This article presents various developments in Dutch health care policy toward a greater role for individual financial responsibility, such as cost-control measures, priority setting, rationing, and market reform. Instead of the collective responsibility that is characteristic of previous times, one can observe in government policies an increased emphasis on the need for individuals to take care of one’s own health and health care needs. Moreover, surveys point to decreasing levels of public support for “unlimited” solidarity and “irresponsible” health behavior. This (...) article attempts to answer the question of how these policies and public attitudes are limiting the ethical principles of solidarity and equal access to care that have long guided Dutch health care policy making. The authors argue that from a moral point of view, the increased emphasis on individual responsibility is acceptable as long as it does not affect solidarity with those weak and vulnerable groups who are not able to take individual responsibility, such as the demented and mentally handicapped. (shrink)

This article analyzes the contribution Christian ethics might be able to make to the ethical debate on policy and caregiving in health and social care in the United Kingdom. The article deals particularly with the concepts of solidarity and subsidiarity which are essential in Christian social ethics and health care ethics, and which may be relevant for the ethical debate on health and social caregiving in the United Kingdom. An important argument in the article is that utilitarian and market-driven policies (...) in the National Health Service (NHS) and the social care system have marginalized the position of the elderly and have seriously impoverished the quality of care for the elderly. The neglect of the elderly and other vulnerable groups is also the result of widespread consumerist attitudes among patients and of libertarian models of noninterference which are affirmed by a public ethos of self-sufficiency and counter-dependency. Those who need care dare not make their need known to others and ask for help, while simultaneously those who could help are so intimidated by the public affirmation of privacy and negative rights that they do not dare to offer help except if this is explicitly demanded. This distant and standoffish attitude is in an important way responsible for the fact that the voice of those in need is altogether lost to the public forum. Christian ethics puts much emphasis on responsibility and solidarity with the needy other but is not able to have much impact on the delivery of care in a secularized society and health care system like the NHS. Nonetheless, Christianity still has a powerful and respected voice, by speaking up for those who cannot speak for themselves, such as the elderly and the handicapped. Christians can find allies in the ethics of care and other relational approaches in health care ethics in order to combat libertarianism, consumerism, and utilitarianism. (shrink)

The transhumanist literature encompasses diverse nonnovel positions on questions of disability and obligation reflecting long-running political philosophical debates on freedom and value choice, complicated by the difficulty of projecting values to enhanced beings. These older questions take on a more concrete form given transhumanist uses of biotechnologies. This paper will contrast the views of Hughes and Sandberg on the obligations persons with "disabilities" have to enhance and suggest a new model. The paper will finish by introducing a distinction between the (...) responsibility society has in respect of the presence of impairments and the responsibility society has not to abandon disadvantaged members, concluding that questions of freedom and responsibility have renewed political importance in the context of enhancement technologies. (shrink)

Background: Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study of the role of nurses in medical end-of-life decisions in hospitals, home care and nursing homes.Aim: This paper reports the findings of a study of the role of nurses in euthanasia and physician-assisted suicide, conducted as part of a study of the role of nurses in medical end-of-life decisions. The findings for hospitals, (...) home care and nursing homes are described and compared.Method: A questionnaire was sent to 1509 nurses, employed in 73 hospitals, 55 home care organisations and 63 nursing homes. 1179 responses were suitable for analysis. The questionnaire was pilot-tested among 106 nurses, with a response rate of 85%.Results: In 37.0% of cases, the nurse was the first person with whom patients discussed their request for euthanasia or physician-assisted suicide. Consultation between physicians and nurses during the decision-making process took place quite often in hospitals and nursing homes and less frequently in home care situations . In some cases , nurses administered the euthanatics.Conclusions: The results show substantial differences between the intramural sector and the extramural sector , which are probably linked to the organisational structure of the institutions. Consultation between physicians and nurses during the decision-making process needs improvement, particularly in home care. Some nurses had administered euthanatics, although this task is by law exclusively reserved to physicians. (shrink)

This article presents standards for setting up and educating institutional ethics committees (IECs). These standards are based on experiences in the Netherlands, where IECs have been established in a large number of health care institutions. Though the IEC has become a generally accepted institution within Dutch health care, there are concerns over its effectiveness regarding the improving of the moral quality of clinical decision making. Health care practitioners and members of IECs too, experience a gap between the IEC and the (...) reality of the clinical environment. At this moment, there is interest in developing programmes which educate practitioners in moral issues and how to deal with them, using the method of a structured debate on the ward. The IEC will not be made obsolete by this development, but can play a guiding role in the implementation of such programmes. Current concerns are the lack of patient representation in the Dutch IEC, and the loss of contact with the local community of health care practitioners because of the merger of hospitals into bodies similar to UK National Health Service (NHS) trusts. (shrink)

