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)

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?

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)

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)

The inherent normativity of HTA can be conceptualized as a result of normative commitments, a concept that we further specify to encompass moral, epistemological and ontological commitments at play in the practice of HTA. Based on examples from literature, and an analysis of the example of assessing Non-Invasive Prenatal Testing (NIPT), we will show that inevitable normative decisions in conducting an assessment commits the HTA practitioner to moral (regarding what makes a health technology desirable), ontological (regarding which effects of health (...) technology are conceivable), and epistemological (regarding how to obtain reliable information about health technology) norms. This highlights and supports the need for integrating normative analysis and stakeholder participation, providing guidance to HTA practitioners when making normative choices. This will foster a shared understanding between those who conduct, use, or are impacted by assessments regarding what are conceivable and desirable outcomes of using health technology, and how to collect reliable information to assess whether these outcomes are (going to be) realized. It also provides more insight into the implications of different normative choices. (shrink)

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)

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)

We describe a new way in which theories about the deontic status of actions can be represented in terms of the standard two-sorted extensional predicate calculus. Some of the resulting formal theories are easy to implement in Prolog; one prototype implementation--R. M. Lee's deontic expert shell DX--is briefly described.

In 1926, Mally presented the first formal system of deontic logic. His system had several consequences which Mally regarded as surprising but defensible. It also, however, has the consequence that A is obligatory if and only if A is the case, which is unacceptable from the point of view of any reasonable deontic logic. We describe Mally's system and discuss how it might reasonably be repaired.

Basisbegrippen. Een formeel model voor de ontwikkeling van de kunst is een structuur T, <, K, , d, p, q, s, B , waarbij T een verzameling van “tijdstippen” is, < (“is eerder dan”) een relatie op T is, K een verzameling van “mogelijke kunstwerken” is, (“levert commentaar op”) een relatie op K is, d, p, q en s functies van K naar de verzameling van alle deelverzamelingen van K zijn, en B een functie van T naar de verzameling van (...) alle deelverzamelingen van K is. d(x) is de discipline waartoe kunstwerk x behoort, p(x) is het proc´ed´e waarmee x vervaardigd is, q(x) is de kwaliteit van x, s(x) is de stijl van x, en B(t) is de verzameling kunstwerken die op tijdstip t bestaan. (shrink)

prevailing view, holding that the contents of our thoughts are mainly the result of external factors. The corollary is that we will never really be able to read a person’s mind.

De mens is in de afgelopen drie eeuwen vaak vergeleken met allerlei soorten machines. In de achttiende eeuw was de klokmetafoor tamelijk populair; psychologische termen als ‘drijfveer’, ‘van slag raken’ en ‘opgewonden zijn’ herinneren hier nog aan [Vroon and Draaisma, 1985]. In de negentiende eeuw overheerste de stoommachine-metafoor. De psychologie van Freud wordt wel als een uitgewerkte versie van deze metafoor beschouwd [Russelmann, 1983]. Ook uitdrukkingen als ‘uitlaatkleppen’, ‘stoom afblazen’ en ‘iemand opstoken’ zijn eraan te danken. De stoommachine-metafoor wordt nog (...) steeds serieus genomen. Zo pleegt men de menselijke geest in de nieuwe ‘dynamische’ school in de cognitieve wetenschappen bij voorkeur te vergelijken met James Watts centrifugale regulateur (1788), het apparaat dat ervoor zorgt dat een stoommachine op een constant snelheid werkt [van Gelder, 1995, 1998]. De laatste vijftig jaar komt men de metafoor van de seri¨ele digitale computer vaak tegen. Een PC is een voorbeeld van zo’n computer. Hij is serieel omdat de centrale processor slechts ´e´en berekening tegelijk kan uitvoeren; hij is digitaal omdat hij alleen met gehele getallen kan omgaan. Het voorbeeld bij uitstek van een seri¨ele digitale computer is de Turing-machine, waarover aanstonds meer. De seri¨ele digitale computer metafoor is op verschillende manieren op mensen toegepast. Zo beschouwen sommigen de gehele mens als een computer van dit type, terwijl anderen menen dat de afzonderlijke zenuwcellen op deze manier beschreven kunnen worden. In het onderstaande zal ik de vraag bespreken in hoeverre men de mens, of onderdelen van de mens, inderdaad als seri¨ele digitale computer mag opvatten. Ik zal laten zien dat deze vergelijking maar een beperkte waarde heeft. Het valt niet uit te sluiten dat de mens in computationeel opzicht een veel sterker of zwakker soort machine is dan de Turing-machine. (shrink)

