After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

The clinical encounter begins with presentation of an illness experience; but throughout that encounter, something else is constructed from it – a symptom. The symptom is a particular interpretation of that experience, useful for certain purposes in particular contexts. The hermeneutics of medicine – the study of the interpretation of human experience in medical terms – has largely taken the process of symptom-construction to be transparent, focussing instead on how constellations of symptoms are interpreted as representative of particular conditions. This (...) paper examines the hermeneutical activity of symptom-construction more closely. I propose a fourfold account of the clinical function of symptoms: as theoretical entities; as tools for communication; as guides to palliative intervention; and as candidates for medical explanation or intervention. I also highlight roles they might play in illness experience. I use this framework to discuss four potential failures of symptom-interpretation: failure of symptom-type and symptom-token recognition; loss of the complete picture of illness experience through overwhelming emphasis on its symptomatic interpretation; and intersubjective feedback effects of symptom description altering the ill person’s own perceptions of their phenomenal experience. I conclude with some suggestions of potential remedies for failures in the process of symptom-construction. (shrink)

An increasing number of patients receive diagnoses of disease without having any symptoms. These include diseases detected through screening programs, as incidental findings from unrelated investigations, or via routine checks of various biological variables like blood pressure or cholesterol. In this article, we draw on narrative identity theory to examine how the process of making sense of being diagnosed with asymptomatic disease can trigger certain overlooked forms of harm for patients. We show that the experience of asymptomatic disease can involve (...) ‘mismatches’ between one’s beliefs about one’s health status on the one hand, and bodily sensations or past experience on the other. Patients’ attempts to integrate these diagnoses into their self-narratives often involve either forming inaccurate beliefs about bodily sensations and/or past experience, or coming to believe that feelings and experience do not necessarily track or predict health status, leading to an ongoing sense of vulnerability to ill health. These resulting alterations in self-understanding can sometimes be considered harmful, in view of their implications for ascriptions of responsibility and ongoing anxiety. (shrink)

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept (...) is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept. (shrink)

The concepts of disease, illness and sickness capture fundamentally different aspects of phenomena related to human ailments and healthcare. The philosophy and theory of medicine are making manifold efforts to capture the essence and normative implications of these concepts. In parallel, socio-empirical studies on patients’ understanding of their situation have yielded a comprehensive body of knowledge regarding subjective perspectives on health-related statuses. Although both scientific fields provide varied valuable insights, they have not been strongly linked to each other. Therefore, the (...) article aims to scrutinise the normative-ethical implications of patient perspectives in building a bridge to the empirical ethics debates. Three potential fields of tension between the illness and the disease perspective are presented. Consequently, findings from empirical research examining patient perspectives on illness are displayed and the practical implications and associated ethical issues which arise are discussed. This leads to the conclusion that an explicit and elaborate empirical-ethical methodology is needed to deal appropriately with the complex interaction between patients’ views and the medico-professional view of disease. Kon’s four-stage model of normative-empirical collaboration is then applied against the background of empirical data on patient perceptions. Starting from this exemplary approach, the article suggests employing empirical-ethical frameworks for further research on the conceptual and normative issues, as they help to integrate perspectives from the philosophy of medicine with socio-empirical research. The combination of theoretical and empirical perspectives suggested contributes to a more nuanced discussion of the normative impact of patients’ actual understanding of illness. Further empirical research in this area would profit from explicitly considering potential ethical issues to avoid naturalistic fallacies or crypto-normative conclusions that may compromise healthcare practice. Vice versa, medico-theoretical debates could be enriched by integrating subjective views of those people who are immediately affected. (shrink)

Today, health systems around the world are under pressure to create greater value for patients and society [81, p. 1, 119]; increasing access, improving client orientation and responsiveness, reducing medical errors and safety, restraining utilization via managed care, and implementing priority allocation of resources for high-burden health problems are examples of strategies towards this end. The quality paradigm by virtue of its strategic consumer focus and its methods for achieving operational excellence has proved an effective approach for creating higher value (...) in many sectors. If applied in a deliberate and holistic manner, the quality paradigm can bring about a more cost-effective organization of the health systems. In this article, we apply quality concepts to healthcare in a conceptual format; we characterize the health system’s customers and outputs with their quality dimensions. The product of this effort is a blueprint for a customer-driven health system which identifies six types of customers, nine types of outputs and the associated operations. As a preliminary step, a new analysis and definition of health and disease is provided. Rethinking the structure of health system in this manner and the related conceptual model can guide medical research, health sciences education, and health services policy, and help the practitioner to integrate all modern trends in healthcare delivery. (shrink)

