The principle of need—the idea that resources should be allocated according to need—is often invoked in priority setting in the health care sector. In this article, I argue that a reasonable principle of need must be indeterminate, and examine three different ways that this can be dealt with: appendicizing the principle with further principles, imposing determinacy, or empowering decision makers. I argue that need must be conceptualized as a composite property composed of at least two factors: health shortfall and capacity (...) to benefit. When one examines how the different factors relate to each other, one discovers that this is sometimes indeterminate. I illustrate this indeterminacy in this article by applying the small improvement argument. If the relation between the factors are always determinate, the comparative relation changes by a small adjustment. Yet, if two needs are dissimilar but of seemingly equal magnitude, the comparative relation does not change by a small adjustment of one of the factors. I then outline arguments in favor of each of the three strategies for dealing with indeterminacy, but also point out that all strategies have significant shortcomings. More research is needed concerning how to deal with this indeterminacy, and the most promising path seems to be to scrutinize the position of the principle of need among a plurality of relevant principles for priority setting in the health care sector. (shrink)

The aim of this study was to illuminate the meaning of professional carers’ experiences in caring situations when a conflict of interest arises with the older person receiving care. The findings reveal the complexity of the carers’ ambivalence when facing a conflict of interest, weighing up between the older persons’ right to self-determination and external demands. The carers are alone in their ambivalence, and the conclusion is that they need help and support to be more present in the encounter. The (...) implication for this study is to focus on care as a person-centered practice and to focus on people as interdependent on support carers to maintain older people’s right to self-determination in the relationship. (shrink)

The aim of this study was to analyse experiences of moral concerns in intensive care nursing. The theoretical perspective of the study is based on relational ethics, also referred to as ethics of care. The participants were 36 intensive care nurses from 10 general, neonatal and thoracic intensive care units. The structural characteristics of the units were similar: a high working pace, advanced technology, budget restrictions, recent reorganization, and shortage of experienced nurses. The data consisted of the participants’ examples of (...) ethical situations they had experienced in their intensive care unit. A qualitative content analysis identified five themes: believing in a good death; knowing the course of events; feelings of distress; reasoning about physicians’ ‘doings’ and tensions in expressing moral awareness. A main theme was formulated as caring about - caring for: moral obligations and work responsibilities. Moral obligations and work responsibilities are assumed to be complementary dimensions in nursing, yet they were found not to be in balance for intensive care nurses. In conclusion there is a need to support nurses in difficult intensive care situations, for example, by mentoring, as a step towards developing moral action knowledge in the context of intensive care nursing. (shrink)

This article presents a fairness principle for evaluating decision-making based on predictions: a decision rule is unfair when the individuals directly impacted by the decisions who are equal with respect to the features that justify inequalities in outcomes do not have the same statistical prospects of being benefited or harmed by them, irrespective of their socially salient morally arbitrary traits. The principle can be used to evaluate prediction-based decision-making from the point of view of a wide range of antecedently specified (...) substantive views about justice in outcome distributions. (shrink)

We offer a functional perspective on hate, showing that hate has a unique pattern of appraisals and action tendencies. Hate is based on perceptions of a stable, negative disposition of persons or groups. We hate persons and groups more because of who they are, than because of what they do. Hate has the goal to eliminate its target. Hate is especially significant at the intergroup level, where it turns already devalued groups into victims of hate. When shared among group members, (...) hate can spread fast in conflict zones where people are exposed to hate-based violence, which further feeds their hate. Hate can be reassuring and self-protective, because its message is simple and helps confirming people’s belief in a just world. (shrink)

While philosophers have discussed the emotion of contempt from antiquity to the present day, contempt has received less attention in psychological research. We review the defining features of contempt, both as a short-term emotion and as a more long-lasting sentiment. Contempt is similar to anger in that it may occur after social or moral transgressions, but it differs from anger in its appraisals, actions, and emotivational goals. Unlike anger, contempt arises when a person’s or group’s character is appraised as bad (...) and unresponsive to change, leading to attempts to socially exclude the target. We discuss associative, self-regulatory, and social distancing functions of contempt and present a dynamic social model of contempt versus anger. (shrink)

