Background: Inclusion or not of a treatment strategy in the publicly financed health care is really a matter of prioritisation. In Sweden priority setting decisions are governed by law in which it is stated that decisions should be guided by firstly the principle of need and secondly the principle of cost-effectiveness.

The aim of this article is to contribute to responsible innovation by developing a conceptual framework for the processes of creativity and innovation. The hypothesis is that creative and innovative processes are similar in that both are affective in nature. I develop this conceptual framework through an interpretation of the insights of Henri Poincaré’s notion of the ‘four stages’ in the creative process and Joseph Schumpeter’s notion of the entrepreneur. Building on this framework, I analyze the creative and innovative practices (...) of the film director Lars von Trier and the entrepreneur Steve Jobs. The interpretation and analysis suggest that the processes of creativity and innovation are similar in nature in that both are based on the moods of disturbance and enthusiasm; but that they differ in that creativity is based on the feelings of interest and irritation, whereas innovation is based on the feelings of desire and anger. In the conclusion I discuss the implications of this for responsible innovation with regard to the social aspect of resistance towards innovation and the ethical aspects of anger in entrepreneurial leadership. (shrink)

Most of us, at one time or another, will have been struck by a thought that we might wish to express in the following words: ‘I could have been born in a different time and place, my position in life and all my personal characteristics could have been completely different from what they are; how amazing then that it should have fallen to my lot to live my life, the only life I shall ever live, as this particular individual rather (...) than any other.’ This thought need not derive from a sense that there is anything unusual about one's life; what it expresses, rather, may be the sense that there is something gratuitous or contingent about one's being any particular individual at all. This sense of contingency might be connected with a feeling of gratitude, perhaps of responsibility towards others less fortunate in life; or it might be bound up with envy, or pride, or self-pity, etc. (shrink)

Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the ethical analysis (...) is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment. (shrink)

In this book Lars Svendsen examines the nature of boredom, how it originated, its history, how and why it afflicts us, and why we cannot seem to overcome it by any act of will.

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (...) (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

Every day, thousands of polls, surveys, and rating scales are employed to elicit the attitudes of humankind. Given the ubiquitous use of these instruments, it seems we ought to have firm answers to what is measured by them, but unfortunately we do not. To help remedy this situation, we present a novel approach to investigate the nature of attitudes. We created a self-transforming paper survey of moral opinions, covering both foundational principles, and current dilemmas hotly debated in the media. This (...) survey used a magic trick to expose participants to a reversal of their previously stated attitudes, allowing us to record whether they were prepared to endorse and argue for the opposite view of what they had stated only moments ago. The result showed that the majority of the reversals remained undetected, and a full 69% of the participants failed to detect at least one of two changes. In addition, participants often constructed coherent and unequivocal arguments supporting the opposite of their original position. These results suggest a dramatic potential for flexibility in our moral attitudes, and indicates a clear role for self-attribution and post-hoc rationalization in attitude formation and change. (shrink)

Throughout the history of social thought, there has been a constant battle over the true nature of society, and the best way to understand and explain it. This volume covers the development of methodological individualism, including the individualist theory of society from Greek antiquity to modern social science. It is a comprehensive and systematic treatment of methodological individualism in all its manifestations.

In recent years the formerly quite strong interest in patient compliance has been questioned for being too paternalistic and oriented towards overly narrow biomedical goals as the basis for treatment recommendations. In line with this there has been a shift towards using the notion of adherence to signal an increased weight for patients’ preferences and autonomy in decision making around treatments. This ‘adherence-paradigm’ thus encompasses shared decision-making as an ideal and patient perspective and autonomy as guiding goals of care. What (...) this implies in terms of the importance that we have reason to attach to (non-)adherence and how has, however, not been explained. In this article, we explore the relationship between different forms of shared decision-making, patient autonomy and adherence. Distinguishing between dynamically and statically framed adherence we show how the version of shared decision-making advocated will have consequences for whether one should be interested in a dynamically or statically framed adherence and in what way patient adherence should be assessed. In contrast to the former compliance paradigm (where non-compliance was necessarily seen as a problem), using observations about (non-)adherence to assess the success of health care decision making and professional-patient interaction turns out to be a much less straightforward matter. (shrink)