This paper suggests the adoption of a ‘capability approach’ to key concepts in healthcare. Recent developments in theoretical approaches to concepts such as ‘health’ and ‘disease’ are discussed, and a trend identified of thinking of health as a matter of having the capability to cope with life’s demands. This approach is contrasted with the WHO definition of health and Boorse’s biostatistical account. We outline the ‘capability approach’, which has become standard in development ethics and economics, and show how existing work (...) in those areas can profitably be adapted to healthcare. Cases are used to illustrate the value of adopting a capability approach. (shrink)

Philosophy of medicine has traditionally examined two issues: the scientific ontology for medicine and the epistemic significance of the types of evidence used in medical research. In answering each question, philosophers have typically brought to bear tools from traditional analytic philosophy. In contrast, this volume explores medical knowledge from the perspective offered by social epistemology.While many of the same issues are addressed, the approach to these issues generates both fresh questions and new insights into old debates. In addition, the broader (...) purview offered by social epistemology opens up opportunities to address new topics such as the role of consensus conferences, epistemic injustice, the value of medical knowledge, continuing medical education, and industry funding. This article situates and summarizes the contributions to this special issue. (shrink)

The long ongoing and partly heated debate on the concept of disease has not led to any consensus on the status of this apparently essential concept for modern health care. The arguments range from claims that the disease concept is vague, slippery, elusive, or complex, and to statements that the concept is indefinable and unnecessary. The unsettled status of the concept of disease is challenging not only to health care where diagnosing, treating, and curing disease are core aims, but also (...) to the branch of philosophy that tries to clarify concepts. This article discusses three claims about the concept of disease: that it is vague, complex, and that it is indefinable. It investigates (a) what is meant by these claims (b) what their implications are, and (c) whether the claims are sound or not. It is argued that some of the arguments are flawed and miss important points about concept analysis. This does not mean, however, that disease is a clear concept with a crisp definition. It only rules out speculative claims that disease necessarily is vague, complex, and indefinable. It appears at least as hard to show that disease is indefinable as it is to define it. (shrink)

The concepts of health and disease are crucial in defining the aim and the limits of modern medicine. Accordingly it is important to understand them and their relationship. However, there appears to be a discrepancy between scholars in philosophy of medicine and health care professionals with regard to these concepts. This article investigates health care professionals’ concepts of health and disease and the relationship between them. In order to do so, four different models are described and analyzed: the ideal model, (...) the holistic model, the medical model and the disjunctive model. The analysis reveals that each model has its pros and cons, and that health care professionals appear to apply more than one models. Furthermore, the models and the way health care professionals’ use them may be helpful for scholars in philosophy of medicine with regard to developing theories and communicating them to health care professionals. (shrink)

In his influential theory of health Nordenfelt bases the concepts of health and illness on the notions of ability and disability. A premise for this is that ability and disability provide a more promising, adequate, and useful basis than well-being and suffering. Nordenfelt uses coma and manic episodes as paradigm cases to show that this is so. Do these paradigm cases (and thus the premise) hold? What consequences does it have for the theory of health and illness if it they (...) do not? These are the key questions in this article, which first presents the relationship between pain and disability in Nordenfelt’s theory and the paradigm cases he uses to argue for the primacy of disability over pain. Then, Nordenfelt’s concepts of illness are outlined, highlighting its presumptions and arguments. The main point is that if you do not have an action-theoretical perspective, it is not obvious that disability is the core concept for illness. The compelling effect of the paradigm cases presupposes that you see ability as the primary issue. To those who do not share this presumption, people in coma may not be ill. There are alternative well founded arguments for the primacy of first person experiences for the concept of illness. Hence, we need better arguments for the primacy of disability over first person experiences in illness, or first-person experience should be more primarily included in the concept of illness. (shrink)

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease (...) as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization. (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)

Demographical changes in high income counties will increase the need of health care services but reduce the number of people to provide them. Welfare technology is launched as an important measure to meet this challenge. As with all types of technologies we must explore its ethical challenges. A literature review reveals that welfare technology is a generic term for a heterogeneous group of technologies and there are few studies documenting their efficacy, effectiveness and efficiency. Many kinds of welfare technology break (...) with the traditional organization of health care. It introduces technology in new areas, such as in private homes, and it provides new functions, e.g. offering social stimuli and entertainment. At the same time welfare technology is developed for groups that traditionally have not been extensive technology users. This raises a series of ethical questions with regard to the development and use of welfare technologies, which are presented in this review. The main challenges identified are: (1) Alienation when advanced technology is used at home, (2) conflicting goals, as welfare technologies have many stakeholders with several ends, (3) respecting confidentiality and privacy when third-party actors are involved, (4) guaranteeing equal access and just distribution, and (5) handling conflicts between instrumental rationality and care in terms of respecting dignity and vulnerability. Addressing these issues is important for developing and implementing welfare technologies in a morally acceptable manner. (shrink)