In the present article we argue that emotional interactions are not appropriately captured in present emotion research and theorizing. Emotional stimuli or antecedents are dynamic and change over time because they often interact and have a specific relationship with the subject. Earlier emotional interactions may, for example, intensify later emotional reactions to a specific person, or our anger reactions towards powerful or powerless others may differ considerably. Thus, we suggest that such social factors not only affect the intensity, but also (...) the nature of emotional experiences and expressions, and specifically the nature of the social movement (e.g., moving towards, away, or against). We discuss different processes that are implicated in the relation between the social environment and our emotions, describe how emotional expressions shape social behavior, and provide suggestions for incorporating the social dimension of emotion in future research. (shrink)

Incommensurability is the impossibility to determine how two options relate to each other in terms of conventional comparative relations. This book features new research on incommensurability from philosophers who have shaped the field into what it is today, including John Broome, Ruth Chang and Wlodek Rabinowicz. The book covers four aspects relating to incommensurability. In the first part, the contributors synthesize research on the competing views of how to best explain incommensurability. Part II illustrates how incommensurability can help us deal (...) with seemingly insurmountable problems in ethical theory and population ethics. The contributors address the Repugnant Conclusion, the Mere Addition Paradox and so-called Spectrum Arguments. The chapters in Part III outline and summarize problems caused by incommensurability for decision theory. Finally, Part IV tackles topics related to risk, uncertainty and incommensurability. Value Incommensurability: Ethics, Risk, and Decision-Making will be of interest to researchers and advanced students working in ethical theory, decision theory, action theory, and philosophy of economics. (shrink)

In this reply, I discuss some important issues raised in two commentaries. One relates to the distinction between hate and revenge, which also touches upon the more general problem of the usefulness of distinguishing between various related emotions. I argue that emotion researchers need to define specific emotions carefully in order to be able to examine such emotions without necessarily using emotion words. A second comment focusses on the factors influencing the development of hate over time. The question is whether (...) there is an intrapersonal mechanism leading to an increase or decrease of hate over time. I think it is the social environment that is essential in the maintenance of hate. (shrink)

As its title suggests, this anthology is a collection of papers presented at a conference on feelings and emotions held in Amsterdam in 2001. One of the symposium’s main goals was to draw some of the most prominent researchers in emotion research together and provide a multi-disciplinary ‘snap shot’ of the state of the art at the turn of the century. In that respect it is truly a cognitive science success story. There are articles from a wide range of fields, (...) encompassing, e.g., philosophy, neuroscience, anthropology, sociology, and psychology. Another.. (shrink)

Distributive theories evaluate distributions of goods based on candidate recipients’ characteristics, e.g. how well off candidates are, how deserving they are, and whether they fare below sufficiency. But such characteristics vary across possible worlds, so distributive theories may differ in terms of the world which for them settles candidates’ characteristics. This paper examines how distributive theories differ in terms of whether candidate recipients’ relevant characteristics are grounded in the possible world that would take place if the distributor does not intervene (...) (call it the “input” world) or if they are grounded in each possible world that the distributor can bring about through different decisions (call each an “output” world). We illustrate the importance of this distinction in relation to one distributive theory, prioritarianism. As we show, both input and output versions of prioritarianism are plausible interpretations of the literature, and there are good reasons to take input prioritarianism seriously. Ultimately, however, we argue that input prioritarianism should be rejected. (shrink)

The goal of this article is to discuss theoretical arguments concerning the idea that emotional mimicry is an intrinsic part of our social being and thus can be considered a social act. For this, we will first present the theoretical assumptions underlying the Emotional Mimicry as Social Regulator view. We then provide a brief overview of recent developments in emotional mimicry research and specifically discuss new developments regarding the role of emotional mimicry in actual interactions and relationships, and individual differences (...) in emotional mimicry. We conclude with open questions for future research. (shrink)

In this paper, I argue that sufficientarian principles are indispensable in the set of principles that have bearing on issues in distributive ethics. I provide two arguments in favor of this claim. First, I argue that sufficientarianism is the only framework that allows us to appropriately analyze what sort of obligations we have toward individuals who are badly off due to their own faults and choices. Second, I argue that sufficientarianism is the only theory that provides an adequate framework for (...) thinking about the desperately badly off. (shrink)

