Christian Munthe

Since a couple of decades, the notion of a precautionary principle plays a central and increasingly influential role in international as well as national policy and regulation regarding the environment and the use of technology. Urging society to take action in the face of potential risks of human activities in these areas, the recent focus on climate change has further sharpened the importance of this idea. However, the idea of a precautionary principle has also been problematised and criticised by scientists, scholars and policy activists, and been accused of almost every intellectual sin imaginable: unclarity, impracticality, arbitrariness and moral as well as political unsoundness. In that light, the very idea of precaution as an ideal for policy making rather comes out as a dead end. On the basis of these contrasting starting points, Christian Munthe undertakes an innovative, in-depth philosophical analysis of what the idea of a precautionary principle is and should be about. A novel theory of the ethics of imposing risks is developed and used as a foundation for defending the idea of precaution in environmental and technological policy making against its critics, while at the same time avoiding a number of identified flaws. The theory is shown to have far-reaching consequences for areas such as bio-, information- and nuclear technology, and global environmental policy in areas such as climate change. The author argues that, while the price we pay for precaution must not be too high, we have to be prepared to pay it in order to act ethically defensible. A number of practical suggestions for precautionary regulation and policy making are made on the basis of this, and some challenges to basic ethical theory as well as consumerist societies, the global political order and liberal democracy are identified.

The Swedish solution to the legal handling of professional conscientious refusal in healthcare is described. No legal right to conscientious refusal for any profession or class of professional tasks exists in Sweden, regardless of the religious or moral background of the objection. The background of this can be found in strong convictions about the importance of public service provision and related civic duties, and ideals about rule of law, equality and non-discrimination. Employee's requests to change work tasks are handled on a case-by-case basis within the frames of labour law, ensuring full voluntariness, and also employer's privilege regarding the organisation and direction of work, and duties of public institutions to provide services. Two complicating aspects of this solution related to the inclusion of ‘alternative medical’ service providers in a national health service, and professional insistence on conscientious refusal rights to accept legalised assisted dying are discussed. The latter is found to undermine the pragmatic reasons behind recent attempts by prolife groups to challenge the Swedish solution related to legal abortion in courts.

This paper is about the idea of a moral distinction between doing harm and allowing harm to occurr. It discusses, and developes a general argument against, the version of the distinction often described as counterfactual, which I characterize in terms of making a moral difference between different ways of causing harm (in contrast to, e.g., the version famously discussed by Jonathan Bennett). The gist of the argument is that all variants of this version of the doing-allowing idea would have to make factors out of the agent's control into wrong-making characteristics and that, therefore, this version violates a plausible extension of the principle that 'ought' implies 'can'.

While health care goals are usually formulated in terms of the securing of good health for the population, the goal of public health is to an increasing extent, at least in Western countries, being formulated in terms of the provision of societal preconditions for securing of good health. This goal may be attained although no one enjoys good health as a result, namely if people choose not to make use of the preconditions provided. However, reaching this goal may still seem desirable in that it promotes the autonomy of people with regard to health-related choices. In this presentation, I address the questions: 1) whether or not the promotion of autonomy may be supported as goal of public health on the basis of ethical theories dealing with autonomy, 2) whether this support is equally strong regardless of the economic, social and cultural conditions of different countries. I will argue that the first question may be answered affirmatively only if certain important revisions are made in the ethical theories in questions but that these revisions at the same time raise a number of very complicated issues in theory as well as in practice. Regarding the second question, I will claim that in so far as the goal of promoting autonomy may be morally justified, there are a number of reasons supporting the suggestion that this justification is much stronger in societal settings where reasonably high health and welfare levels are allready secured.

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.

