the priority setting context, the conclusion that severity does not contain plausible ethical content is too hasty. Rather than abandonment, our proposal is to take severity seriously by carefully mapping the (...) possibly multiple underlying accounts to well-established ethical theories, in a way that is both morally defensible and aligned with the term’s colloquial uses. (shrink)

It is uncontroversial to claim that the extent to which health care interventions benefit patients is a relevant consideration for health care priority setting. However, when effects accrue to the individual patient, effects of a more indirect kind may accrue to other individuals as well, such as the patient's children, friends, or partner. If, and if so how, such relational effects should be considered relevant in priority setting is contentious. In this paper, we illustrate this question by using disease‐modifying drugs (...) for Alzheimer's disease as a case in point. The ethical analysis begins by sketching the so‐called prima facie case for ascribing moral weight to relational effects and then moves on to consider a number of objections to it. We argue that, whereas one set of objections may be dismissed, there is another set of arguments that poses more serious challenges for including relational effects in priority setting. (shrink)

In Gustavsson et al,1 we discussed the ethical issues that arise when identifying the relevant population for disease-modifying drugs targeting Alzheimer disease. More specifically, we focused on novel immunotherapies aimed at amyloid β and tau, two relevant biomarkers. The commentaries to our paper2 3 acknowledge our conclusion: screening for AD involve ethical costs that cannot be justified unless a drug with clinically relevant effect becomes available. Since Aduhelm is the only immunotherapy targeting AD currently approved by the Food and (...) Drug Administration, we use that as a …. (shrink)

Background Genetic testing is moving from targeted investigations of monogenetic diseases to broader testing that may provide more information. For example, recent health economic studies of genetic testing for an increased risk of breast cancer suggest that it is associated with higher cost-effectiveness to screen for pathogenic variants in a seven gene panel rather than the usual two gene test for variants in BRCA1 and BRCA2. However, irrespective of the extent to which the screening of the panel is cost-effective, there (...) may be ethical reasons to not screen for pathogenic variants in a panel, or to revise the way in which testing and disclosing of results are carried out. Main text In this paper we discuss the ethical aspects of genetic testing for an increased risk of breast cancer with a special focus on the ethical differences between screening for pathogenic variants in BRCA1/2 and a seven gene panel. The paper identifies that the panel increases the number of secondary findings as well as the number of variants of uncertain significance as two specific issues that call for ethical reflection. Conclusions We conclude that while the problem of handling secondary findings should not be overstated with regard to the panel, the fact that the panel also generate more variants of uncertain significance, give rise to a more complex set of problems that relate to the value of health as well as the value of autonomy. Therefore, it is insufficient to claim that the seven gene panel is preferable by only referring to the higher cost effectiveness of the panel. (shrink)

Granulocyte transfusions have been administered to patients with life-threatening infections for more than five decades. However, to what extent this should be the case is far from established. On the one hand, the clinical effects of these transfusions are difficult to prove in clinical studies, and the donors of granulocytes may be exposed to certain risks. On the other hand, clinical experience seems to support the idea that granulocyte transfusions do play an important role for severely ill patients, and the (...) donors are primarily motivated by altruistic reasons. In this paper, we first discuss the ethical issues that arise from the fact that there is a conflict between clinical experience and the results from the attempts to perform randomized control trials, and second, the risk/benefit assessment that has to be made between two different parties, namely the recipient and the donor of granulocyte transfusions. (shrink)

Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that (...) are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries. (shrink)

This article has two main divisions, the first consisting in parts 1-3, the second in parts 4-8. The purpose of the first division is to assess Hauerwas's contentions regarding what he takes to be serious debilities in modern theological culture. The objects of Hauerwas's criticism are: (1) natural theology; (2) reason as it is represented in the structure of the modern university and in the "Enlightenment Project"; and (3) liberal Protestantism--the latter particularly as it turns up, by his account, in (...) Reinhold Niebuhr's theology. The article will offer a defense of natural theology and an alternative approach to Niebuhr's theology while showing how Hauerwas's contentions concerning these two matters are mistaken. Parts 4-8 are theological studies. These studies concentrate on selected though main aspects of Hauerwas's outlook. Part 4 concerns a problematic implication of the notion, mainly from Barth, of divinity's humanity; Part 5 a note of difficulty from William James about the idea of the theistic God and its pertinence to the Barthian or Hauerwasian God; Part 6 the relation between belief and witness; Part 7 theology's discourse and analogy; Part 8 the Barthian-Hauerwasian theology as a metaphysics. Part 1, concerning natural theology, stands over both divisions. These observations are not in the main intended as textual studies, though in certain passages the analysis is closely attentive to Hauerwas's text. Also, the paper does not offer the sort of account that would come from a historian, intellectual biographer, or social or cultural analyst or critic. Its focus is philosophical-theological criticism. (shrink)