In this article we examine gender differences in nonverbal expressiveness, with a particular focus on crying and smiling. We show that women cry and smile more as well as show more facial expressiveness in general, but that the size of this gender difference varies with the social and emotional context. We interpret this variation within a contextual framework (see also Brody & Hall, 2008; Deaux & Major, 1987; LaFrance, Hecht, & Paluck, 2003). More specifically, we distinguish three factors that predict (...) the size of gender differences in emotional expressiveness: gender-specific norms, social role and situational constraints, and emotional intensity. These factors interact in different ways for smiling and crying. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How Fool Is a "Holy Fool"?Agneta Schreurs (bio)The editors asked me to write a short response to your commentaries. They asked me to do that as a set; therefore, I respond to your texts as a whole.First, I thank you for your comments. I appreciate very much that you took the time to read and reflect on my article. I am really very happy with your positive evaluation (...) of my article, particularly because my choice for this subject has much to do with my own biography. I have been raised by nonreligious parents and grandparents. My mother being a classical scholar and my father a scientist, I knew more about antiquity and chemistry than about the Bible, which in fact did not figure at all in my education. However, when I was forty years old, I took on theology at the University of Utrecht as an extra study in my free time, mainly because I felt embarrassed whenever my students or clients brought the subject up and I did not know the first thing about it. Right from the beginning I became absolutely excited about this study, not only about the broad range of fascinating subjects, but also because quite a number churches had merged the academic part of their seminaries with the theological faculty of the University of Utrecht into an academically very high-standard curriculum. Students and teachers were a mix of Dutch Reformed, Roman Catholic, Old Catholic, Baptist, and several other denominations, in my time even a Jewish rabbi and a Winti (an indigenous religion in the former Dutch West Indies). Outsider as I was, this offered me a unique opportunity to become acquainted in a personal and natural way with their various faiths. Nevertheless, it took me three years before I realized what all those fascinating things had to do with my life and with my work! This realization was the reason why, after getting my master's degree in theology, I decided to choose a combination of philosophy of religion and psychology of religion for my doctoral dissertation and to change my group practice into work that explicitly dealt with the interconnections between spirituality and psychotherapy.I also want to thank you for sharing your thoughts on the larger contexts of my subject. From my biographical sketch, you can see that I agree with both of you in that it is high time that psychiatry and psychotherapy pay more attention to—and become more knowledgeable about—their religious patients' religion and spirituality. Not because I think the "talking cures" may have much in common with "faith healing" (in fact, I agree with Gibson [2000] that they have much more in common with the gentle craft of taking confession), but because it is unprofessional not to do so. When a person consults a priest or minister with regard to a religious problem, it often appears that there are also psychological problems involved. That is why theological curricula include pastoral psychology and clinical training courses. This is also true the other way round: psychological problems treated in psychotherapy and counseling may involve a patient's religious mindset. However [End Page 205], most psychotherapists are generally neither religious themselves nor trained in assessing and understanding the great variety of ways in which people may be religious and how these may be intertwined with the problems for which they have sought therapeutic help. In particular, they are mostly not trained in discovering how their patients' religiousness may be a cause of therapeutic failure or, alternatively, a source of support and as such a help toward therapeutic progress. In addition to such lack in information and training, and in contrast with most clergy, clients in therapy may easily have very different religious backgrounds. As a result of this professional situation, many psychotherapists feel uncomfortable in this area and unprofessionally tend to ignore, avoid, or reinterpret in psychological terms their patients' spiritual expressions.The point I tried to make is this: to successfully discover and assess how a patients' religiousness may be a cause of psychological problems or conversely, be a source of support and as such a help toward therapeutic progress, you need at least some basic... (shrink)

This article offers a relational approach for understanding and dealing with a patient's spiritual concerns. Insight into the relational structure of a particular patient's spirituality may help to (1) analyze in what way psychological and spiritual factors are interconnected and in what way the patient's "spiritual relationship" influences his mental health problems either positively or negatively, and (2) identify the latent opportunities for therapeutic and spiritual healing that are present within their spiritually minded patients' own religious frame of reference.

