Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians? experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold (...) nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging. [Supplementary materials are available for this article. Go to the publisher's online edition of American Journal of Bioethics for the following free supplemental resource(s): An additional table (Table 5) referred to on p. 5]. (shrink)

Advances in psychopharmacology raise the prospects of enhancing neurocognitive functions of humans by improving attention, memory, or mood. While general ethical reflections on psychopharmacological enhancement have been increasingly published in the last years, ethical criteria characterizing physicians’ role in neurocognitive enhancement and guiding their decision-making still remain highly unclear. Here it will be argued that also in the medical domain the use of cognition-enhancing drugs is not intrinsically unethical and that, in fact, physicians should assume an important role in gating (...) their usage. For finding normative orientation, concepts of disease, normality or medicine will not be helpful since—due to their cryptonormative nature—they rather hamper than allow targeted discussion and decision-making. As an alternative, the common and widely accepted bioethical criteria of beneficence, non-maleficence, autonomy and distributive justice allow a clinically applicable, highly differentiated context- and case-sensitive approach. By embedding decision-making in a participative physician–patient relationship extrinsic objections against neurocognitive enhancement (e.g. invalid perceptions about efficacy, benefit or risk; questionable voluntariness; restrained decision-making capacity) can be curtailed. (shrink)

In this article, it is argued that it is problematic to construe the debate around the process labelled ‘surrogacy’ as a form for infertility treatment. Firstly, this way of defining what happens opens up a new form of medical desire where a growing number of people wish to have children through ‘surrogacy’. This medicalizes childlessness and creates pressure within health services to respond to the desires of an ever-growing group of patients. Secondly, this labels the woman who carries the child (...) as a ‘surrogate’ and defines her as a core element in a ‘treatment method’. This way of phrasing and defining what happens puts the woman carrying the child in an unacceptable moral position within the health system. Thirdly, by viewing the woman carrying the child as a ‘substitute’ for a mother or as a ‘temporary custodian’ ignores the unique relationship between the foetus and the pregnant woman. To keep the ethical issues in focus in the ‘surrogacy’ process, it is necessary for health professionals to always... (shrink)

The purpose of the article is to argue for the significance of a clarified goal of health care for the setting of priorities. Three arguments are explored. First, assessment of needs becomes necessary in so far as the principle of need should guide the priority-setting. The concept of health care need includes a goal component. This component should for rational reasons be identical with the goal of health care. Second, in order to use resources efficiently it is necessary to assess (...) the effects of health care. It is not, however, a question of assessing whether there is an effect but a question of assessing whether there is the right effect. And what constitutes the right effect can only be determined in relation to the goal of the enterprise. Third, the health sector involves several groups of actors such as politicians, administrators, doctors, nurses, physiotherapists, occupational therapists, educationists and patients. It is common knowledge that successful teamwork requires an understanding of a common goal. The article ends with an example of a goal chosen from ethics. (shrink)

Das normative Grundverständnis der kurativen Medizin und ein Trend, sich ihr zu entwinden, wird beschrieben. Durch systematische Betrachtung des Trends wird der Begriff einer „wunscherfüllenden Medizin“ eingeführt und mit der kurativen Medizin kontrastiert. Am Beispiel der Schönheitschirurgie und der Kritik des „Schönheitswahns“ wird deutlich gemacht, dass die Bewertung von Phänomenen wunscherfüllender Medizin in liberalen Gesellschaften sich nur auf schwache normative Ressourcen stützen kann. Nutzen-Risiko-Argumente und Kohärenzargumente, bezogen auf Lebensentwürfe, stellen die vergleichsweise stärksten dar. Wunscherfüllende Medizin erscheint zwiespältig, einerseits erhöht sie (...) die Klientenzentrierung und Responsivität des Medizinsystems, andererseits befördert sie Kommerzialisierungstendenzen. (shrink)

