Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls' A Theory of Justice in 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls' A Theory of Justice has been (...) remodeled for healthcare philosophy by Norman Daniels. Nozick's libertarian manifesto Anarchy, State, and Utopia has been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare. (shrink)

Family members do not have an official position in the practice of euthanasia and physician assisted suicide in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point (...) for further empirical and ethical inquiry. A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies. Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families’ experiences and grief after EAS. 4) Family and ‘the good euthanasia death’ according to Dutch physicians. Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making. (shrink)

In this article I will argue that there are two theories of distributive justice hidden in Walzer's Spheres of Justice. The first one emphasises the separation of distributive spheres. It tries to formulate distributive criteria by sticking faithfully to sphere‐specificity. I shall refer to this theory as ‘pure pluralism’. The second theory downplays the separation of spheres and emphasises ‘across spheres’ or ‘between spheres’ criteria instead. I shall call this theory ‘mitigated pluralism’. Mitigated pluralism has become popular among Walzer's friendly (...) critics who apparently do not want to charge him with a distributive theory as clear and rigid as pure pluralism. Although I consider myself another friendly critic, I shall argue in favour of pure pluralism. (shrink)

All articles in May 2019’s special issue of Bioethics offer profound insights into the issue of “being a burden to others” in relation to wishes to die, which are highly relevant for ethical debates about end‐of‐life care and physician‐assisted dying. In this reply, we wish to stress the importance of acknowledging and analyzing the sociopolitical context of the phenomenon “being a burden” in relation to wishes to die and we will show how this analysis could benefit from a care ethical (...) approach. As discussions in care ethics have made clear, caring practices are both social and political practices. An empirical and ethical analysis of “being a burden” therefore needs to take institutional and societal norms and structures into account, in addition to first‐person experiences and concepts such as caring needs, relational autonomy, and interdependency. Besides the relevance of the sociopolitical context for the phenomenon “being a burden” as such, the sociopolitical context also seems relevant for the investigation of the phenomenon, which we will illustrate by reflecting on “being a burden” in relation to the practice of physician‐assisted dying in the Netherlands. (shrink)

Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls'A Theory of Justicein 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls'A Theory of Justicehas been remodeled for healthcare philosophy (...) by Norman Daniels. Nozick's libertarian manifestoAnarchy, State, and Utopiahas been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker (be it Christopher Lasch, Alisdair Maclntyre, or Amitai Etzioni) in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare. (shrink)

In the 1970s policy making in the Netherlands took place in sectoral networks, consisting of professional interest groups and like minded civil servants, advisory councils, MPs and departmental ministers. In this article the author examines whether such a sectoral policy network still exists in Dutch health care by comparing past and present data on the background of civil servants, mp’s and departmental ministers. Next she describes the political fight against the health care sectoral network, which has gone on for decades. (...) She concludes that the health care sectoral network has been severely weakened, although it remains to be seen whether this will lead to a substantial reduction of health care costs, which was one of the main reasons why politicians fought against sectoral interests in the first place. (shrink)

Encompassing health care systems in modern welfarestates embody several forms of solidarity: between thesick and the healthy, the old and the young andbetween those who take good care of their health onthe one hand and fellow citizens who choose to risktheir lives by smoking or unsafe sex on the other. Thelatter form is called lifestyle solidarity. In theNetherlands this type of solidarity has become theobject of a debate between medical ethicists. Mostmedical ethicist seem to want to uphold lifestylesolidarity. Most Dutch (...) citizens agree with them. TheDutch government, however, embarked on a project tochange the health care system by transferring stateresponsibilities to other actors (employers, insurers,individuals). This changing policy may diminish ordestroy lifestyle solidarity despite the fact that noone intended this to happen. (shrink)

