ABSTRACT In The Netherlands, the public funding of a number of health care services is controversial. What can we learn from this about the moral concerns that underlie these judgements? And, if there is anything to learn, can we use this improved understanding to scrutinise the adequacy of particular decisions concerning the public funding of health care services? In the present paper, I will analyse three cases: corrective surgey, In Vitro Fertilisation and liver transplantation. I will summarise the arguments that (...) have been used to support or to challenge the public funding of these services. I will then assess the merits of Daniels’fair equality of opportunity account of justice in health care. Can this account improve our understanding of the moral concerns underlying our judgements about the public funding of these services? Can it serve to scrutinise the adequacy of particular decisions that are made concerning the public funding of health care services? My answer to both questions will be a qualified yes. Daniels’account can provide guidance, but not because we can deductively infer from it what is right and what is wrong. Instead, I will argue for a more casuistic use of the concept of fair equality of opportunity. (shrink)

Health technology assessment consists of thesystematic study of the consequences of theintroduction or continued use of the technology in aparticular context, with the explicit objective toarrive at a judgment of the value or merit of thetechnology. Ideally, it is aimed at assessing allaspects of a given technology or group oftechnologies, including non-technical, e.g.socio-ethical, aspects. However, methods for assessingsocio-ethical implications of health technology arerelatively undeveloped and few mechanisms exist totake action based on the results of such evaluations.Still, the examples of cochlear (...) inplants and other cases illustratethat HTA is not a matter of merely collecting thefacts about a technology. The facts must beplausible and relevant from a particular framework,which is not always shared by different groups. It ishere that socio-ethical aspects are encountered. Ifhealth technology assessment aims to enhance theaccountability of the decision making processregarding funding and use of health technology, it isa major challenge to assessors of health technologiesto deal adequately with existing value pluralism. Inthis respect interactive evaluation may have somethingto offer. (shrink)

Health technology assessment (HTA) is often biased in the sense that it neglects relevant perspectives on the technology in question. To incorporate different perspectives in HTA, we should pursue agreement about what are relevant, plausible, and feasible research questions; interactive technology assessment (iTA) might be suitable for this goal. In this way a kind of procedural ethics is established. Currently, ethics too often is focussed on the application of general principles, which leaves a lot of confusion as to what really (...) is the matter in specific cases; in an iTA clashes of values should not be approached by use of such ethics. Instead, casuistry, as a tool used within the framework of iTA, should help to articulate and clarify what is the matter, as to make room for explication and consensus building. (shrink)

Health technology assessment (HTA) is often biased in the sense that it neglects relevant perspectives on the technology in question. To incorporate different perspectives in HTA, we should pursue agreement about what are relevant, plausible, and feasible research questions; interactive technology assessment (iTA) might be suitable for this goal. In this way a kind of procedural ethics is established. Currently, ethics too often is focussed on the application of general principles, which leaves a lot of confusion as to what really (...) is the matter in specific cases; in an iTA clashes of values should not be approached by use of such ethics. Instead, casuistry, as a tool used within the framework of iTA, should help to articulate and clarify what is the matter, as to make room for explication and consensus building. (shrink)

Two answers to the question ‘how can we allocate health care resources fairly?’ are introduced and discussed. Both utilitarian and egalitarian approaches are found relevant, but both exhibit considerable theoretical and practical difficulties. Neither seems capable of solving the problem on its own. It is suggested that, for practical purposes, a version of Rawls' famous thought experiment might provide at least some enlightenment about which theoretical approach should be used to address the question.