We give a historical overview of the development of almost 50 years of empirical research on the affordances in the past and in the present. Defined by James Jerome Gibson in the early development of the Ecological Approach to Perception and Action as the prime of perception and action, affordances have become a rich topic of investigation in the fields of human movement science and experimental psychology. The methodological origins of the empirical research performed on affordances can be traced back (...) to the mid 1980’s and the works of Warren (1984, 1988) and Michaels (1988). Most of the research in Ecological Psychology performed since has focused on the actualization of discretely defined actions, the perception of action boundaries, the calculation of pi-numbers, and the measurement of response times. The research efforts have resulted in advancements in the understanding of the dynamic nature of affordances, affordances in a social context and the importance of calibration for perception of affordances. Although affordances are seen as an instrumental part of the control of action most studies investigating affordances do not pay attention to the control of the action. We conclude that affordances are still primarily treated as a utility to select behaviour, which creates a conceptual barrier that hinders deeper understanding of affordances. A focus on action-boundaries has largely prevented advancement in other aspects of affordances, most notably an integrative understanding of the role of affordances in the control of action. (shrink)

This paper urges that if we wish to give social intelligence to our agents, it pays to look at how we acquired our social intelligence ourselves. We are born with drives and motives that are innate and deeply social. Next, as children we are socialized to acquire norms and values and to understand rituals large and small. These social elements are the core of our being. We capture them in the acronym GRASP: Groups, Rituals, Affiliation, Status, Power. As a consequence, (...) economic rationality or logical reasoning do not suffice when it comes to social intelligence. Basic features of our social behaviour, of the kind that one sees early in the lives of children, need to be prominent. These include fear, love, and aggression. They extend to the combination of these drives with basic social clues from the environment such as big and small, good and bad, as well as culture-specific specializations of these. This will make agents respond differentially to inferred attributes such as gender, age, group membership. This level of universality in social intelligence should receive our full attention. The general insights gained can then be re-used in myriad implementations to specific modelling issues. (shrink)

The paper presents a formal explication of the early Wittgenstein's views on ontology, the syntax and semantics of an ideal logical language, and the propositional attitudes. It will be shown that Wittgenstein gave a "language of thought" analysis of propositional attitude ascriptions, and that his ontological views imply that such ascriptions are truth-functions of (and supervenient upon) elementary sentences. Finally, an axiomatization of a quantified doxastic modal logic corresponding to Tractarian semantics will be given.

We describe a new way in which theories about the deontic status of actions can be represented in terms of the standard two-sorted first-order extensional predicate calculus. Some of the resulting formal theories are easy to implement in Prolog; one prototype implementation—R. M. Lee's deontic expert shell DX—is briefly described.

In 1926, Mally presented the first formal system of deontic logic. His system had several consequences which Mally regarded as surprising but defensible. It also, however, has the consequence that A is obligatory if and only if A is the case, which is unacceptable from the point of view of any reasonable deontic logic. We describe Mally's system and discuss how it might reasonably be repaired.

It has been argued that ethically correct robots should be able to reason about right and wrong. In order to do so, they must have a set of do’s and don’ts at their disposal. However, such a list may be inconsistent, incomplete or otherwise unsatisfactory, depending on the reasoning principles that one employs. For this reason, it might be desirable if robots were to some extent able to reason about their own reasoning—in other words, if they had some meta-ethical capacities. (...) In this paper, we sketch how one might go about designing robots that have such capacities. We show that the field of computational meta-ethics can profit from the same tools as have been used in computational metaphysics. (shrink)

In 1926, Ernst Mally proposed a number of deontic postulates. He added them as axioms to classical propositional logic. The resulting system was unsatisfactory because it had the consequence that A is the case if and only if it is obligatory that A. We present an intuitionistic reformulation of Mally’s deontic logic. We show that this system does not provide the just-mentioned objectionable theorem while most of the theorems that Mally considered acceptable are still derivable. The resulting system is unacceptable (...) as a deontic logic, but it does make sense as a lax logic in the modern sense of the word. (shrink)

This paper explores the function of cities in the knowledge economy. The knowledge economy asks for “creative cities,” i.e. competitive urban areas that combine concentration, diversity, instability and a positive reputation. For a review of the concept of creative cities from a historical and theoretical perspective, we draw the conclusion that knowledge, creativity and innovation cannot be planned from scratch by local governments. However, creative cities par excellence such as Austin, the Øresund and Barcelona demonstrate that local policymakers in fact (...) can play a part in preparing cities for the requirements of the knowledge economy. We conclude that local governments can increase the chance that urban creativity emerges by providing the appropriate underlying framework conditions. (shrink)