This article analyzes approaches to nondeterminacy that suggest that one can make justified choices when primary criteria fail to fully determine a best alternative by introducing a secondary criterion. It is shown that these approaches risk violating Basic Contraction Consistency. Some ways of adjusting two-step models in order to protect against this are addressed, and it is suggested that proponents of two-step models should adopt formal conditions which qualify what counts as a permissible secondary criterion that resemble supervaluationist conditions that (...) qualify what counts as admissible precisifications of vague terms. (shrink)

A notorious problem that has recently received increased attention in axiology, normative theory and population ethics is the apparent ubiquity of what can be generally called nondeterminacy. This paper illustrates how nondeterminacy can spawn cyclical rankings. So, accepting that practical reasons can admit of nondeterminacy challenges the widely held idea that ‘better than’ is transitive. As a result, standard approaches to rational choice under nondeterminacy fail to be action-guiding, since in some situations all options are dominated, that is, impermissible according (...) to standard rational choice criteria. (shrink)

How should one understand comparisons in which neither of two alternatives is at least as good as the other? Much recent literature on comparability problems focuses on what the appropriate explanation of the phenomenon is. Is it due to vagueness or the possibility of non-conventional comparative relations such as parity? This paper argues that the discussions on how to best explain comparability problems has reached an impasse at which it is hard to make any progress. To advance the discussion we (...) suggest a new classification of comparability problems that focuses on the problems they cause for practical reasoning. (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)

How should states and international organizations allocate global health resources? This paper examines proposals for distributing these resources in the literature. First, we look at the literature on the metrics for measuring what matters and consider how they might be modified to avoid some common objections—e.g., that these measures discriminate against the disabled or fail to give due weight to helping the young (or old) or those in present (or future) generations. Second, we canvas existing approaches to evaluating allocations of (...) health‐related resources utilizing such measures and advance a new way of doing so. We suggest that it is important to provide substantive arguments for directly evaluating alternative allocations, but there is also room for deliberation about fair procedures for selecting allocation criteria and securing just outcomes. (shrink)

Lifetime quality-adjusted life-year (QALY) prioritarianism has recently been defended as a reasonable specification of the prioritarian view that benefits to the worse off should be given priority in health-related priority setting. This paper argues against this view with reference to how it relies on implausible assumptions. By referring to lifetime QALY as the basis for judgments about who is worse off lifetime QALY prioritarianism relies on assumptions of strict additivity, atomism and intertemporal separability of sublifetime attributes. These assumptions entail that (...) a health state at some period in time contributes with the same amount to how well off someone is regardless of intrapersonal and interpersonal distributions of health states. The paper argues that this is implausible and that prioritarians should take both intrapersonal and interpersonal distributions of goods into account when they establish who is worse off. They should therefore not accept that lifetime QALY is a reasonable ground for ascribing priority and reject lifetime QALY prioritarianism. (shrink)

Much research aimed at developing measures for normative criteria to guide the assessment of healthcare resource allocation decisions has focused on health maximization, equity concerns and more recently approaches based on health capabilities. However, a widely embraced idea is that health resources should be allocated to meet health needs. Little attention has been given to the principle of need which is often mentioned as an alternative independent criteria that could be used to guide healthcare evaluations. This paper develops a model (...) and indicator of need satisfaction that aggregates the health needs of a population in a particular time period into a single measure that weights individual health needs by the severity of their ill health. The paper provides a first step towards formalizing the principle of need as a measurable objective for healthcare policy and we discuss some challenges for future research, including incorporating the duration of time into need-based health evaluations. (shrink)

A notorious debate in the ethics of healthcare rationing concerns whether to address rationing decisions with substantial principles or with a procedural approach. One major argument in favour of procedural approaches is that substantial principles are indeterminate so that we can reasonably disagree about how to apply them. To deal with indeterminacy, we need a just decision process. In this paper I argue that it is a mistake to abandon substantial principles just because they are indeterminate. It is true that (...) reasonable substantial principles designed to deal with healthcare rationing can be expected to be indeterminate. Yet, the indeterminacy is only partial. In some situations we can fully determine what to do in light of the principles, in some situations we cannot. The conclusion to draw from this fact is not that we need to develop procedural approaches to healthcare rationing, but rather that we need a more complex theory in which both substantial principles and procedural approaches are needed. (shrink)