ABSTRACTIn The Netherlands, the public funding of a number of health care services is controversial. What can we learn from this about the moral concerns that underlie these judgements? And, if there is anything to learn, can we use this improved understanding to scrutinise the adequacy of particular decisions concerning the public funding of health care services? In the present paper, I will analyse three cases: corrective surgey, In Vitro Fertilisation and liver transplantation. I will summarise the arguments that have (...) been used to support or to challenge the public funding of these services. I will then assess the merits of Daniels’fair equality of opportunity account of justice in health care. Can this account improve our understanding of the moral concerns underlying our judgements about the public funding of these services? Can it serve to scrutinise the adequacy of particular decisions that are made concerning the public funding of health care services? My answer to both questions will be a qualified yes. Daniels’account can provide guidance, but not because we can deductively infer from it what is right and what is wrong. Instead, I will argue for a more casuistic use of the concept of fair equality of opportunity. (shrink)

The Dutch health care system is developing a two, or multiple, tier system. How can moral principles be of help in assessing whether this is the right track? Instead of dismissing as unhelpful the principles that have been suggested so far and exchanging them for other, usually more complex, principles, it is suggested that the methods of moral inquiry be reconsidered. Keywords: diversification in health care, health care financing, public and private responsibility in health care CiteULike Connotea Del.icio.us What's this?

From 1991 to 1994 the Dutch Health Insurance Council financed research on Extracorporeal Membrane Oxygenation (ECMO). This is a technique for providing cardiopulmonary bypass to patients with pulmonary and/or cardiac failure. Most often, these patients are premature neonates. During ECMO, blood is drained from the right atrium, pumped along a membrane where gas exchange takes place, and then redirected to the aorta. To prevent blood clotting, heparin is added. However, with the heparin added, the risk of hemorrhage is considerably increased. (...) Therefore, both the chance of surviving and the chance of severe disability are higher with ECMO than with conventional treatment (i.e., ventilator support). (shrink)

From 1991 to 1994 the Dutch Health Insurance Council financed research on Extracorporeal Membrane Oxygenation . This is a technique for providing cardiopulmonary bypass to patients with pulmonary and/or cardiac failure. Most often, these patients are premature neonates. During ECMO, blood is drained from the right atrium, pumped along a membrane where gas exchange takes place, and then redirected to the aorta. To prevent blood clotting, heparin is added. However, with the heparin added, the risk of hemorrhage is considerably increased. (...) Therefore, both the chance of surviving and the chance of severe disability are higher with ECMO than with conventional treatment. (shrink)

In the field of health technology assessment, there are several approaches that can be used for ethical analysis. However, there is a scarcity of literature that critically evaluates and compares the strength and weaknesses of these approaches when they are applied in practice. In this paper, we analyse the applicability of some selected approaches for addressing ethical issues in HTA in the field of complex health interventions. Complex health interventions have been the focus of methodological attention in HTA. However, the (...) potential methodological challenges for ethical analysis are as yet unknown.Six of the most frequently described and applied ethical approaches in HTA were critically assessed against a set of five characteristics of complex health interventions: multiple and changing perspectives, indeterminate phenomena, uncertain causality, unpredictable outcomes, and ethical complexity. The assessments are based on literature and the authors’ experiences of developing, applying and assessing the approaches.The Interactive, participatory HTA approach is by its nature and flexibility, applicable across most complexity characteristics. Wide Reflective Equilibrium is also flexible and its openness to different perspectives makes it better suited for complex health interventions than more rigid conventional approaches, such as Principlism and Casuistry. Approaches developed for HTA purposes are fairly applicable for complex health interventions, which one could expect because they include various ethical perspectives, such as the HTA Core Model® and the Socratic approach.This study shows how the applicability for addressing ethical issues in HTA of complex health interventions differs between the selected ethical approaches. Knowledge about these differences may be helpful when choosing and applying an approach for ethical analyses in HTA. We believe that the study contributes to increasing awareness and interest of the ethical aspects of complex health interventions in general. (shrink)

A possible explanation for policy implementation failure is that the views of the policy’s target groups are insufficiently taken into account during policy development. It has been argued that involving these groups in an interactive process of policy development could improve this. We analysed a project in which several target populations participated in workshops aimed to optimise the utilisation of an expensive novel drug (interferon beta) for patients with Multiple Sclerosis. All participants seemed to agree on the appropriateness of establishing (...) a central registry of Multiple Sclerosis patients and developing guidelines. Nevertheless, these policy measures were not implemented. Possible explanations include (1) the subject no longer had high priority when the costs appeared lower than expected, (2) the organisers had paid insufficient attention to the perceived problems of parties involved, and (3) changes within the socio-political context. The workshops in which representatives of the policy’s target populations participated did not provide enough interactivity to prevent policy implementation failure. (shrink)