Surveillance cameras. Airport security lines. Barred store windows. We see manifestations of societal fears everyday, and daily news reports on the latest household danger or raised terror threat level continually stoke our sense of impending doom. In _A Philosophy of Fear_, Lars Svendsen now explores the underlying ideas and issues behind this powerful emotion, as he investigates how and why fear has insinuated itself into every aspect of modern life. Svendsen delves into science, politics, sociology, and literature to explore (...) the nature of fear. He examines the biology behind the emotion, from the neuroscience underlying our “fight or flight” instinct to how fear induces us to take irrational actions in our attempts to minimize risk. The book then turns to the political and social realms, investigating the role of fear in the philosophies of Machiavelli and Hobbes, the rise of the modern “risk society,” and how fear has eroded social trust. Entertainment such as the television show “Fear Factor,” competition in extreme sports, and the political use of fear in the ongoing “War on Terror” all come under Svendsen’s probing gaze, as he investigates whether we can ever disentangle ourselves from the continual state of alarm that defines our age. Svendsen ultimately argues for the possibility of a brighter, less fearful future that is marked by a triumph of humanist optimism. An incisive and thought-provoking meditation, _A Philosophy of Fear _pulls back the curtain that shrouds dangers imagined and real, forcing us to confront our fears and why we hold to them. (shrink)

CHAPTER 1 From Bentham to Kanger I. Introduction In the analytical tradition established by Jeremy Bentham and John Austin, and continued in the twentieth ...

In health care priority setting different criteria are used to reflect the relevant values that should guide decision-making. During recent years there has been a development of value frameworks implying the use of multiple criteria, a development that has not been accompanied by a structured conceptual and normative analysis of how different criteria relate to each other and to underlying normative considerations. Examples of such criteria are unmet need and severity. In this article these crucial criteria are conceptually clarified and (...) analyzed in relation to each other. We argue that disease-severity and condition-severity should be distinguished and we find the latter concept better reflects underlying normative values. We further argue that unmet need does not fulfil an independent and relevant role in relation to condition-severity except for in some limited situations when having to distinguish between conditions of equal severity. (shrink)

In On Certainty, the emphasis is on the solitary individual as subject of knowledge. The importance of our dependence on others, however, is brought out in Wittgenstein's remarks about trust. In this paper, the role and nature of trust are discussed, the grammar of trust being contrasted with that of reliance. It is shown that to speak of trust is to speak of a fundamental attitude of one person towards others, an attitude which, unlike reliance, is not to be explained, (...) or assessed, by an appeal to reasons. It is, rather, because we have such a fundamental readiness to accept what we are taught by others that we can come to develop an understanding of reasons. The idea that believing something without evidence is always a weakness is shown to be a philosophical prejudice. Trust is always for something we can rightfully demand from others: misplaced trust, accordingly, is not a shortcoming on the part of the trustful person, but of the person in whom the trust was placed. The destruction of trust is a tragedy of life; in Culture and Value, Wittgenstein suggests a connection between distrust and madness. (shrink)

Political candidates often believe they must focus their campaign efforts on a small number of swing voters open for ideological change. Based on the wisdom of opinion polls, this might seem like a good idea. But do most voters really hold their political attitudes so firmly that they are unreceptive to persuasion? We tested this premise during the most recent general election in Sweden, in which a left- and a right-wing coalition were locked in a close race. We asked our (...) participants to state their voter intention, and presented them with a political survey of wedge issues between the two coalitions. Using a sleight-of-hand we then altered their replies to place them in the opposite political camp, and invited them to reason about their attitudes on the manipulated issues. Finally, we summarized their survey score, and asked for their voter intention again. The results showed that no more than 22% of the manipulated replies were detected, and that a full 92% of the participants accepted and endorsed our altered political survey score. Furthermore, the final voter intention question indicated that as many as 48% (69.2%) were willing to consider a left-right coalition shift. This can be contrasted with the established polls tracking the Swedish election, which registered maximally 10% voters open for a swing. Our results indicate that political attitudes and partisan divisions can be far more flexible than what is assumed by the polls, and that people can reason about the factual issues of the campaign with considerable openness to change. (shrink)

Voluntary actions and their distal effects are intimately related in conscious awareness. When an expected effect follows a voluntary action, the experience of the interval between these events is compressed in time, a phenomenon known as ‘intentional binding’ . Current accounts of IB suggest that it serves to reinforce associations between our goals and our intention to attain these goals via action, and that IB only occurs for self-generated actions. We used a novel approach to study IB in the context (...) of shared intentions and actions. Pairs of participants judged the time of occurrence of actions and events attributed either to oneself or to another agent. We found that IB and subjective agency are not mutually predictive when an action can be attributed to only one of two ‘co-intending’ agents. Our results pose a complication for the prevailing view that IB and subjective agency reflect a common mechanism. (shrink)