This article presents an approach to how to make reasonable social choices when independent criteria (e.g., prioritarianism, religious freedom) fail to fully determine what to do. The article outlines different explanations of why independent criteria sometimes fail to fully determine what to do and illustrates how they can still be used to eliminate ineligible alternatives, but it is argued that the independent criteria cannot ground a reasonable social choice in these situations. To complement independent criteria when they fail to fully (...) determine what to do, it is suggested that society must engage in public deliberation by way of generating new reasons that can determine how to rank the alternatives. It is suggested that the approach to social choice presented here reveals a way of accepting the relevance of independent criteria for social choice without letting go of the idea that the attitudes of affected parties matter. (shrink)

How should scarce health-related resources be allocated? This paper argues that values that apply to these decisions fail to always fully determine what we should do. Health maximization and allocation-according-to-need are suggested as two values that should be part of a general theory of how to allocate health-related resources. The “small improvement argument” is used to argue that it is implausible that one alternative is always better, worse, or equal to another alternative with respect to these values. Approaches that rely (...) on these values are thus incomplete. To deal with this, it is suggested that we ought to use incomplete theories in a two-step process. Such a process first discards ineligible alternatives, and, second, uses reasons grounded in collective commitments to identify a unique, best alternative in the remaining set. (shrink)

This paper argues that decision problems and money-pump arguments should not be a deciding factor against accepting non-transitive better than relations. If the reasons to accept normative standpoints that entail a non-transitive better than relation are compelling enough, we ought to revise our decision method rather than the normative standpoints. The paper introduces the most common argument in favor of non-transitive better than relations. It then illustrates that there are different ways to reconceptualize rational choice so that rational choice is (...) possible also when the relevant better than relation is non-transitive. (shrink)

I focus on some differences between negative emotional states and how they are coped with in explaining different cardiac risks. The different cognitive, motivational, and physiological characteristics of emotions imply different appraisals of the negative event, and different resources to cope with the event. Cardiovascular activity depends on these different appraisals and coping strategies. For example, cortisol levels have shown to be differently associated with anger and fear responses to social stress. In addition, different ways to regulate one’s emotions are (...) also associated with different bodily responses that may increase or decrease cardiac risks. Future research should not only examine different emotions to stressors, but also more long-term regulation strategies and coping resources, such as self-esteem. (shrink)

In 1997 John Broome presented the Collapsing Argument that was meant to establish that non-conventional comparative relations cannot exist. Broome's argument has faced a lot of scrutiny and a certain type of counterexample has been used to undermine it. Most of the counterexamples focus on the Collapsing Principle which plays a central role in Broome's argument. In this article we will take a closer look at the most common type of counterexample and propose how to adjust the Collapsing Principle in (...) order to avoid objections based on these counterexamples. We argue that a weaker version of the Collapsing Principle is not susceptible to the classical counterexamples. Furthermore, after an explorative discussion about the intuitions behind the original principle, we show that this weaker formulation is at least as intuitive as the principle suggested by Broome. (shrink)

This article argues that values that apply to health care allocation entail the possibility of “spectrum arguments,” and that it is plausible that they often fail to determine a best alternative. In order to deal with this problem, a two-step process is suggested. First, we should identify the Strongly Uncovered Set that excludes all alternatives that are worse than some alternatives and not better in any relevant dimension from the set of eligible alternatives. Because the remaining set of alternatives often (...) contain more than one element, we need some complementary method of selecting a unique alternative. In order to address this issue, I suggest that we must invoke caps on the values that are used to evaluate alternatives, and that these caps must be grounded in collective commitments. (shrink)

This article addresses the prioritization questions that arise when people attempt to institutionalize reasonable ethical principles and create guidelines for microlevel decisions. I propose that this instantiates an incommensurability problem, and suggest two different kinds of practical solutions for dealing with this issue.

This article shows that introducing the positive comparative relation parity only helps one block so‐called “Spectrum Arguments” in order to avoid their unsavoury implications if one specifies parity in a specific way with respect to its persistence. The article illustrates how parity must both admit of persistency and be weakly non‐persistent for parity to block Spectrum Arguments, and identifies some consequences of that discovery for the general debate on Spectrum Arguments, value theory and comparability problems.