The participation of vulnerable patients in clinical research poses apparent ethical dilemmas. Depending on the nature of the vulnerability, their participation may challenge the ethical principles of autonomy, non-maleficence, or justice. On the other hand, non-participation may preclude the building of a knowledge base that is a prerequisite for defining the optimal clinical management of vulnerable patients. Such clinical uncertainty may also incur substantial economic costs. We present the participation of pre-menopausal women with atrial fibrillation in trials of novel oral (...) anticoagulant drugs as a case study. Due to their non-participation in pivotal trials, it is uncertain whether for them, the risks that are associated with these drugs are outweighed by the advantages compared with conventional treatment. We addressed the question whether research of this new class of drugs in this subgroup would be appropriate from both, an ethical as well an economic perspective. We used the method of specifying norms as a wider framework to resolve the apparent ethical dilemma, while incorporating the question whether research of oral anticoagulants in premenopausal women with atrial fibrillation can be justified on economic grounds. For the latter, the results of a value-of-information analysis were used. Further clinical research on NOACs in premenopausal women with atrial fibrillation can be justified on both, ethical and economic grounds. Addressing apparent ethical dilemmas by invoking a method such as specifying norms can improve the quality of public practical reasoning. As such, the method should also prove valuable to committees that have formally been granted the authority to review trial protocols and proposals for scientific research. (shrink)

Medical technology assessment deals with the evaluation of novel or existing health care procedures. This paper addresses the interdependence between factual and normative issues, using the controversies about acceptability and desirability of reduced-size liver transplantations with living donors as example.

The much-acclaimed present-day philosophical turn to the letters of Saint Paul points to a profound consonance between ancient and modern thought. Such is the bold claim of this study in which scholars from contemporary continental philosophy, new testamentary studies and ancient philosophy discuss with each other the meaning Paul's terms pistis, faith. In this volume, this theme discusses in detail the threefold relation between Paul and continental thought, the Graeco-Roman world, and political theology. It is shown that pistis does not (...) only concern a mode of knowing, but rather concerns the human ethos or mode of existence as a whole. Moreover, it is shown that the present-day political theological interest in Paul can be seen as an attempt to recuperate Paul’s pistis in this comprehensive sense. Finally, an important discussion concerning the specific ontological implications and background of this reinterpretation of pistis is examined by comparing the ancient ontological commitments to those of the present-day philosophers. Thus, the volume offers an insight in a crucial consonance of ancient and modern thought concerning the question of pistis in Paul while not forgetting to stipulate important differences. (shrink)

A systematic study of testimony rooted in contemporary continental philosophy and drawing on literary case studies. From analytic epistemology to gender theory, testimony is a major topic in philosophy today. Yet, one distinctive approach to testimony has not been fully appreciated: the recent history of contemporary continental philosophy offers a rich source for another approach to testimony. In this book, Gert-Jan van der Heiden argues that a continental philosophy of testimony can be developed that is guided by those forms (...) of bearing witness that attest to limit experiences of human existence, in which the human is rendered mute, speechless, or robbed of a common understanding. In the first part, Van der Heiden explores this sense of testimony in a reading of several literary texts, ranging from Plato’s literary inventions to those of Kierkegaard, Melville, Soucy, and Mortier. In the second part, based on the orientation offered by the literary experiments, Van der Heiden offers a more systematic account of testimony in which he distinguishes and analyzes four basic elements of testimony. In the third part, he shows what this analysis implies for the question of the truth and the truthfulness of testimony. In his discussion with philosophers such as Heidegger, Derrida, Lyotard, Agamben, Foucault, Ricoeur, and Badiou, Van der Heiden also provides an overview of how the problem of testimony emerges in a number of thinkers pivotal to twentieth- and twenty-first-century thought. “The Voice of Misery is a special book. Van der Heiden has presented an argument that is poised to challenge discourse in analytic philosophy, reshape approaches in continental philosophy, and give new orientation to interdisciplinary research in continental philosophy and literary theory. The book will find a large readership across the discipline of philosophy and in several areas of the humanities.” — Theodore George, author of Tragedies of Spirit: Tracing Finitude in Hegel’s Phenomenology. (shrink)