In a recent article in Utilitas, Gerald Lang suggests a solution to the so-called (WKR problem) for the buck-passing account of value. In two separate replies to Lang, Jonas Olson and John Brunero, respectively, point out serious problems with Lang's suggestion, and at least Olson concludes that the solution Lang opts for is of the wrong kind for solving the WKR problem. I argue that while both Olson and Brunero have indeed identified considerable flaws in Lang's suggestion for a solution (...) to the WKR problem, they have not provided sufficient grounds for dismissing the kind of solution that Lang proposes. I show how a version of this kind of solution can be formulated so as to avoid both Olson's and Brunero's objections. I also raise some worries concerning an alternative solution to the WKR problem suggested by Sven Danielsson and Jonas Olson. (shrink)

Stakeholder participation is an increasingly popular ingredient within environmental management and decision-making. While much has been written about its purported benefits, a question that has been largely neglected is whether decision-making informed through stakeholder participation is actually likely to yield decisions that are morally justified in their own right. Using moral methodology as a starting point, we argue that stakeholder participation in environmental decision-making may indeed be an appropriate means to produce morally justified decisions, the reason being that such participation (...) may constitute an efficient way to satisfy the standard requirements on moral reasoning and moral justification. This finding also emphasizes the importance of identifying those settings most conducive to allowing different stakeholders to both challenge each other’s arguments and to adopt each other’s perspectives in order to make effective use of participation in environmenta... (shrink)

Two ways of understanding the notion of autonomy are outlined and discussed in this article, in order to clarify how and if informed consent requirements in biotechnological research are to be justified by the promotion of personal autonomy: A proceduralist conception linking autonomy with authenticity, and a substantivist conception linking autonomy with control. The importance of distinguishing autonomy from liberty is emphasised, which opens for a possible conflict between respecting the freedom and the autonomy of research participants. It is argued (...) that this has implications for how consent requirements based on different criteria of specificity and understanding should be viewed and justified. (shrink)

Three paradigms of legal positivism -- The pure theory of law : science or political theory? -- Kelsen's principles of legality -- Kelsen's theory of democracy : reconciliation with social order -- Democratic constitutionalism : Kelsen's theory of constitutional review -- Kelsen's legal cosmopolitanism -- Conclusions : the pure theory of law and contemporary positivism.

Dealing with ethical issues is a central aspect of many professions. Consequently, ethics is taught to diverse student groups in universities and colleges, alongside philosophy students. In this paper, we address the question of how ethics is best taught to such “non-philosophy” student groups. The standard way of introducing ethics to non-philosophy students is to present them with a set of moral theories. We refer to this approach as the “smorgasbord approach”, due to the impression it is likely to make (...) on non-philosophy students approaching ethics as an academic discipline for the first time. This approach invites the assumption that adopting an ethical position is mainly a matter of choosing from this smorgasbord of different theories. We argue that this approach is problematic for several reasons, both theoretical and practical, and we suggest a methodsbased approach – focusing on methods for moral reasoning – as a more fruitful alternative. The main purpose of this paper is to explain and defend this methods-based approach to teaching ethics to non-philosophy students. In so doing, we also consider and meet some expected objections to this approach. (shrink)

Ever since environmental ethics began to take form as an academic discipline in the early 1970s, the notion of intrinsic value has occupied a prominent position within the field. Recently, however, various types of critique have emerged within EE against invoking this notion. Contrary to these critiques, I argue that appeals to intrinsic value are not problematic, given the reason-implying sense of 'intrinsic value' that is most relevant to EE. I further argue that also those who criticise 'intrinsic-value-talk' in EE (...) actually need this reason-implying concept of intrinsic value. However, once we realise that this is the sense of 'intrinsic value' that is most relevant to EE, it also becomes clear that it is the concept of a reason, rather than that of intrinsic value, that is most important to EE. (shrink)

How to handle orphan drugs for rare diseases is a pressing problem in current health-care. Due to the group size of patients affecting the cost of treatment, they risk being disadvantaged in relation to existing cost-effectiveness thresholds. In an article by Niklas Juth it has been argued that it is irrelevant to take indirectly operative factors like group size into account since such a compensation would risk discounting the use of cost, a relevant factor, altogether. In this article we analyze (...) Juth’s argument and observe that we already do compensate for indirectly operative factors, both outside and within cost-effectiveness evaluations, for formal equality reasons. Based on this we argue that we have reason to set cost-effectiveness thresholds to integrate equity concerns also including formal equality considerations. We find no reason not to compensate for group size to the extent we already compensate for other factors. Moreover, groups size implying a systematic disadvantage also on a global scale, i.e. taking different aspects of the health condition of patients suffering from rare diseases into account, will provide strong reason for why group size is indeed relevant to compensate for. (shrink)