In a qualitative study, 22 stroke patients undergoing rehabilitation in three nursing homes were interviewed about constraints on and improvements in their autonomy and about approaches of health professionals regarding autonomy. The data were analysed using grounded theory, with a particular focus on the process of regaining autonomy. An approach by the health professionals that was responsive to changes in the patients’ autonomy was found to be helpful for restoration of their autonomy. Two patterns in health professionals’ approach appeared to (...) be facilitatory: (1) from full support on admission through moderate support and supervision, to reduced supervision at discharge; and (2) from paternalism on admission through partial paternalism (regarding treatment) to shared decision making at discharge. The approach experienced by the patients did not always match their desires regarding their autonomy. Support and supervision were reduced over time, but paternalism was often continued too long. Additionally, the patients experienced a lack of information. Tailoring interventions to patients’ progress in autonomy would stimulate their active participation in rehabilitation and in decision making, and would improve patients’ preparation for autonomous living after discharge. (shrink)

Modelling human reasoning characterizes the fundamental human cognitive capacity to describe our past experience and use it to form expectations as well as plan and direct our future actions. Natural language semantics analyzes dynamic forms of reasoning in which the real-time order determines the temporal relations between the described events, when reported with telic simple past-tense clauses. It provides models of human reasoning that could supplement ACT-R models.

REFERENCES Barwise, J. & R. Cooper (1981) — 'Generalized Quantifiers and Natural Language', Linguistics and Philosophy 4:2159-219. Van Benthem, J. (1983a) — ' Five Easy Pieces', in Ter Meulen (ed.), 1-17. Van Benthem, J. (1983b) ...

The question of whether old age should or should not play a role in medical decision-making for the elderly patient is regularly debated in ethics and medicine. In this paper we investigate exactly how age influences the decision-making process. To explore the normative argumentation in the decisions regarding an elderly patient we make use of the argumentation model advanced by Toulmin. By expanding the model in order to identify normative components in the argumentation process it is possible to analyse the (...) way that age-related value judgements influence the medical decision-making process. We apply the model to practice descriptions made by medical students after they had attended consultations and meetings in medical practice during their clinical training. Our results show the pervasive character of age-related value judgements. They influence the physician’s decision in several ways and at several points in the decision-making process. Such explicit value judgements were not exclusively used for arguments against further diagnosis or treatment of older patients. We found no systematic “ageist” pattern in the clinical decisions by physicians. Since age plays such an important, yet hidden role in the medical decision-making process, we make a plea for revealing such normative argumentation in order to gain transparency and accountability in this process. An explicit deliberative approach will make the medical decision-making process more transparent and improve the physician–patient relationship, creating confidence and trust, which are at the heart of medical practice. (shrink)

This article reports the findings of a study into the role of Dutch nurses in the alleviation of pain and symptoms with a life-shortening intention, conducted as part of a study into the role of nurses in medical end-of-life decisions. A questionnaire survey was carried out using a population of 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The response rate was 82.0%; 78.1% (1179) were suitable for analysis. The results show that in about half (...) of the cases (55.8%) nurses were involved in the decision making by the physician and that nurses were frequently (81.5%) involved in administering the medication. The authors' conclusion is that alleviation of pain and symptoms with a life-shortening intention represents a `grey' area, in which physicians and nurses act on the basis of personal ethical norms rather than legal rules, professional guidelines or shared moral values. (shrink)

This article reports the findings of a study into the role of Dutch nurses in the alleviation of pain and symptoms with a life-shortening intention, conducted as part of a study into the role of nurses in medical end-of-life decisions. A questionnaire survey was carried out using a population of 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The response rate was 82.0%; 78.1% were suitable for analysis. The results show that in about half of (...) the cases nurses were involved in the decision making by the physician and that nurses were frequently involved in administering the medication. The authors' conclusion is that alleviation of pain and symptoms with a life-shortening intention represents a `grey' area, in which physicians and nurses act on the basis of personal ethical norms rather than legal rules, professional guidelines or shared moral values. (shrink)

Health care policy in the Netherlands has long been guided by the values of solidarity and equality. As a result of several forces, particularly the scarcity of resources, the retreat of the Welfare State and the introduction of market forces in health care, both values are increasingly under strain. Next to solidarity and equality, freedom of choice and financial responsibility are playing an important role in Dutch health care. Consequently, there is a growing division in Dutch heaith care between two (...) tiers, one basic tier giving access to a basic package of services and a luxury tier giving access to a higher quality of care and to services not included in the basic package. The main thesis of the article is that a two-tier system is morally justified on the condition that the basic tier is universally accessible and is based on the value of humanitarian solidarity. Keywords: access to health care, health insurance, resource allocation, solidarity CiteULike Connotea Del.icio.us What's this? (shrink)