Symptomatic of the crisis of the current global political order are the millions of displaced that have fled their homes but are not allowed to enter the country in which they seek refuge. Instead, they are placed in camps. To understand the site of the camp and the bare life it produces, testimonies of refugees are indispensable. This essay aims to examine and listen to these testimonies by, first, introducing the notion of testimony and some of the characteristics of the (...) testimony of refugees; second, examining what it means to listen to testimony and which role is played therein by the narrative, literary structure of testimony; and, third, by interpreting the form of life to which the testimonies of the camp attest, which several witnesses describe as a life in “limbo.” This essay concludes with some brief remarks on the relation between experience, truth, and language in testimony. (shrink)

_Phenomenological Perspectives on Plurality_ offers twelve essays that discuss how the question of plurality is thought in contemporary continental philosophy. Its essays investigate how this issue influences topics in ontology, aesthetics, and social and political philosophy.

ABSTRACTThe remarkable philosophical present-day turn to Paul pays a lot of attention to the particular role played by the famous distinctions that structure Paul’s rhetoric such as the distinction between faith and law, life and death, and spirit and flesh. These distinctions lead to the question of whether Paul endorses a dualism or not. In this essay, the author investigates Badiou’s and Agamben’s readings of Paul and asks whether one cannot find a form of dialectics rather than dualism in these (...) readings. The concept of the exception seems to corroborate this suggestion. To examine whether this suggestion makes sense, the author first discusses Badiou’s focus on the antidialectics of death and resurrection as well as the dialectical remnants in Badiou’s reading of Paul. Subsequently, the author analyses Agamben’s dialectical account of the Pauline terms katargein, chrēsis and charis. (shrink)

In both “Answering for Sense” and “Sharing Voices,” Jean-Luc Nancy offers an account of the poet as an interpreter of the gods. The voice of the poet in both Homer’s Iliad and Plato’s Ion is intrinsically and originally doubled. Although there is no divine voice outside of the poet’s voice, the divine voice speaks in the poet’s voice and the poetic voice gives a voice to that of the goddess or the muse. What exactly is at stake in this phenomenon (...) that we encounter here in the poet, namely that of gods making us speak? How is it related to the threshold of speech and communication that Nancy invokes in Adoration, when he also mentions the gods that make us speak? In this essay, I want to think with Nancy to see what is at stake in the figure of a voice on the threshold of speech and communication. I consider how the figure of the gods that make us speak is brought into play to elucidate the threshold of language and how this figure, as that which makes us speak, somehow offers the crossing of this threshold. To this end, I want to discuss three different figures or scenes in which the gods make us speak. In the first part of this article, I explore in more detail Nancy’s own account of the poet as interpreter of the divine voice. What does it mean for the poet to give a voice to the goddess and to desire this giving a voice? What is the demand or call to which the poet in giving a voice answers? To further the analysis of this divine interpreter, I want to compare this interpreter with two other ones which arise in two other basic scenes in which the gods make an interpreter speak. The first concerns the scene of the calling of the prophet Jeremiah in the book of the same name. The second concerns Saint Paul’s reflections on the glossolalist in the First Letter to the Corinthians. By exploring the differences between these three divine interpreters, I aim to further elucidate and assess the phenomenon of the interpreter and the double voice that characterizes Nancy’s poet. (shrink)

In order to develop a hermeneutic-phenomenological analysis of testimony, this essay will first argue that testimony is “said in many ways” without being homonymous and that contemporary epistemological approaches to testimony are not capable of accounting for all paradigmatic forms of testimony. Second, it is argued, following and extending the work of Paul Ricoeur, that by emphasizing the sense of engagement or Bezogenheit as a basic characteristic of testimony, we may find another approach to testimony that offers a phenomenological alternative (...) to the observational model of witnessing and the accompanying conception of testimony as report. Third, this approach is further developed and analyzed in terms of the four elements of testimony, namely, subject matter, witness, act of testifying, and addressee. (shrink)