The subject-matter of this essay is the moral status of nature. This subject is dealt with in terms of normative reasons. The main question is if there are direct normative reasons to care for nature in addition to the numerous indirect normative reasons that there are for doing so. Roughly, if there is some such reason, and that reason applies to any moral agent, then nature has direct moral status as I use the phrase. I develop the notions of direct (...) normative reason and direct moral status in detail and identify and discuss the two main types of theory according to which nature has direct moral status: analogy-based nature-considerism and non-analogy-based nature-considerism. I argue for the plausibility of a particular version of the latter, but against the plausibility of any version of the former. The theory that is representative of AN claims that nature has direct moral status in virtue of possessing interests. Proponents of this theory fail to show that nature has interests of the kind that they reasonably want to ascribe to it, and that interests of this kind are morally significant. In contrast to AN, NN comes in a variety of different forms. I elaborate a version of NN according to which there are direct normative reasons to care for nature in virtue of its unique complexity, and its indispensability. I argue that even if these reasons should turn out not to apply to any moral agent, they are still genuine direct normative reasons: there is nothing irrational or misdirected about them. Finally, I show how the question of whether there are direct normative reasons to care for nature is relevant to private and political decision-making concerning nature. This is exemplified with a case from the Swedish mountain region. (shrink)

Why do some people withdraw from biobank studies? To our knowledge, very few studies have been done on the reflections of biobank ex-participants. In this article, we report from such a study. 16 years ago, we did focus group interviews with biobank participants and ex-participants. We found that the two groups interestingly shared worries concerning the risks involved in possible novel uses of their biobank material, even though they drew opposite conclusions from their worries. Revisiting these interviews today reveals a (...) remarkable relevance to present concerns, since the possible developments that worried ex-participants and participants 16 years ago now are becoming realities. Drawing on conceptual distinctions by sociologist and philosopher Niklas Luhmann, we argue that while ex-participants express a loss of trust in the biobank institution to manage the use of their biobank material in a legitimate way, remaining participants expressed confidence in the management of the biobank institution to secure their interests. This analysis brings out important aspects of emerging trends in biobank research participation. (shrink)

This article analyses and presents a survey of ethical conflicts in prehospital emergency care. The results are based on six focus group interviews with 29 registered nurses and paramedics working in prehospital emergency care at three different locations: a small town, a part of a major city and a sparsely populated area. Ethical conflict was found to arise in 10 different nodes of conflict: the patient/carer relationship, the patient’s self-determination, the patient’s best interest, the carer’s professional ideals, the carer’s professional (...) role and self-identity, significant others and bystanders, other care professionals, organizational structure and resource management, societal ideals, and other professionals. It is often argued that prehospital care is unique in comparison with other forms of care. However, in this article we do not find support for the idea that ethical conflicts occurring in prehospital care are unique, even if some may be more common in this context. (shrink)

A small set of allocation principles is said to be behind several theories of distributive justice. However, disagreement about the appropriate relationship between these notions remains, so that compromises between principles may generate more agreement. Truncated utilitarianism is a prominent candidate. It demands maximising total wealth subject to a floor level of individual wealth for all people. Based on some well-known distributive notions, we developed a questionnaire setting and confronted student respondents with corresponding allocation problems, where an exogenously given poverty (...) line served as a floor. However, support for allocations resulting from this specific interpretation of truncated utilitarianism remained rather low. This is surprising because the respective solution was close to an equal split of resources, and aspects of efficiency and responsibility were explicitly introduced to promote more general acceptance. We argue that people may either wish to see higher floor levels or are more inequality averse than probably expected. Moreover, high support for an unconditional consideration of the poverty line can be witnessed, even though aspects of responsibility, but not efficiency arguments, display an influence. In general, attitudes with respect to the equality–efficiency trade-off are found to remain heterogeneous, although different equality concerns are prominent. Furthermore, trade-offs are moderated by the responsibility principle. (shrink)