Societal decisions regarding the possible granting of permission for industrial and power plants, waste disposals, traffic routes and other facilities implementing modern science and technology (here simply called technology-decisions) often provoke debates regarding the risks involved. A main theme in these debates concerns the magnitudes of these risks and whether or not they are worth taking to reach some aim. This is also a main theme in traditional risk-analysis and critical discussions of risk-management. However, sometimes the fact that some people do not want to be exposed to the risks in question has been suggested as an independent argument, i.e. regardless of the magnitudes of these risks. A well known phenomenon in this respect on the local and national level is what has been labelled "not in my backyard" (NIMBY), but the argument also has been used on an international level. In accordance, the view that unwanted risks are less acceptable than wanted or indifferent ones (regardless of their magnitudes) has been proposed as being highly relevant for technology-decisions. The paper explores to what extent there are good reasons for accepting such a proposal. The main part of the paper is devoted to an examination of the extent to which the view that unwanted risks are less acceptable than wanted ones can be supported by, on the one hand, welfare-based ethical theories underlying standard models for risk-analysis, such as utilitarianism, and, on the other, a moral requirement to respect the autonomy of individual persons. Also, the very concept of an unwanted risk is explored and some peculiarities are noted. It is argued that no categorical impermissibility of exposing people to unwanted risks can be supported. However, there are still good reasons for policy-makers to consider the degree to which risks are unwanted as a factor in technology-decisions that is relevant independently of the welfare-gains at stake. In particular, policy-makers should avoid paternalism in risk-management, i.e..

While promoting population health has been the classic goal of public health practice and policy, in recent decades, new objectives in terms of autonomy and equality have been introduced. These different goals are analysed, and it is demonstrated how they may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in different contexts. A basic conflict of perspective is handled by integrating the ideas of public health striving for health-related autonomy and equality, resulting in a prioritarian oriented population approach to health-related autonomy. This integrated goal is demonstrated to constrain itself in several ways attractive from the point of view of the classic goal, but several serious problems remain. For this reason, a model where all of the three goals are integrated into one coherent structure where they can be assigned varying degrees of importance relative to the level of population health is described. It is argued that this model avoids the problems set out earlier, and is actually normatively preferable to the classic goal alone. It is furthermore argued that the model may be employed as a useful tool for descriptive ethics, as well as a vehicle for international harmonisation of public health policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of public health resources are noted, as are a battery of questions for further research.

Standard versions of the requirement of informed consent state that patients who are offered to enter a clinical trial of a medical procedure should be informed about risks and possible benefits of this procedure (compared to available alternatives) in order to facilitate a rational decision whether or not to participate. However, in many real cases where new medical procedures are to be clinically tested for the first time the information available for such communication to prospective patients is very scarce, vague and/or uncertain. This phenomenon is illustrated by the clinical introduction of new procedures in reproductive medicine, such as preimplantation genetic diagnosis (PGD). Regarding such procedures, it has ben argued that, in such cases, the quality of the available information may be too low for the obtaining of informed consent to be possible, even if it is successfully communicated. Others, instead, holds that informed consent may always be obtained regardless of the quality of the available information. Unfortunately, the standard litterature on informed consent give no clue as to which of these interpretations is correct. This issue is explored by connecting the concept of informed consent to ethical ideas of respect for autonomy and ideas of rational decision making. It is argued, first, that low quality of available information regarding the risks and possible benefits of a medical procedure may indeed make the obtaining of informed consent from patients to undergo this procedure impossible even in theory. However, it is also argued that whether or not this is the case must be relativized to the actual needs and deires of individual patients. Thus, regarding one and the same procedure, informed consent may be impossible to obtain from some patients due to the low quality of the available information regarding this procedure, but still be possible to obtain from other patients.

The phenomenon of twinning in early fetal development has become a popular source for doubt regarding the ascription of moral status to early embryos. In this paper, the possible moral basis for such a line of reasoning is critically analysed with sceptical results. Three different versions of the argument from twinning are considered, all of which are found to rest on confusions between the actual division of embryos involed in twinning and the property of early embryos to be divisible, be based on highly questionable ethical assumptions, or to imply inconsistent claims regarding the moral importance of potentiality and/or the moral status of embryos. This is taken to expose a number of related inconsistencies in the moral basis of pro-life positions. In particular, ascribing moral significance to the property of being (in)divisible is found to be incompatible with the claim that human individuals possess unique values which could underpin an absolute moral ban on murder.