An energy condition, in the context of a wide class of spacetime theories, is, crudely speaking, a relation one demands the stress-energy tensor of matter satisfy in order to try to capture the idea that "energy should be positive". The remarkable fact I will discuss in this paper is that such simple, general, almost trivial seeming propositions have profound and far-reaching import for our understanding of the structure of relativistic spacetimes. It is therefore especially surprising when one also learns that (...) we have no clear understanding of the nature of these conditions, what theoretical status they have with respect to fundamental physics, what epistemic status they may have, when we should and should not expect them to be satisfied, and even in many cases how they and their consequences should be interpreted physically. Or so I shall argue, by a detailed analysis of the technical and conceptual character of all the standard conditions used in physics today, including examination of their consequences and the circumstances in which they are believed to be violated. (shrink)

Beyond Human is an informative and accessible guide for all those interested in the developing sciences of genetic engineering, bioprinting, and human cloning. Illustrating the ideas with reference to well-known science fiction films and novels, the author provides a unique insight into and understanding of how genetic manipulation, cloning, and other novel bio-technologies will one day allow us to redesign our species. It also addresses the legitimate concerns about "playing God", while at the same time embracing the positive aspects of (...) the scientific trajectory that will lead to our transhuman future. (shrink)

Many believe that objective morality requires a theistic foundation. I maintain that there are sui generis objective ethical facts that do not reduce to natural or supernatural facts. On my view, objective morality does not require an external foundation of any kind. After explaining my view, I defend it against a variety of objections posed by William Wainwright, William Lane Craig, and J. P. Moreland.

The standard way of representing an epistemic state in formal philosophy is in terms of a set of sentences, corresponding to the agent’s beliefs, and an ordering of those sentences, reflecting how well entrenched they are in the agent’s epistemic state. We argue that this wide-spread representational view – a view that we identify as a “Quinean dogma” – is incapable of making certain crucial distinctions. We propose, as a remedy, that any adequate representation of epistemic states must also include (...) the agent’s research agenda, i.e., the list of question that are open or closed at any given point in time. If the argument of the paper is sound, a person’s questions and practical interests, on the one hand, and her beliefs and theoretical values, on the other, are more tightly interwoven than has previously been assumed to be the case in formal epistemology. (shrink)

We argue that two well-known examples (strawberry distribution and Konigsberg bridges) generally considered genuine cases of distinctively _mathematical_ explanation can also be understood as cases of distinctively _generic_ explanation. The latter answer resemblance questions (e.g., why did neither person A nor B manage to cross all bridges) by appealing to ‘generic task laws’ instead of mathematical necessity (as is done in distinctively mathematical explanations). We submit that distinctively generic explanations derive their explanatory force from their role in ontological unification. Additionally, (...) we argue that distinctively generic explanations are better seen as standardly mathematical instead of distinctively mathematical. Finally, we compare and contrast our proposal with the work of Christopher Pincock on abstract explanations in science and the views of Michael Strevens on abstract causal event explanations. (shrink)

Seeing from somewhere in particular -- Embracing binocularity -- Creativity and gratitude -- Technology as vlaue-free and as value-laden -- Nobody's against true enhancement -- Comprehending persons as subjectss and as objects -- Respecting persons as subjects and as objects.

We have argued that the counterfactual comparative account of harm and benefit (CCA) violates the plausible adequacy condition that an act that would harm an agent cannot leave her much better off than an alternative act that would benefit her. In a recent paper in this journal, however, Neil Feit objects that our argument presupposes questionable counterfactual backtracking. He also argues that CCA proponents can justifiably reject the condition by invoking so-called plural harm and benefit. In this reply, we argue (...) that Feit’s lines of criticism are both unsuccessful. (shrink)

In this paper, we put forward two novel arguments against the counterfactual comparative account (CCA) of harm and benefit. In both arguments, the central theme is that CCA conflicts with plausible judgements about benefit and prudence.

Divine command theory is experiencing something of a renaissance, inspired in large part by Robert Adams’s 1999 masterpiece Finite and Infinite Goods. I argue here that divine commands are not always necessary for actions to be morally obligatory. I make the case that the DCT-ist’s own commitments put pressure on her to concede the existence of some moral obligations that in no way depend on divine commands. Focusing on Robert Adams’s theistic framework for ethics, I argue that Adams’s views about (...) good, evil, reasons, and the nature of moral obligation suggest that there can be moral obligations that exist independently of any divine commands. My argument proceeds through the development of an example in which there is a moral obligation that is not even partially grounded in a divine command. I focus primarily on Adams’s view because, many contemporary divine command theorists work in a broadly Adams-ian framework, so the argument that I advance here poses a challenge for many contemporary versions of DCT. (shrink)