Patient organizations increasingly play an important role in health care decision-making in Western countries. The Netherlands is one of the countries where this trend has gone furthest. In the literature some problems are identified, such as instrumental use of patient organizations by care providers, health insurers and the pharmaceutical industry. To strengthen the position of patient organizations government funding is often recommended as a solution. In this paper we analyze the ties between Dutch government and Dutch patient organizations to learn (...) more about the effects of such a relationship between government and this part of civil society. Our study is based on official government documents and existing empirical research on patient organizations. We found that government influence on patient organizations has become quite substantial with government influencing the organizational structure of patient organizations, the activities these organizations perform and even their ideology. Financing patient organizations offers the government an important means to hold them accountable. Although the ties between patient organizations and the government enable the former to play a role that can be valued as positive by both parties, we argue that they raise problems as well which warrant a discussion on how much government influence on civil society is acceptable. (shrink)

Jacobson finds two distinct meanings of “dignity” in the literature on dignity and health: intrinsic human dignity and social dignity constituted through interactions with caregivers. Especially the latter has been central in empirical health research and warrants further exploration. This article focuses on the social dignity of people marginalized by mental illness, substance abuse and comparable conditions in extramural settings. 35 studies published between 2007 and 2017 have addressed this issue, most of them identifying norms for social dignity: civilized interactions, (...) non-stigmatizing treatment, treatment as unique individuals, being taken seriously, maintaining a positive identity, experiencing independence, relating to others, and participating in daily life. We argue that these norms belong to ideal theory, whereas we agree with Robeyns and others that improving practice is better served by non-ideal theory. Towards this end, we derive from the literature four building blocks for a non-ideal theory of dignity: avoid violations of dignity rather than seeking to promote it; dignity is not a goal to be reached; it requires ongoing effort; promoting dignity is a balancing act; contradictory norms can make it impossible to realize; and dignity can be undermined by organizational and discursive constraints. (shrink)

BackgroundThe Netherlands is one of the few countries where euthanasia is legal under strict conditions. This study investigates whether Dutch newspaper articles use the term ‘euthanasia’ according to the legal definition and determines what arguments for and against euthanasia they contain.MethodsWe did an electronic search of seven Dutch national newspapers between January 2009 and May 2010 and conducted a content analysis.ResultsOf the 284 articles containing the term ‘euthanasia’, 24% referred to practices outside the scope of the law, mostly relating to (...) the forgoing of life-prolonging treatments and assistance in suicide by others than physicians. Of the articles with euthanasia as the main topic, 36% described euthanasia in the context of a terminally ill patient, 24% for older persons, 16% for persons with dementia, and 9% for persons with a psychiatric disorder. The most frequent arguments for euthanasia included the importance of self-determination and the fact that euthanasia contributes to a good death. The most frequent arguments opposing euthanasia were that suffering should instead be alleviated by better care, that providing euthanasia can be disturbing, and that society should protect the vulnerable.ConclusionsOf the newspaper articles, 24% uses the term ‘euthanasia’ for practices that are outside the scope of the euthanasia law. Typically, the more unusual cases are discussed. This might lead to misunderstandings between citizens and physicians. Despite the Dutch legalisation of euthanasia, the debate about its acceptability and boundaries is ongoing and both sides of the debate are clearly represented. (shrink)

To explore whether market reforms in a health care system affect medical professional ethics of hospital-based specialists on the one hand and physicians in independent practices on the other. Qualitative interviews with 27 surgeons and 28 general practitioners in The Netherlands, held 2–3 years after a major overhaul of the Dutch health care system involving several market reforms. Surgeons now regularly advertise their work (while this was forbidden in the past) and pay more attention to patients with relatively minor afflictions, (...) thus deviating from codes of ethics that oblige physicians to treat each other as brothers and to treat patients according to medical need. Dutch GPs have abandoned their traditional reticence and their fear of medicalization. They now seem to treat more in accordance with patients’ preferences and less in accordance with medical need. Market reforms do affect medical professional principles, and it is doubtful whether these changes were intended when Dutch policy makers decided to introduce market elements in the health care system. Policy makers in other countries considering similar reforms should pay attention to these results. (shrink)