Utilitarian arguments on bioethical issues regarding human reproduction typically start with the view that it is wrong, other things being equal, not to procreate when this would have resulted in an additional being with a life worth living. The paper takes this view for granted and examines the common utilitarian claim that overpopulation and destitution in the world mean that, in practice, this obligation to procreate, other things being equal, often turns into a (categorical) obligation not to procreate. A version of this argument is defended -- a version called the argument from transfer -- according to which, rather than having additional children and care for them in order to make them happy, many people in the West ought to abstain from procreation and take care of destitute children already existing. The reasoning leading up to this conclusion raises some philosophical questions, seldom discussed in connection with bioethics, which indicate that the argument from transfer, although supporting the claim above, cannot neutralise the obligation to create more happy people as easily as assumed by utilitarians. It is argued that the argument from transfer may place many people facing the choice of procreation in a peculiar moral dilemma

In recent years a principle for responsible risk-taking called "The Precautionarity Principle" (PP) has been put forward in several policy documents regarding risk-management of technological and environmental issues. PP involves two claims: 1. An ethical claim according to which it is irresponsible to, for example, use new technologies, regdless of how large benefits these are known to bring, unless it has been proven that they will not give rise to unacceptable long term risks. 2. An administrative/political claim according to which the burden of supplying the proof spoken of in claim 1 is to be laid on the supplier of the new technology. This paper deals only with claim 1, which is the real "precautionarity claim". PP has produced much enthusiasm in different political circles, where it is often held out as a landmark for a new thinking in risk-management. However, while claim 2 is clear enough, it is rather obscure how the precautionarity claim is to be understood. In particular, it is not clear to what extent (if any) this claim implies anything new for risk-analysis. This is so since the precautionarity claim does not say anything about what is to be counted as a proof, or what constitutes an unacceptable risk. The paper explores different conlicting interpretations of the precautionarity claim and demonstrates how the choice between these actualise hard ethical issues. In particular, the issue of how much damage we are allowed to cause in order to pursue safety and certainty is discussed. This issue is actualized when new technologies with known beneficiary effects cannot be proven to be "safe enough" according to some interpretations of the precautionarity claim unless investigated for a rather long period of time, during which the technology is not allowed to be used to produce the beneficiary effects it can produce. This problem is structurally similar to a well known issue in medical ethics regarding the rsponsibility of continuing a controlled clinical trial of a drug known to cure when this means that half of the patients suffers extra agony and earlier death because they get a placebo instead of the new drug..

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.

The precautionary principle (PP) has been criticised for almost every intellectual sin one may imagine: unclarity, impracticability, rigidity, implausibility etc. Recognising the rather obvious fact that there is no such thing as one PP, this paper attempts to address this criticism on a more constructive note than merely view it as forcing us to be "for or against" precaution. This is done by connecting an underlying ethical ideal regarding the imposition of risks present in most formulations of PP to the criticism and use the latter for discussing how such an idea may be plausibly designed and used for underpinning policies that may plausibly be said to express the spirit of PP. It is argued that the most important issue regarding this is to recognise that there is something to the idea that imposing risks on people has a morally significant price, but that we must also acknowledge that taking precautionary measures to avoid or decrease such risks has such a price. The critical issue in the ethics of risk of relevance for PP thus becomes what constitutes a proper price of precaution. It is demonstrated how two simple constraints on this amkes it easy to meet many typical arguments against PP, but also how this issue must be further attacked by means transcending the traditional tools of normative ethics and decision theory, as well as how further reflection along such lines connects PP to issues of international..

Public health is often distinguished from heaslth care in that it is said to serve more 'collective' goals, such as 'the common good' rather than the good of individual people. However, it is not clear what this good is supposed to be (although it is supposed to be 'common'). In regular health care we see in the West a gradual expansion of traditional goals exclusively in terms of length and quality of life to goals having to do more with autonomy - the ability of people to control and direct their own lives. This has lead to a number of questions regarding how such an ethical ideal of promotion of autonomy may be construed, whether or not it really is an ideal, what practical consequences it has etc.

Medical genetic interventions can be performed in two ways. First, genetic defects may be repaired (gene therapy). Secondly, a possible future individual (an embryo or a possible combination of gametes) may be preselected because of its favourable genetic make-up (by using genetic diagnostic methods and procedures from reproductive medicine so called Preimplantation Genetic Diagnosis). The first kind of intervention means that someone gets medical treatment in the normal sense, however, the second kind does not. Rather, in that case, the potential patient is exchanged for another individual who is in no need of treatment. The paper explores to what extent arguments for and against these kinds of genetic intervention apply equally to all of them. For example, may the benefits that can be achieved through gene therapy be equally well achieved through genetic preselection? Are fears of a resurrection of eugenic practices through gene technology more warranted regarding therapeutic interventions than regarding preselective ones (or vice versa)? Since genetic preselection is an intervention at the germ-line level and is presently clinically applied: How is it possible to motivate that clinical application of germ-line gene therapy is not similarily permitted?