Norway provides total social welfare coverage for organ transplantations, including free immunosuppressive medication and prepaid life-long follow up for both recipients and donors. Despite these benefits the proportion of living kidney donors has in recent years declined from around 40% of all kidney transplantations to 24%. This study suggests harnessing patient- and donor-narratives as a tool for addressing the current fall in donation rates. The hospital records of 18 recipient/donor dyads were compared with patient and donor accounts elicited in semi-structured (...) interviews. Narratives afford a pertinent supplement to the primarily biomedical and technical information stored in medical records. Even in condensed form, the messages embedded in narratives contribute to a ‘thicker’ understanding of the complexity of living kidney donation -decisions. Narratives represent a source of education for referring-nephrologists wishing to deepen their evaluation skills and avoid making decisions based on insufficient insight into patients’ and potential donors’ values and life-situation. Recipients’ and donors’ unedited accounts of their motivations, worries, doubts and expectations afford a revealing and edifying supplement to the primarily biomedical and technical information stored in medical records. In narratives, the predicaments and dilemmas surrounding LKD become visible and debatable and can serve as support for future donors, recipients and the nephrologists responsible for evaluation–conclusions. Generating narratives raises a number of practical, epistemic and normative challenges. (shrink)

The “One Health” initiative promises to combine different health-related issues concerning humans and animals in an overarching concept and in related practices to the benefit of both humans and animals. Far from dismissing One Health, this paper nevertheless argues that different veterinary interventions are determined by social practices and connected expectations and are, thus, hardly compliant with only one single conceptualization of health, as the One Health concept suggests. One Health relies on a naturalistic understanding of health focusing on similar (...) bodies that show a similar etiology. However, logics, normativity, and practices exhibit differences when it comes to combatting infectious diseases, maintaining productivity of livestock animals or preventing companion animals from suffering. Therefore, drawing from Charles Rosenberg’s groundbreaking texts on framing disease, we suggest to conceive of health as dispersed in different frames. Thus, this paper proposes to interpret health as complex and multi-layered concept. We distinguish and introduce an objectivist, a functional, and a sentientistic frame of health. Instead of reducing the differential veterinary practices to one paradigmatic understanding, health is seen as a model case of Wittgenstein’s concept of family resemblance. Different and distinct perspectives on veterinary medicine show sufficient overlapping that allows for a common conceptualization, but there is not one single underlying logic suitable to understand and ethically reflect all veterinary interventions. This differentiability promises to reduce moral stress in veterinary professionals since it allows the interpretation of various, seemingly contradicting practices as dependent on multi-layered and socially determined scopes of responsibility. (shrink)

Recent developments in the study of our brain and neurochemical maps have sparked much enthusiasm in some scholars, making room for speculations over the possibility to shape our morality from within ourselves rather than through [failed] socio-political projects. This paper aims at criticising the prospected scenario put forward by some scholars supporting a specific version of Moral Enhancement as an overly optimistically described manipulative tools. To do so, I will focus on a specific version of Moral Enhancers, namely Emotional Enhancers. (...) By looking from close at this group of enhancers and the potential results of their implementation, I will underline the risks that those could pose to sexual minorities, and I will use this analysis to support a much more cautious assessment of these drugs and a broader assessment of what their social acceptance would mean. (shrink)

Recovery is a commonly used concept in both professional and everyday contexts. Yet despite its extensive use, it has not drawn much philosophical attention. In this paper, I question the common understanding of recovery, show how the concept is inadequate, and introduce new and much needed terminology. I argue that recovery glosses over important distinctions and even misrepresents the process of moving away from malady as "going back" to a former state of health. It does not invite important nuances needed (...) to distinguish between biomedical, phenomenological, and social perspectives. In addition, I claim that there are many conditions where we are making use of the concept of recovery, although the person recovered from the condition in question, has not regained the same degree of soundness. I show how the concept of recovery leads to conceptual discrepancies that can result in worsening patients' conditions. To gain a fuller understanding, I propose to rethink the direction of the process in question. I define the process of moving away from malady as a move forward towards a new state of soundness. I also suggest three terms, corresponding to different perspectives, to describe this movement forward: 'curing', 'healing', and 'habilitating'. This new terminology provides a more nuanced understanding of the states of both malady and soundness and an attentiveness as to how they differ and relate. (shrink)