Health care has become increasingly patient-centred and medical guidelines are considered to be one of the instruments that contribute towards making it so. We reviewed the literature to identify studies on this subject. Both normative and empirical studies were analysed. Many studies recommend active patient participation in the process of guideline development as the instrument to make guidelines more patient-centred. This is done on the assumption that active patient participation will enhance the quality of the guidelines. We found no empirical (...) evidence, however, to support this assumption. Moreover, the studies show that patients experience several difficulties in the participation process, which cannot solely be traced back to flawed practices. Given this poor track record we conclude that the plea to actively involve patients in the guideline development process should be reconsidered. (shrink)

Patient organizations increasingly play an important role in health care decision-making in Western countries. The Netherlands is one of the countries where this trend has gone furthest. In the literature some problems are identified, such as instrumental use of patient organizations by care providers, health insurers and the pharmaceutical industry. To strengthen the position of patient organizations government funding is often recommended as a solution. In this paper we analyze the ties between Dutch government and Dutch patient organizations to learn (...) more about the effects of such a relationship between government and this part of civil society. Our study is based on official government documents and existing empirical research on patient organizations. We found that government influence on patient organizations has become quite substantial with government influencing the organizational structure of patient organizations, the activities these organizations perform and even their ideology. Financing patient organizations offers the government an important means to hold them accountable. Although the ties between patient organizations and the government enable the former to play a role that can be valued as positive by both parties, we argue that they raise problems as well which warrant a discussion on how much government influence on civil society is acceptable. (shrink)

The first book to provide a full overview of human--animal studies, this volume focuses on the conceptual construction of animals in American culture and the way in which it reinforces and perpetuates hierarchical human relationships rooted ...

The distinction between clinical practice and surgical research may seem trivial, but this distinction can become a complex issue when innovative surgeries are substituted for standard care without patient knowledge. Neither the novelty nor the risk of a new surgical procedure adequately defines surgical research. Some institutions tacitly allow the use of new surgical procedures in series of patients without informing individuals that they are participating in a scientific study, as long as no written protocol or hypothesis exists. Institutions can (...) justify this practice by viewing human research in narrow terms as an activity outlined in a formal protocol. Application of limited definitions, however, erodes patients' rights and risks losing public confidence in how biomedical research is conducted. I propose an operational definition of human research also be recognised. Enforcing more rigid and less ambiguous guidelines of human research may curtail enrolment into some studies, but it will also protect patients from being used as subjects without their knowledge. (shrink)

Dietary restriction (DR) famously extends lifespan and reduces fecundity across a diverse range of species. A prominent hypothesis suggests that these life‐history responses evolved as a survival‐enhancing strategy whereby resources are redirected from reproduction to somatic maintenance, enabling organisms to weather periods of resource scarcity. We argue that this hypothesis is inconsistent with recent evidence and at odds with the ecology of natural populations. We consider a wealth of molecular, medical, and evolutionary research, and conclude that the lifespan extension effect (...) of DR is likely to be a laboratory artifact: in contrast with captivity, most animals living in natural environments may fail to achieve lifespan extension under DR. What, then, is the evolutionary significance of the suite of responses that extend lifespan in the laboratory? We suggest that these responses represent a highly conserved nutrient recycling mechanism that enables organisms to maximize immediate reproductive output under conditions of resource scarcity. (shrink)

Collective intelligence in organizational teams has been predominantly understood and explained in terms of the quality of the outcomes that the team produces. This manuscript aims to extend the understanding of CI in teams, by disentangling the core of actual collective intelligent team behavior that unfolds over time during a collaboration period. We posit that outcomes do support the presence of CI, but that collective intelligence itself resides in the interaction processes within the team. Teams behave collectively intelligent when the (...) collective behaviors during the collaboration period are in line with the requirements of the tasks the team is assigned to and the environment. This perspective results in a challenging, but promising research agenda armed with new research questions that call for unraveling longitudinal fine-grained interactional processes over time. We conclude with exploring methodological considerations that assist researchers to align concept and methodology. In sum, this manuscript proposes a more direct, thorough, and nuanced understanding of collective intelligence in teams, by disentangling micro-level team behaviors over the course of a collaboration period. With this in mind, the field of CI will get a more fine-grained understanding of what really happens at what point in time: when teams behave more or less intelligently. Additionally, when we understand collectively intelligent processes in teams, we can organize targeted interventions to improve or maintain collective intelligence in teams. (shrink)