This paper shows that versions of prioritarianism that focus at least partially on well-being levels at certain times conflict with conventional views of prudential value and prudential rationality. So-called timeslice prioritarianism, and pluralist views that ascribe importance to timeslices, hold that a benefit matters more, the worse off the beneficiary is at the time of receiving it. We show that views that evaluate outcomes in accordance with this idea entail that an agent who delays gratification makes an outcome worse, even (...) if it is better for the agent and worse for no one else. We take this to show that timeslice prioritarianism and some pluralist views violate Weak Pareto, and we argue that these versions of prioritarianism are implausible. (shrink)

This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers’ biases, whims, and prejudices, (...) which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers. (shrink)

Abstract Normative criteria for evaluations of economic and social outcomes are often formulated in terms of social welfare functions which are essentially and importantly non-satiable. However, there are good reasons to consider certain normative criteria and many policy objectives to be capped, i.e. bounded, and thus satiable provided sufficient resources are made available for their satisfaction. Inspired by the Foster–Greer–Thorbecke class of indicators, this paper uses an interdisciplinary approach to develop a model for assessing outcomes in terms of capped objectives (...) based on an understanding of individual shortfalls from the objective, denoted needs. We present an indicator to measure need satisfaction in a population of individuals with heterogeneous needs and highlight an aggregation problem under scarcity. For such situations, we develop three ways in which the indicator can be weighted that reflect respectively concerns over the frequency, depth and severity of the need shortfalls and show that normative evaluations based on these weighting schemes can conflict, yielding mutually inconsistent outcome rankings. The indicator can be adapted to measure a wide variety of phenomena, e.g. health needs, education shortfalls, deprivation, etc., and it is suited for targeting exercises and other policy implementations. In particular, it allows for exogenous weighting schemes, i.e. weights that can incorporate non-shortfall characteristics relevant for the evaluation, e.g. age, gender, ethnicity, etc. The indicator thus enables new ways for researchers to promote and study satiable objectives in a wide variety of contexts relevant to economic and social policy, e.g. human development programs, poverty reduction, healthcare policies, etc. (shrink)

Vigil's socio-relational framework of sex differences in emotional expressiveness emphasizes general sex differences in emotional responding, but largely ignores the social context in which emotions are expressed. There is much empirical evidence showing that sex differences in emotion displays are flexible and a function of specific social roles and demands, rather than a reflection of evolutionary-based social adjustments.

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 aim of this article is to describe the synthesis of the concept of moral stress and to attempt to identify its preconditions. Qualitative data from two independent studies on professional issues in nursing were analysed from a hypothetical-deductive approach. The findings indicate that moral stress is independent of context-given specific preconditions: (1) nurses are morally sensitive to the patient’s vulnerability; (2) nurses experience external factors preventing them from doing what is best for the patient; and (3) nurses feel that (...) they have no control over the specific situation. The findings from this analysis are supported by recent research on stress in the workplace but differ in that the imperatives directing work are moral in nature. Stress researchers have found that persons who experience that they have no control over their work situation and at the same time experience high demands may be prone to cardiovascular diseases. An important question raised by this study is whether moral stress should be recognized as a health risk in nursing. Further research is required in order to generate intervention models to prevent or deal with moral stress. (shrink)

This paper addresses how to think about the permissibility of introducing deadweight costs on candidate recipients of goods in order to attain better outcomes. The paper introduces some distinctions between different kinds of value dimensions that should be taken into account when such judgements are made and draws from the literature on comparisons across different value dimensions in order to canvas what sort of situations one might arguably face when evaluating ordeals. In light of the distinctions drawn and the possibilities (...) canvassed, the paper proceeds to outline what circumstances indicate which of the possible situations one is in. (shrink)

This article provides a new argument and a new value-theoretical ground for person-centered care and shared decision making that ascribes to it the role of enabling rational choice in situations involving clinical choice. Rather than referring to good health outcomes and/or ethical grounds such as patient autonomy, it argues that a plausible justification and ground for person-centered care and shared decision making is preservation of rationality in the face of comparative non-determinacy in clinical settings. Often, no alternative treatment will be (...) better than or equal to every other alternative. In the face of such comparative non-determinacy, Ruth Chang has argued that we can make rational decisions by invoking reasons that are created through acts of willing. This article transfers this view to clinical decision making and argues that shared decision making provides a solution to non-determinacy problems in clinical settings. This view of the role of shared decision making provides a new understanding of its nature, and it also allows us to better understand when caregivers should engage in shared decision making and when they should not. (shrink)