The last two volumes of Giorgio Agamben’s Homo Sacer series are concerned with developing a theory of use. This article offers a critical assessment of the two concepts, use and form-of-life, that form the heart of this theory: how do these two notions offer a solution to the problem of bare life that forms the core of the Homo Sacer series? First, the author describes how the original problem of bare life is taken up in The Use of Bodies and (...) how the notion of use offers an important additional characteristic of bare life. Second, inspired by Foucault’s analysis of ancient Cynicism, the author discusses in which sense the type of ‘solution’ Agamben offers to the problem of bare life might be seen as an heir to ancient Cynicism and how this interpretation clarifies his connection of form-of-life and exile. Third, the author critically assesses the different usages of use that we can find in Agamben, by comparing how Franciscan usus, Pauline chrēsis and Platonic chrēsis are taken up in his analysis. Fourth, following Foucault, the author deepens the Platonic sense of use and its relation to taking care of justice. The article concludes with a critical assessment of Agamben’s reading of Plato’s myth of Er, in which the motifs of use, exile, and care are gathered. (shrink)

This volume explores the issues at the center of many historical and contemporary reflections on community and sociality in Continental philosophy. The essays reflect on the thought of Nietzsche, Heidegger, Levinas, Arendt, Derrida, Badiou, Fanon, Baldwin, Nancy, Agamben and Laruelle. Continental Perspectives on Community brings the different approaches of these thinkers into conversation with each other. It discusses the possibility of how the concept of community can extend beyond the one and beyond any sense of unity and totality. Additionally, the (...) book shows how notion of community in plurality is at the heart of ethical and political reflections on alterity and race, of political philosophical reflections on the exception, and of ontological reflections on what it means for humans to be social. In this way, it offers an important contribution to the examination of how a community can be thought today. This book will be of interest to scholars and advanced students working on social, political, and cultural issues in Continental philosophy. (shrink)

Heidegger has often been considered as the proponent of the end of metaphysics in the post-Hegelian philosophy, due to his persistent attempts to overcome the onto-theological framework of traditional metaphysics. Yet, this dismissal of metaphysical, theological, and religious motives is deeply ambiguous since new forms of metaphysical and religious experience re-emerge in his philosophical works. Heidegger shares this ambiguous relation to the notions of faith and religion with authors such as Nietzsche and Wittgenstein whose works are also marked by a (...) critique of metaphysics and by a characteristic rethinking of the role of faith and religion. In fact, all three still remain, among other things, reference points for contemporary philosophical debates relating to the phenomenon of religion and faith. Rethinking Faith explores how the phenomena of religion and faith are present in the works of Heidegger, Nietzsche, and Wittgenstein, and how these phenomena are brought into play in their discussion of the classical metaphysical motives they criticize. (shrink)

In this short introduction, the guest editors present the main themes of the special issue.

One of the key concepts of Paul Ricoeur’s hermeneutics is the notion of distanciation. In this article we show that Ricoeur introduces this notion as a correction of Heidegger’s focus on being-in and Gadamer’s emphasis on belonging . Ricoeur argues that distanciation does not lead to the uprooting of our belonging to a tradition. Rather, distanciation is an integral part of the dynamics that constitutes tradition. We discuss the different senses in which Ricoeur understands distanciation as a positive and productive (...) aspect of tradition. In particular, we discuss the ontological aspect of distanciation. In his discussion of both the long way of hermeneutics and the creative dimension of distanciation in fiction, Ricoeur argues that it is distanciation that opens up the possibility of understanding our own being-in-the-world. This involvement of distanciation in the disclosure and understanding of being allows us to show that distanciation determines what “kind” of being is understood: what is interpreted in hermeneutics and disclosed in poetics is never being as such, but “being-interpreted” and “being-as,” respectively. This leads us to a description of the difference between Ricoeur’s and Heidegger’s thought concerning the ontological dimension of their hermeneutics. (shrink)