In central definitions of shared decision-making within medical consultations we find the concept of negotiation used to describe the interaction between patient and professional in case of conflict. It has been noted that the concept of negotiation is far from clear in this context and in other contexts it is used both in terms of rational deliberation and bargaining. The articles explores whether rational deliberation or bargaining accurately describes the negotiation in shared decision-making and finds that it fails to do (...) so on both descriptive and normative grounds. At the end some notes on further analysis is given and it is suggested that the interaction is more accurately described in terms of an internal balancing of values like patient best interest, patient autonomy and patient adherence by the professional that is accepted by the patient. (shrink)

ABSTRACT:This article provides a normative justification for unions. It discusses three arguments. The argument from consent justifies unions in some circumstances, but if the employer prefers to not bargain with unions, it may provide very little justification. The argument from contestability takes as its starting point the fact that employment contracts are incomplete contracts, where authority takes the place of complete contractual terms. This theory of contracts implies that consent to authority has been given under ignorance, and, therefore, that authority (...) cannot be justified by consent. Contestability is a mechanism that can handle this problem for consent theory. It demands transparency, channels for voice, and a forum where contestations can be evaluated. This idea can be implemented in firms in different ways, but the argument from the separation of powers implies that unions are uniquely suited to implement contestability, since they are organized outside of the employer’s domain of authority. (shrink)

The aim of this paper is to investigate whether or not ethical conflicts can be identified, analysed and solved using ethical principles. The relation between the physician and the patient with ischemic heart disease (IHD) as life style changes are recommended in a secondary prevention program is used as an example. The principal persons affected (the patient and his or her spouse) and the ethical principles (respect for autonomy, non-maleficence, beneficence and justice) are combined in a two dimensional model. The (...) most important person affected by the recommendations is the patient. His or her autonomy is challenged by the suggested life style changes, the purpose of which is to promote the future wellbeing and health of the patient. The spouse is indirectly involved in and affected by the process. He or she often feels neglected by caregivers. Ethical conflicts can both be identified and analysed using ethical principles, but often no solution is implied. Most (if not all) physicians would strongly encourage life style changes, but surprisingly there is no uncontroversial justification for this conclusion using principles. (shrink)

A fundamental assumption of theories of decision-making is that we detect mismatches between intention and outcome, adjust our behavior in the face of error, and adapt to changing circumstances. Is this always the case? We investigated the relation between intention, choice, and introspection. Participants made choices between presented face pairs on the basis of attractiveness, while we covertly manipulated the relationship between choice and outcome that they experienced. Participants failed to notice conspicuous mismatches between their intended choice and the outcome (...) they were presented with, while nevertheless offering introspectively derived reasons for why they chose the way they did. We call this effect choice blindness. (shrink)

The ethical debate on whistleblowing concerns centrally the conflict between the right to political free speech and the duty of loyalty to the organization where one works. This is the moral dilemma of whistleblowing. Political free speech is justified because it is a central part of liberal democracy, whereas loyalty can be motivated as a way of showing consideration for one’s associates. The political philosophy of John Rawls is applied to this dilemma, and it is shown that the requirement of (...) loyalty, in the sense that is needed to create the moral dilemma of whistleblowing, is inconsistent with that theory. In this sense, there is no moral dilemma of whistleblowing. This position has been labelled extreme in that it says that whistleblowing is always morally permitted. In a discussion and rejection of Richard De George’s criteria on permissible whistleblowing, it is pointed out that the mere rejection of loyalty will not lead to an extreme position; harms can still be taken into account. Furthermore, it is argued that the best way is, in this as in most other political circumstances, to weigh harms is provided by the free speech argument from democracy. (shrink)

Respecting people’s consent choices for use of their material and data is a cornerstone of biobank ethics. Participation in biobanks is characteristically based on broad consent that presupposes an ongoing possibility of informing and interacting with participants over time. The death of a participant means the end of any interaction, but usually not the end of participation. Research on causes of death makes biobank material from deceased participants extremely valuable. But as new research questions and methods develop over time, the (...) question arises whether stored biobank material from deceased persons still can be used on the basis of their broad consent. In this paper, we discuss policies for postmortem use of biobank material, including consent options, proxy consent and criteria for limitation of types of use and duration of storage. We conclude that the interests of participants in biobank research are best served by asking at enrolment if and how the biobank material may be used after death. We state that the use of biobank material from deceased participants should be delimited both by their consent and by the prevailing broad consent choices of living participants.Biobanks also need to inform participants at enrolment about the duration of storage of biobank material or at minimum have procedures for deciding how long material will be stored for and for which purpose. For older collections, in the absence of such information or consent options, relevant authorities should decide. (shrink)