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)

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)

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)

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)

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

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)

There is growing interest in contact tracing apps for pandemic management. It is crucial to consider ethical requirements before, while, and after implementing such apps. In this paper, we illustrate the complexity and multiplicity of the ethical considerations by presenting an ethical framework for a responsible design and implementation of CT apps. Using this framework as a starting point, we briefly highlight the interconnection of social and political contexts, available measures of pandemic management, and a multi-layer assessment of CT apps. (...) We will discuss some trade-offs that arise from this perspective. We then suggest that public trust is of major importance for population uptake of contact tracing apps. Hasty, ill-prepared or badly communicated implementations of CT apps will likely undermine public trust, and as such, risk impeding general effectiveness. (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 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. 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)

In recent years the formerly quite strong interest in patient compliance has been questioned for being too paternalistic and oriented towards overly narrow biomedical goals as the basis for treatment recommendations. In line with this there has been a shift towards using the notion of adherence to signal an increased weight for patients’ preferences and autonomy in decision making around treatments. This ‘adherence-paradigm’ thus encompasses shared decision-making as an ideal and patient perspective and autonomy as guiding goals of care. What (...) this implies in terms of the importance that we have reason to attach to (non-)adherence and how has, however, not been explained. In this article, we explore the relationship between different forms of shared decision-making, patient autonomy and adherence. Distinguishing between dynamically and statically framed adherence we show how the version of shared decision-making advocated will have consequences for whether one should be interested in a dynamically or statically framed adherence and in what way patient adherence should be assessed. In contrast to the former compliance paradigm (where non-compliance was necessarily seen as a problem), using observations about (non-)adherence to assess the success of health care decision making and professional-patient interaction turns out to be a much less straightforward matter. (shrink)

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)

The precautionary principle (PP) has been criticised for almost every intellectual sin one may imagine: unclarity, impracticability, rigidity, implausibility etc. Recognising the rather obvious fact that there is no such thing as one PP, this paper attempts to address this criticism on a more constructive note than merely view it as forcing us to be "for or against" precaution. This is done by connecting an underlying ethical ideal regarding the imposition of risks present in most formulations of PP to the (...) criticism and use the latter for discussing how such an idea may be plausibly designed and used for underpinning policies that may plausibly be said to express the spirit of PP. It is argued that the most important issue regarding this is to recognise that there is something to the idea that imposing risks on people has a morally significant price, but that we must also acknowledge that taking precautionary measures to avoid or decrease such risks has such a price. The critical issue in the ethics of risk of relevance for PP thus becomes what constitutes a proper price of precaution. It is demonstrated how two simple constraints on this amkes it easy to meet many typical arguments against PP, but also how this issue must be further attacked by means transcending the traditional tools of normative ethics and decision theory, as well as how further reflection along such lines connects PP to issues of international.. (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 contrast to standardized guidelines, personalized medicine and person centered care are two notions that have recently developed and are aspiring for more individualized health care for each single patient. While having a similar drive toward individualized care, their sources are markedly different. While personalized medicine stems from a biomedical framework, person centered care originates from a caring perspective, and a wish for a more holistic view of patients. It is unclear to what extent these two concepts can be combined (...) or if they conflict at fundamental or pragmatic levels. This paper reviews existing literature in both medicine and related philosophy to analyze closer the meaning of the two notions, and to explore the extent to which they overlap or oppose each other, in theory or in practice, in particular regarding ethical assumptions and their respective practical implications. (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)

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 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 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, 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)

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)

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)

This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support (...) the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy. (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)

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)

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)

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)

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)

This article addresses how health professionals should monitor and safeguard their patients’ ability to participate in making clinical decisions and making subsequent decisions regarding the implementation of their treatment plan. Patient participation in clinical decision-making is essential, e.g. in self-care, where patients are responsible for most ongoing care. We argue that one common, fact-oriented patient education strategy may in practice easily tend to take a destructive form that we call error trawling. Illustrating with empirical findings from a video study of (...) consultations between clinicians and adolescent patients with diabetes, we argue on independent grounds that this strategy not only risks to overlook significant weaknesses in patient decision competence, but also to undermine patient capacity for decision-making and implementing care. In effect, this strategy for clinically monitoring and addressing the problem of fragile decision-making capacity brings hazards in need of address. We clo... (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...

The notion of the best interest of children figures prominently in family and reproductive policy discussions and there is a considerable body of empirical research attempting to connect the interests of children to how families and society interact. Most of this research regards the effects of societal responses to perceived problems in families, thus underlying policy on interventions such as adoption, foster care and temporary assumption of custodianship, but also support structures that help families cope with various challenges. However, reference (...) to the best interest of children can also be applied to a more basic issue in family policy, namely that of what is to be considered a family in the first place. This issue does not raise any questions regarding the proper conditions for when society should intervene in or change the family context of a child. Rather, it is about what social configurations should be recognized as a potentially fitting context for children to enter into and (if all goes well) eventually develop into adulthood within /.../ such that society’s default institutional arrangements allow it to have (by sexual and artificial reproduction, adoption, and combinations of these), care for and/or guard children. [This] will frame any further discussion of /.../ policies having further implications for, for example, the practices of adoption and reproductive technology, as well as regulation of custody in the event of separation or parental disagreement. (shrink)

This paper is about the idea of a moral distinction between doing harm and allowing harm to occurr. It discusses, and developes a general argument against, the version of the distinction often described as counterfactual, which I characterize in terms of making a moral difference between different ways of causing harm (in contrast to, e.g., the version famously discussed by Jonathan Bennett). The gist of the argument is that all variants of this version of the doing-allowing idea would have to (...) make factors out of the agent's control into wrong-making characteristics and that, therefore, this version violates a plausible extension of the principle that 'ought' implies 'can'. (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.

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)

Daniel Steel’s new book on the precautionary principle illustrates the need to work ahead to fuse perspectives of epistemology and philosophy of science with those of ethics to accomplish progress in the debate on the proper role of precaution in a broad selection of bioethical areas. Steel advances the territory greatly with regard to conceptual clarity and epistemology, but from a bioethics standpoint he is mistaken in discounting the need for ethical underpinnings of a sound theory of the precautionary principle.

We proposed adding a sustainability principle to the operational ethical principles guiding public healthcare resources allocation decisions. All our commentators acknowledge our core message: healthcare needs to pay attention to the future. They also strengthen our proposal by offering support by luck egalitarian and Rawlsian arguments, and helpfully point out ambiguities and gaps requiring attention in the further development of the proposal, and its practical implementation.

Moral relativism comes in many forms. Most discussed of these are metaethical ideas that make claim to some form of relativity regarding the truth, meaning and/or knowledge of moral judgements. Notwithstanding the vast differences that exist between more precise versions of metaethical relativism (MR), they all have one basic feature in common: A moral judgement can only be true (or have a certain meaning, or be known) relative to a person or some group of persons. However, a moral judgement to (...) which this applies need not be true (or have the same meaning or be known) relative to some other person or group of persons. This, in turn, is allegedly due to the actual existence or possibility of substantial differences between people when it comes to moral opinions, language and general belief systems. Obviously, such ideas tell us nothing about what is right or wrong, good or bad (not even relatively so) – in itself they lack all normative content. However, in philosophical discussions they are not seldom connected to normative ideas that in a similar manner position themselves with regard to the fact that people actually do or may have very different ways of thinking about moral matters and the world in general. (shrink)

Introductory anthology to the philosophy of hate crime, written in the EU project "When Law and Hate Collide".

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 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)

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)