The “new natural lawyers” (NNLs) are a prolific group of philosophers, theologians, and political theorists that includes John Finnis, Robert George, Patrick Lee, Gerard Bradley, and Germain Grisez, among others. These thinkers have devoted themselves to developing and defending a traditional sexual ethic according to which homosexual sexual acts are immoral per se and marriage ought to remain an exclusively heterosexual institution. The sterility objection holds that the NNLs are guilty of making an arbitrary and irrational distinction between same-sex couples (...) and sterile heterosexual couples. The NNLs believe that it is a necessary condition for two people’s being morally and legally entitled to get married that they be able to perform sexual acts that are “suited to procreating.” But sterile heterosexual couples are incapable of performing such acts. Therefore, it should follow from the NNLs’ own premises that sterile heterosexual couples are not entitled to marry. But the NNLs do not draw this conclusion. Instead, they maintain that sterile heterosexuals can marry while denying that the same is true of same-sex couples. The sterility objection claims the NNLs are being inconsistent in treating the two kinds of couples differently. Although the sterility objection has been endorsed by recent critics, I don’t think it has yet been adequately defended. The NNLs have responded by arguing that there is a sense in which the sex acts of sterile heterosexual couples are as suited to reproduction as those of fertile heterosexuals. Thus they maintain that the distinction they draw between the two kinds of couple has a rational basis. A successful defense of the sterility objection must show that this response on the part of the NNLs fails. Such is the task I undertake in this paper. I argue that the NNLs’ response fails because acts of penile-vaginal intercourse between sterile heterosexuals lack the actual causal power to produce conception that sexual acts need to be considered truly reproductive, and because their assumption that penile-vaginal intercourse always functions reproductively is bad biology. (shrink)

In 2006 was 'jij' volgens het Amerikaanse blad 'Time Magazine' als individu de persoon van het jaar. Tien jaar later is het selfietijdperk helemaal doorgebroken. Het 'ik' staat centraal en onze identiteit heeft veel weg van een bouwpakket uit een doe-het-zelf zaak. In het boek 'De mythe van de ik-dentiteit' staan auteurs uit uiteenlopende maatschappelijke velden stil bij de consequenties en uitdagingen van deze maatschappelijke evolutie. Met bijdragen van Erik Borgman, Marc Calmeyn, Marc Colpaert, Paul Delva, Patrick Develtere, (...) class='Hi'>Erik Galle, Anja T?Kindt, Ivan Van de Cloot, Leen Van den Neste, Guido Vanheeswijck, Frédéric Van Leeuw, Ellen Van Stichel, Christoffel Waelkens en Walter Weyns. (shrink)

In everyday life we often act adequately, yet without deliberation. For instance, we immediately obtain and maintain an appropriate distance from others in an elevator. The notion of normativity implied here is a very basic one, namely distinguishing adequate from inadequate, correct from incorrect, or better from worse in the context of a particular situation. In the first part of this paper I investigate such ‘situated normativity’ by focusing on unreflective expert action. More particularly, I use Wittgenstein’s examples of craftsmen (...) (tailors and architects) absorbed in action to introduce situated normativity. Situated normativity can be understood as the normative aspect of embodied cognition in unreflective skillful action. I develop Wittgenstein’s insight that a peculiar type of affective behaviour, ‘directed discontent’, is essential for getting things right without reflection. Directed discontent is a reaction of appreciation in action and is introduced as a paradigmatic expression of situated normativity. In the second part I discuss Wittgenstein’s ideas on the normativity of what he calls ‘blind’ rule-following and the ‘bedrock’ of immediate action. What matters for understanding the normativity of (even ‘blind’) rule-following, is not that one has the capacity for linguistic articulation or reflection but that one is reliably participating in a communal custom. In the third part I further investigate the complex relationships between unreflective skillful action, perception, emotion, and normativity. Part of this entails an account of the link between normativity at the level of the expert’s socio-cultural practice and the individual’s situated and lived normativity. (shrink)

There have through history been many attempts to define 'life' but there is no generally accepted definition of 'life' at this date. As a result, some have come to believe that defining 'life' is not a fruitful endeavour. This seems to be a minority view, however, since the quest to find or create a definition of 'life' is as active as ever.

Learned, exigent, original, and timely, Erik Roraback's The Power of the Impossible: On Community and the Creative Life presents authoritative readings of what important theorists from Spinoza to Bataille, Blanchot, Nancy, Žižek, and others have had to say about community and the individual, with sections along the way on how those theorists might lead us to approach work by Henry James, James Joyce, Ralph Ellison, Dante Alighieri, and, surprisingly, the great tennis player, Ivan Lendl. Roraback also develops on the (...) basis of his theorists his own persuasive concept of an impossible/possible global community yet to come that would facilitate individual creativity as well as contest the repressive hegemony of finance capitalism and technology, especially digital technology. (J. Hillis Miller, The University of California at Irvine). (shrink)

Critical Gaming: Interactive History and Virtual Heritage can be seen as a collection of chapters designed to provoke thought and discussion, or it can be seen and used as separate chapters that may help class debate in courses dealing with the digital humanities, game studies (especially in the areas of serious games and game-based learning) or aspects of virtual heritage. While there are very few books in this intersecting area, the range of topics that could be investigated and debated is (...) huge. So instead I have concentrated on questions in areas that appear to be central to the intersection of these three areas, have not currently been debated to any great extent or are topics that would suit either individual reflection or classroom discussion and debate. (shrink)

Calls into question the traditional polarity of theism and atheism.