Das normative Grundverständnis der kurativen Medizin und ein Trend, sich ihr zu entwinden, wird beschrieben. Durch systematische Betrachtung des Trends wird der Begriff einer „wunscherfüllenden Medizin“ eingeführt und mit der kurativen Medizin kontrastiert. Am Beispiel der Schönheitschirurgie und der Kritik des „Schönheitswahns“ wird deutlich gemacht, dass die Bewertung von Phänomenen wunscherfüllender Medizin in liberalen Gesellschaften sich nur auf schwache normative Ressourcen stützen kann. Nutzen-Risiko-Argumente und Kohärenzargumente, bezogen auf Lebensentwürfe, stellen die vergleichsweise stärksten dar. Wunscherfüllende Medizin erscheint zwiespältig, einerseits erhöht sie (...) die Klientenzentrierung und Responsivität des Medizinsystems, andererseits befördert sie Kommerzialisierungstendenzen. (shrink)

Health care systems throughout the developed world face ‘crises’ of quality, financing and sustainability. These pressures have led governments to look for more efficient and equitable ways to allocate public resources. Prioritisation of health care services for public funding has been one of the strategies used by decision makers to reconcile growing health care demands with limited resources. Priority setting at the macro level has yet to demonstrate real successes. This paper describes international approaches to explicit prioritisation at the macro-governmental (...) level in the six experiences most published in the English literature; analyzes the ways in which values, principles and other normative concepts were presented in these international priority setting experiences; and identifies key elements of a more robust framework for ethical analysis which could promote meaningful and effective health priority setting. (shrink)

The widespread application of technology in health care has imposed a broad range of challenges. The field of health technology assessment (HTA) is developed in order to face some of these challenges. However, this strategy has not been as successful as one could hope. One of the reasons for this is that social and ethical considerations have not been integrated in the HTA process. Nowadays however, such considerations have been included in many HTAs. Still, the conclusions and recommendations of the (...) HTAs are not followed. The reason for this may be that the methods for integrating ethics for HTA are not sufficiently developed, or that they are not adequate. This article presents a supplementary approach to the ethical inquiry in HTA. It is argued that a value analysis is crucial in order to address the ethical issues of health care technology in a fruitful way and to make viable decisions about such technology. (shrink)

Science and technology have vastly expanded the realm of medicine. The numbers of and knowledge about diseases has greatly increased, and we can help more people in many more ways than ever before. At the same time, the extensive expansion has also augmented harms, professional responsibility, and ethical concerns. While these challenges have been studied from a wide range of perspectives, the problems prevail. This article adds value to previous analyses by identifying how the moral imperative of medicine has expanded (...) in three ways: (1) from targeting experienced phenomena, such as pain and suffering, to non-experienced phenomena (paraclinical signs and indicators); (2) from addressing present pain to potential future suffering; and (3) from reducing negative wellbeing (pain and suffering) to promoting positive wellbeing. These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship. In order to find ways to manage the moral expansion of medicine, four traditional ways of setting limits are analyzed and dismissed. However, basic asymmetries in ethics suggest that it is more justified to address people’s negative wellbeing (pain and suffering) than their positive wellbeing. Moreover, differences in epistemology, indicate that it is less uncertain to address present pain and suffering than future wellbeing and happiness. Based on these insights the article concludes that the moral imperative of medicine has a gradient from pain and suffering to wellbeing and happiness, and from the present to the future. Hence, in general present pain and suffering have normative priority over future positive wellbeing. (shrink)