The idea that an adequate semantics of ordinary language calls for some theory of events has sparked considerable debate among linguists and philosophers. On the one hand, so many linguistic phenomena appear to be explained if (and, according to some authors, only if) we make room for logical forms in which reference to or quantification over events is explicitly featured. Examples include nominalization, adverbial modification, tense and aspect, plurals, and singular causal statements. On the other hand, a number of deep (...) philosophical questions arise as soon as we take events into consideration. Are events entities of a kind? What are their identity and individuation criteria? How does semantic theorizing depend on such metaphysical issues? The aim of this book is to address such issues in some depth, with emphasis precisely on the interplay between linguistic applications and philosophical implications. Contributors: N. Asher, P. M. Bertinetto, J. Brandl, D. Delfitto, R. Eckardt, J. Higginbotham, A. Lenci, T. Parsons, A. ter Meulen, H. Verkuyl. A comprehensive introductory essay (pp. 3-47) is included. (shrink)

The topic of temporal meaning in texts has received considerable attention in recent years from scholars in linguistics, logical semantics, cognitive science, and artificial intelligence. Representing Time in Natural Language offers a systematic and detailed account of how we use temporal information contained in a text or in discourse to reason about the flow of time, inferring the order in which events happened when this is not explicitly stated. A new representational system is designed to formalize an appropriately context-dependent notion (...) of situated inference. The Dynamic Aspect Tree, representing temporal dependencies, constitutes a novel and important dynamic temporal logic, one that makes it easy to see "what follows when" from the information given in an ordinary English text. (shrink)

The purpose of this paper is to explore the meaning of solidarity and its proper position in the legal frames, with particular focus on health care. Solidarity is often identified with welfare arrangements and social guarantees. In this institutional version, it tends to humiliate citizens and restrict their entrepreneurship. Moreover, administrative solidarity is unable to recognize the actual needs of the most vulnerable members of society, which should be one of its primary concerns. Solidarity, in its original meaning, understood as (...) supportive cooperation of fellow citizens, links their rights and freedoms with mutual duties and responsibilities. Hence, an alternative framework for solidarity should be provided. This framework, committed to the idea of decency, introduces the distinction between the minimum and maximum content of solidarity enforceable by legal means, which should be translated into certain health care practices. (shrink)

Private health insurance is a domain of mutually conflicting models of healthcare systems. Most European healthcare systems are built upon the principles of solidarity and equality, and are provided by public entities. But the private health insurance market can threaten these values, limiting solidarity, equality and universality for the sake of cost effectiveness, consumer choice and market competition. The aim of this article is to analyse these risks and present mechanisms for their mitigation, which would allow the construction of effective (...) and socially acceptable models, or private-public partnerships, in this domain. (shrink)

According to Bayertz the core meaning of solidarity is the perception of mutual obligations between the members of a community. This definition leaves open the various ways solidarity is perceived by individuals in different communities and how it manifests itself in a particular community. This paper explores solidarity as manifested in the context of families in respect of caregiving for a family member who has become dependent because of disease or illness. Though family caregiving is based on the same perception (...) of mutual obligation as the solidarity that supports welfare arrangements in society, the manifestation of solidarity in families is different. Solidarity that underpins welfare arrangements is based on a perception of mutual obligation towards an anonymous dependent other and is enforced by the government. Solidarity in families is directed towards a concrete other and is based on free choice, albeit often accompanied by a strong sense of personal duty. In this paper we try to distinguish between solidarity as a sociological concept and as a moral concept. An important moral element of solidarity, as expressed in families, is the need for recognition of family caregivers, not only of their concrete practical efforts, but also of their own identity as caregivers and as individuals. We illustrate this argument by referring to examples in the Nuffield Council on Bioethics report Dementia : ethical issues, about the experiences of family caregivers in dementia care and the importance for them of recognition of their role. (shrink)

This book critically explores and analyses the scientific and ethical debates surrounding cognitive enhancers. Including contributions from neuroscientists, neuropsychopharmacologists, ethicists, philosophers, public health professionals, and policy researchers, the book offers a multidisciplinary, critical consideration of this topic.

This article tries to analyze the meaning and relevance of the concept of solidarity as compared to the concept of justice. While ‘justice’ refers to rights and duties , the concept of solidarity refers to relations of personal commitment and recognition . The article wants to answer the question whether solidarity and liberal justice should be seen as mutually exclusive or whether both approaches should be regarded as complementary to each other. The paper starts with an analysis of liberal theories (...) of justice which are followed by an analysis of the descriptive and a moral understanding of the concept of solidarity. The importance of solidarity lies in its relational aspects, particularly its emphasis on cooperation and commonality. The paper argues that while solidarity is more fundamental than justice, both concepts are important for the arrangement of health care practices. The paper gives special attention to the concept of decent care, reflective solidarity and humanitarian solidarity which is seen as fundamental for all health care policies and care practices. (shrink)

Evidence-based medicine is seen not only as an important means to improve the quality of medical care, but also as an instrument to control costs. In view of the scarcity of health care resources, decisions on the allocation of care will have to be made more explicitly and should be made more transparent.