Many or almost all writers about truth seem to agree that the entailment by a more or less formal account of truth of all the instances of the so-called disquotational schema - (DQ) <p> is true if and only if p - is at least a necessary condition for this account to count as an adequate account of truth. My first task in this paper is to show that the correctness of the observation (DQ) does not by itself imply that (...) truth lacks substance. My second task is to establish the instances of (DQ) as not only necessary but also sufficient for a characterisation of truth. Such a minimal theory of truth would seem to rob truth of all substance but going in for a more eloquent alternative as I shall attempt to show could result in an unwanted epistemisation of truth. (shrink)

In his book Neoliberalism’s War on Higher Education, Henry Giroux bemoans, “[H]igher education increasingly stands alone, even in its attenuated state, as a public arena where ideas can be debated, critical knowledge produced, and learning linked to important social issues.”1 Colleges of education, like public schools themselves, have become more fragmented and compartmentalized in recent years. Persistent at universities is “the view that students are basically consumers and faculty providers of a saleable commodity such as a credential or a set (...) of workplace skills.”2 Professors and teachers alike feel the impact of neoliberal policies aimed at efficiency and productivity, which further alienate and emphasize data... (shrink)

France and New Caledonia are currently involved in an ongoing debate surrounding the independence of the latter from the former that will lead to referenda in 2018–2022. The main stakeholders in the negotiation process are France, the Caldoche population of the island agglomeration and its Kanak inhabitants. Most critical discourse studies analyse texts as expressions of power entrenched in monologues. In this paper, however, the debate between the social actors is seen as a plurilogue. The study argues that the dominant (...) interactants propagate a rhetoric of unity and homogeneity, aiming to further marginalise the Kanak people and other minority groups in New Caledonian society by rendering them invisible. It further argues that the French political power aims to persuade the other groups to accept the reality of a common destiny as a given truth. The paper combines Systemic Functional Linguistics and Pragma-dialectics, and incorporates postcolonial and poststructuralist perspectives into a critical study of discourse samples, taken from a larger corpus of French data, across various genres and registers. The analysis reveals that the French rhetoric of unity is built upon Republican principles inherent to neo-colonialist ideology. It also shows that the French rhetoric is being reproduced by local settler interactants, based on values that pertain to Caldoche nationalist ideology. Both French and Caldoche ideologies are in discord with Kanak socialist ideology. By exposing the existing power inequalities the study does not only contribute to defending the Kanak minority discourse, but also emphasises the rights for recognition and self-determination of the Kanak indigenous people of New Caledonia. (shrink)

«Le droit et la science en action», ce titre est la parfaite illustration les domaines d’intérêts de l’auteure dont les textes ici présentés, Sheila Jasanoff, et ceux de l’auteur de la traduction et de la présentation des dits textes, Olivier Leclerc. Ce livre publié aux éditions Dalloz dans la collection Rivages du droit est une sélection et une traduction de cinq textes écrits par Sheila Jasanoff, sociologue des sciences américaine, Pforzheimer Professor of Science and Technology Studies au sein de la (...) très prestigieuse Université de Harvard. Ses travaux s’intéressent principalement au rôle de la science et des technologies au sein des sociétés contemporaines et notamment à leurs interactions avec le droit et la politique. Sheila Jasanoff n’est pas seulement sociologue, ce que rappelle à juste titre par Olivier Leclerc dans l’introduction de l’ouvrage. Titulaire d’un doctorat en linguistique, elle est avocate et a exercé dans le contentieux de l’environnement avant de se tourner vers .. (shrink)