_Helsevesenet har blitt en sentral samfunnsaktør og medisinen dets førende fag. Hvorfor har det blitt slik? En grunn er at medisinen fører sammen sfærer som ellers har vært adskilt: det sanne, det gode og det skjønne. Medisinen som fag og helsevesenet som institusjon, har blitt et fascinerende skjæringspunkt nettopp mellom evidens, etikk og estetikk. Her kobles kunnskap til det som er vondt og skjønnhet til det som er friskt. Kunnskapsproduksjonen dirigeres ut fra ønsket om å gjøre det gode ved å (...) unngå det vonde. Samtidig styres helsevesenets normer også av estetikkens normer. Koblingene mellom evidens, estetikk og etikk gir noen grunnleggende utfordringer, som det er viktig å være oppmerksom på. Riktig håndtert gjør de helsevesenet generelt og medisinen spesielt til et fascinerende og fruktbart skjæringspunkt mellom det sanne, det gode og det skjønne. _ _Nøkkelord:_ Evidens, etikk, estetikk, sannhete, godhet, skjønnhet _English Title:_ Evidence, ethics and aesthetics: Medicine at the intersection of the true, the good and the beautiful _Abstract:_ While Western history of ideas has tried to differentiate truth, goodness, and beauty, medicine is a fascinating meeting place precisely between evidence, ethics, and aesthetics. In medicine, knowledge is connected to pain and suffering and beauty to health. The production of knowledge is directed towards doing good by avoiding bad. At the same time, medicine is also governed by aesthetics. A range of challenges follow from the connection between the three spheres, but if we are attentive to the interconnectedness medicine becomes a fascinating and fruitful rendezvous of truth, goodness, and beauty. _Keywords_: Evidence, ethics, aesthetics, truth, goodness, beauty. (shrink)

This article critically evaluates the conception of conscience underlying the debate about the proper place and role of conscience in the clinical encounter. It suggests that recovering a conception of conscience rooted in the Catholic moral tradition could offer resources for moving the debate past an unproductive assertion of conflicting rights, namely, physicians’ rights to conscience versus patients’ rights to socially and legally sanctioned medical interventions. It proposes that conscience is a necessary component of the moral life in general and (...) a necessary resource for maintaining a coherent sense of moral agency. It demonstrates that an earlier and intellectually richer conception of conscience, in contrast with common contemporary formulations, makes the judgments of conscience accountable to reason, open to critique, and protected from becoming a bastion for bigotry, idiosyncrasy, and personal bias. (shrink)

The debate about the appropriate methodology of medical education has been (and still is) dominated by the opposing poles of teaching science versus teaching practical skills. I will argue that this conflict between scientific education and practical training has its roots in the underlying, more systematic question about the conceptual foundation of medicine: how far or in what respects can medicine be considered to be a science? By analyzing the epistemological status of medicine I will show that the internal aim (...) of medicine( promoting health through the prevention and treatment of disease ) differs from the internal aim of science ( the methodological and systematic acquisition of knowledge ). Therefore, medicine as a whole discipline should not be considered as a science. However, medicine can be conceptually and methodologically scientific in so much as it is based on scientific knowledge. There is evidence from cognitive science research that diagnostic reasoning not only relies on the application of scientific knowledge but also — especially in routine cases – on a process of pattern recognition, a reasoning strategy based on the memory of previously encountered patients. Hence, medical education must contain both: the imparting of scientific knowledge and the rich exposure to concrete cases during practical training. Hence, the question of teaching science vs. the apprentice model will not be either-or but rather both — but in which proportion? (shrink)

There is a growing tendency for medicine to be used not to prevent or heal illnesses, but to fulfil individual personal wishes such as wishes for enhanced work performance, better social skills, children with specific characteristics, stress relief, a certain appearance or a better sex life. While recognizing that the subject of wish-fulfilling medicine may vary greatly and that it may employ very different techniques, this article argues that wish-fulfilling medicine can be described as a cohesive phenomenon with distinctive features. (...) Following a few examples of well established wish-fulfilling medical practices and a brief definition of the phenomenon, both theoretical aspects and ethical implications of such practices are discussed and the question is raised how wish-fulfilling medicine should be evaluated from an ethical point of view. It is concluded that modern medicine is currently ill equipped to provide reasons why wish-fulfilling medicine should be banned or discouraged. The phenomenon of wish-fulfilling medicine serves as a prime example of the vagueness of the descriptive and the lack of decisive orientation of the normative categories employed in modern medicine. (shrink)

The objective of this article is to analyse the value-ladenness of technology in the context of medicine. To address this issue several characteristics of technology are investigated: i) its interventive capacity, ii) its expansiveness and iii) its influence on the concept of disease, iv) its generalising character, v) its independence of the subjective experience of the patient. By this analysis I hope to unveil the double face of technology: Technology has a Janus-face in modern medicine, and the opposite of its (...) factual face is evaluative. (shrink)