Inspired by the recent rediscovery of work of Schumpeter in science and policymaking the author reviews and appraises Schumpeterian theory and that of his followers in innovation studies. Although Schumpeter’s vision suffers from some defects, I argue that there is more to learn from this author than his well-known idea of “creative destruction”. In particular, Schumpeter’s view on innovation policy is something that may have vital relevance to today’s increasingly policy-dominated world. We therefore conclude that besides his key ideas on (...) innovation-led development also his policy view should be regarded as a significant legacy in innovation studies. (shrink)

We present a new axiomatization of the deontic fragment of Anderson's relevant deontic logic, give an Andersonian reduction of a relevant version of Mally's deontic logic previously discussed in this journal, study the effect of adding propositional quantification to Anderson's system, and discuss the meaning of Anderson's propositional constant in a wide range of Andersonian deontic systems.

Despite the urgency of this issue, AI still struggles to represent social life. This article presents a comprehensive agent-based model that investigates status-power dynamics in groups. Kemper’s sociological status–power theory of social relationships, and a literature review on school children in middle youth, is its basis. The model allows us to investigate causation of the near-ubiquitous phenomenon that females have lower social status on average than males. Possible causes included in the model are children’s dispositional traits (kindness, beauty, and physical (...) power), schoolyard culture (social acceptability of fighting), behavioural strategy (amount of rough-and-tumble play) and the balance between public and dyadic sources of status. An agent-based model of a virtual schoolyard was created in which the children assemble in changing groups and mutually confer status. The status conferred upon a child modifies the status it holds. Rough-and-tumble is modelled as ambiguous: it is intended as a status conferral, but may be perceived as a power move. Running many trials of the model we found that in time, depending on the parameter settings, a gender-based status gap emerged. Rough-and-tumble play had more impact on emergent status differences than did physical power differences. Social acceptability of fighting also strongly moderated the resulting status gap. Placing more weight on dyadic relationship could alleviate status loss. All these model behaviours are in line with empirical findings of child behaviour studies at schools. They have face validity for social status issues in the adult world. We conclude from this that this kind of agent-based model merits use in studying the status–power dynamics of other issues in child behaviour, or indeed in social behaviour in general. (shrink)

We present axiomatizations of the deontic fragment of Anderson's relevant deontic logic (the logic of obligation and related concepts) and the eubouliatic fragment of Anderson's eubouliatic logic (the logic of prudence, safety, risk, and related concepts).

We discuss three aspects of the intuitionistic reformulation of Mally’s deontic logic that was recently proposed ). First, this reformulation is more similar to Standard Deontic Logic than appears at first sight: like Standard Deontic Logic, it is Kanger reducible and Anderson reducible to alethic logic and it has a semantical interpretation that can be read in deontic terms. Second, this reformulation has an extension that provides 100% of the theorems stated by Mally himself. Third, it is interesting to view (...) Mally’s original deontic logic as an extension of this reformulation. (shrink)

In 1926, Mally proposed the first formal deontic system. As Mally and others soon realized, this system had some rather strange consequences. We show that the strangeness of Mally's system is not so much due to Mally's informal deontic principles as to the fact that he formalized those principles in terms of the propositional calculus. If they are formalized in terms of relevant logic rather than classical logic, one obtains a system which is related to Anderson's relevant deontic logic and (...) not nearly as strange as Mally's own system. (shrink)

The paper presents a formal explication of the early Wittgenstein's views on ontology, the syntax and semantics of an ideal logical language, and the propositional attitudes. It will be shown that Wittgenstein gave a language of thought analysis of propositional attitude ascriptions, and that his ontological views imply that such ascriptions are truth-functions of (and supervenient upon) elementary sentences. Finally, an axiomatization of a quantified doxastic modal logic corresponding to Tractarian semantics will be given.

This article contributes to the contemporary debate on land and water grabbing through a detailed, qualitative case study of horticultural agribusinesses which have settled in Tanzania, disrupting patterns of land and water use. In this paper we analyse how capitalist settler farms and their upstream and downstream peasant neighbours along the Nduruma river, Tanzania, expand and defend their water use. The paper is based on 3 months of qualitative field work in Tanzania. We use the echelons of rights analysis framework (...) combined with the concept of institutional bricolage to show how this contestation takes place over the full spectrum of actual abstractions, governance and discourses. We emphasise the role different (inter)national development narratives play in shaping day-to-day contestations over water shares and rule-making. Ultimately, we emphasise that water grabbing is not a one-time event, but rather an on-going struggle over different water resources. In addition, we show how a perceived beneficial development of agribusinesses switching to groundwater allows them to avoid peasant-controlled institutions, avoiding further negotiation between the different actors and improving their image among neighbouring communities. This development illustrates how complex and obscured processes of water re-allocation can be without becoming illegal per se. (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)