Reach into the heart and soul of people from every inhabited continent through sixty tour de force black-and-white portraits by Margo Davis. Under One Sky is a collection of nearly forty years of portrait making by one of the inheritors of California’s photographic legacy. Esthetically powerful and convincing were words used by Ansel Adams in 1968 to describe the work of Davis and her fellow students. Indeed, the same words can be used today in describing these portraits. As Davis (...) says in her accompanying essay, “A portrait that has the power to truly look inward can shake us up and make us question our assumptions. Like the finest literature, a powerful photographic portrait permits us to leap into the other’s mind and heart.”. (shrink)

Traditional welfare states were based on passive solidarity. Able bodied, healthy minded citizens paid taxes and social premiums, usually according to a progressive taxation logic following the ability to pay principle. Elderly, fragile, weak, unhealthy and disabled citizens were taken care of in institutions, usually in quiet parts of the country. During the nineteen eighties and nineties of the twentieth century, ideas changed. Professionals, patients and policy makers felt that it would be better for the weak and fragile to live (...) in mainstream society, rather than be taken care of in institutions outside society. This might be cheaper too. Hence policy measures were taken to accomplish deinstitutionalization. This article discusses the implications of deinstitutionalization for distributive justice. It is argued that the weakest among the weak and fragile stand to lose from this operation. For able bodied citizens deinstitutionalization entails a move from passive to active solidarity. Rather than just pay taxes they have to actively care for and help the needy themselves. The move from passive to active solidarity tends to take advantage of benevolent citizens and burden the socioeconomically disadvantaged. This may be a reason to reconsider the policy move toward deinstitutionalization. (shrink)

Using Rappaport’s notion of liturgical orders, the essay argues that the fixity of features in some ritual scenes in the Iliad may denote a high communicational register and level of sanctity. The features of commensal and oath-sacrificing scenes are compared and contrasted – death is highlighted in oath-sacrifice, muffled in commensal sacrifice. There is a relative paucity of figurative language in ritual scenes, except in the case of the “pitiless bronze” which takes the life of the lambs and boar in (...) the oath-sacrifices of Books III and XIX. This figurative paucity is to be contrasted to the plenum of such language in scenes which depict battlefield killings. Finally the features of the cremation sacrifices of Iliad XXIII are examined against those of commensal and oath-sacrifices. The focalization on the “bulls cut down bellowing” in the precremation feast is startling because it jars with typical commensal sacrifices, but may be explained by the broken nature of the narrative and its punctuation by an oath-making ritual leitmotif. In contrast, the actual cremation sacrifices are situated within a strongly formalized liturgical order which does not permit focalization on dying victims, despite the references to poinē which introduce and conclude the funeral sacrifices.« Des bœufs mugissants égorgés ». Leitmotive rituels et pressions poétiques au chant XXIII de l’Iliade. En utilisant la notion d’ordres liturgiques de Rappaport, l’étude affirme que la fixité des traits de certaines scènes rituelles de l’Iliade pourrait refléter un registre communicationnel élevé, ainsi qu’un niveau de sacralité. Les traits des scènes de sacrifice alimentaire et de sacrifice juratoire sont comparés et mis en contraste – la mort est soulignée dans le sacrifice juratoire, dissimulée dans le sacrifice alimentaire. La rareté relative de langage figuré caractérise les scènes rituelles, à l’exception du « bronze sans pitié » qui prend la vie des agneaux et de l’ours dans les sacrifices juratoires des chants III et XIX. Une telle rareté s’oppose au foisonnement de ce type de langage dans les scènes qui décrivent les tueries sur le champ de bataille. Enfin, les traits des sacrifices de crémation du chant XXIII sont examinés en regard de ceux des sacrifices alimentaires et juratoires. La mise en perspective des « bœufs mugissants égorgés » dans la célébration qui précède la crémation est frappante, dans la mesure où elle détonne par rapport aux sacrifices alimentaires typiques, mais peut s’expliquer par la nature décousue de la narration et l’insertion ponctuelle du leitmotiv d’un rituel juratoire. Par contraste, les véritables sacrifices de crémation s’insèrent dans un ordre liturgique fortement formalisé qui ne permet pas la mise en perspective des victimes mourantes, en dépit des références à la poinē qui introduit et referme les sacrifices funèbres. (shrink)