In this essay, the author takes up the responses of Dennis J. Schmidt and Carolyn Culbertson to his monograph The Voice of Misery: A Continental Philosophy of Testimony. It first observes that both respondents have a shared interest in the ethical dimension of the question of testimony, which has much to do with the exceptional subject matter, namely that of bare life, that The Voice of Misery takes as its point of departure to analyze what testimony is. In the first (...) section, the author engages with Schmidt’s account of the importance of Heidegger, Plato’s myth of Er and Celan’s poetry for thinking testimony and shows how exactly these references allow us to think the ethos and the ethics of textimony. In the second section, he discusses the three questions Culbertson raised concerning the practical, more everyday stakes of testimony in relation to the epistemology of testimony and the question of epistemic justice. (shrink)

Departing from two diverging lines of inquiry of testimony that characterize philosophy today, this article aims to show what a hermeneutic phenomenology of witnessing and testimony is and how this approach to testimony offers a new framework to understand witnessing and testimony, which also repositions the present-day main lines of inquiry of testimony. The first section offers a critical assessment of the state of the art in the philosophy of testimony today and the second section reinterprets the two main diverging (...) lines of inquiry as a conflict. The major part of this article is devoted to a hermeneutic-phenomenological account of witnessing and testimony. The third and fourth sections describe several relations between subject matter, witness, acts of bearing witness, and addressee, to develop this hermeneutic-phenomenological framework and in the process also shows which place is awarded to the two main lines of the present-day inquiry within this framework. (shrink)

Ricoeur’s hermeneutics provides us with an important and original account of the meaning and the implications of the “ontological turn” that has taken place in hermeneutics since Heidegger’s work. By means of the pair ontologisation and hermeneutisation, which is borrowed from Jean Grondin, this paper examineshow Ricoeur rethinks the relation between being and language. Distancing itself from Nancy’s critique of Ricoeur’s hermeneutics, this paper first shows thatRicoeur’s hermeneutic ontology should not be understood as a “secondary” form of hermeneutics. Rather, it (...) provides us with a critical revision of Heidegger’s “primordial” hermeneutics that is centered on the notion of announcement. Secondly, it shows how, by this revision, Ricoeur does not only develop an alternative to Heidegger’s accounts of announcement and attestation, but also to Derrida’s account of equivocity. (shrink)

ABSTRACTThe remarkable philosophical present-day turn to Paul pays a lot of attention to the particular role played by the famous distinctions that structure Paul’s rhetoric such as the distinction between faith and law, life and death, and spirit and flesh. These distinctions lead to the question of whether Paul endorses a dualism or not. In this essay, the author investigates Badiou’s and Agamben’s readings of Paul and asks whether one cannot find a form of dialectics rather than dualism in these (...) readings. The concept of the exception seems to corroborate this suggestion. To examine whether this suggestion makes sense, the author first discusses Badiou’s focus on the antidialectics of death and resurrection as well as the dialectical remnants in Badiou’s reading of Paul. Subsequently, the author analyses Agamben’s dialectical account of the Pauline terms katargein, chrēsis and charis. (shrink)

Investigating Subjectivity examines the importance of a phenomenological account of the subject for the nature and the status of phenomenology, for different themes from practical philosophy and in relation to issues from the philosophy of mind.

In this article, I will explore the archeology of the concept of attestation in Ricoeur’s work. In a brief discussion of his early reflections on Husserl’s concept of the ego (as an example of reflexive philosophy), I show how the dialectic of trust and suspicion enters Ricoeur’s hermeneutic concerns. I argue that this dialectics remains present in his account of attestation. By a brief confrontation with Heidegger’s notion of attestation as developed in Being and Time, I show that the uniqueness (...) of Ricoeur’s account of attestation is to be found in this dialectic of trust and suspicion that he reinterprets in his later work in light of the concept of attestation. (shrink)