Solidarity has for a long time been referred to as the core value underpinning European health and welfare systems. But there has been debate in recent years about whether solidarity, with its alleged communitarian content, can be reconciled with the emphasis on individual freedom and personal autonomy. One may wonder whether there is still a place for solidarity, and whether the concept of justice should be embraced to analyse the moral issues regarding access to health care. In this article, I (...) will answer this question by analysing the normative foundations of the concept of justice, followed by a deeper examination of the concept of solidarity in continental philosophy. More specifically, I will compare the philosophical traditions rooted in Kant to approaches rooted in Hegel. In addition, I will present the work of Avishai Margalit on the decent society to criticize a predominantly liberal approach to access to health care. The importance of solidarity lies particularly in its emphasis on relational aspects and the role of recognition in care practices, which are usually ignored in liberal approaches to justice. However, the article will argue that solidarity is not an alternative to a rights-based concept of justice, but must be considered as a necessary complement to it. (shrink)

This article tries to analyze the meaning of a decent minimum of health care, by confronting the idea of decent care with the concept of justice. Following the ideas of Margalith about a decent society, the article argues that a just minimum of care is not necessarily a decent minimum. The way this minimum is provided can still humiliate individuals, even if the end result is the best possible distribution of the goods as seen from the viewpoint of justice. This (...) analysis is combined with an analysis from the perspective of solidarity, particularly of reflective solidarity, as a way to develop decent care, which is care that does not humiliate individuals and maintains their dignity. (shrink)

This article presents a critical analysis of the views of Michael Sandel on human enhancement in his book The Case Against Perfection (2007). Sandel argues that the use of biotechnologies for human enhancement is driven by a will to mastery or hybris, leading to an ‘explosion of responsibility’ and a disappearance of solidarity. I argue that Sandel is using a traditional concept of solidarity which leaves little room for individual differences and which is difficult to reconcile with the modern trend (...) towards individual autonomy and cultural heterogeneity. With reference to the sociology of Giddens, I argue that the ‘explosion of responsibility’ can be considered an expression of the insecurity in modern society and the need for reflexivity in personal and social life. I argue that the need for reflexivity is a driving social and cultural force behind the interest in human enhancement, and that this trend can go together with a commitment to take care of the needs of others. I agree with Sandel that there is a risk that human enhancement may develop into ‘hybris’, particularly when enhancement is driven by scientism and a naturalist reduction of human values to neurological processes. Enhancement based on scientism will threaten solidarity defined by Honneth as an interactive relationship aimed at the mutual recognition of individual identities in relation to a shared value horizon. I will call for a reflective approach in which human enhancement technologies are explored in the context of a ‘system of reference’. Such a reflective approach will help to protect against the hybris of scientism and to maintain solidarity with vulnerable groups. (shrink)

Logically, weighting is transitive, but similarity is not, so clustering cannot be either. Entailments must help a child to review attribute lists more efficiently. Children's understanding of exceptions to generic claims precedes their ability to articulate explanations. So agency, as enabling constraint, may show coherent covariation with attributes, as mere extensional, observable effect of intensional entailments.

In designing stratified models of human language, understanding notions of logical consequence and validity of inference require separating the aspects of meaning that vary between models from logical constants. Modelling meaning requires choices regarding the primitives, where the Fregean program is still offering us the fundamental insights on the role of truth, judgement, and grasping or sharing of thoughts.

Logicians have always found inspiration for new research in the ordinary language that is used on a daily basis and acquired naturally in childhood. Whereas the logical issues in the foundations of mathematics motivated the development of mathematical logic with its emphasis on notions of proof, validity, axiomatization, decidability, consistency, and completeness, the logical analysis of natural language motivated the development of philosophical logic with its emphasis on semantic notions of presupposition, entailment, modality, conditionals, and intensionality. The relation between research (...) programs in both mathematical and philosophical logic and natural language syntax and semantics as branches of theoretical linguistics has increased in importance throughout the last fifty years. This chapter reviews the development of one particularly interesting and lively area of interaction between formal logic and linguistics—the semantics of natural language. Research in this emergent field has proved fruitful for the development of empirically, cognitively adequate models of reasoning with partial information, sharing or exchanging information, dynamic interpretation in context, belief revision and other cognitive processes. (shrink)

Semantic realism fits Millikan's account of kind terms in its focus on information-theoretic abilities and strategic ways of gathering information in human communication. Instead of the traditional logical necessity, we should interpret rigid designation in a dynamic semantics as a legislative act to constrain possible ways in which our belief may change.