Christian Munthe

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 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.

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 other parts of medicine and health care seems traditionally to be primarily directed at preventing losses of bodily functions, repairing said functions in the case of such losses, or at least to provide ailment for unpleasant symptoms, sports medicine has allready from the beginning been involved with the project of enhancing bodily functions with regard to sports performance. First, when sports medicine involve itself in the traditional health care activity of prevention, therapy and ailment, the aim is often very different from ordinary medical activities in that it tries to secure bodily functions far beyond what is required to reach what would normally be seen as a non-pathological state of a person. Second, sports medicine actively involves itself in the project of extending and enhancing human performance capacities through medical knowledge and technology. This raises several issues both with regard to medical ethics and the ethics of sports. For example, how should the goals of sports medicine be viewed from the perspective of rationing scarce health care resources? Should sports medicine be restricted by rules from the sports community as to which performance enhancing activities are tolerated in that sector? Or should sports medicine rather direct what is to be accepted within the world of sports? Both lines of reasoning are to be found in debates about, e.g., doping, controversial training methods and the potential use of gene technology in sports. The paper will address these issues and analyse them from a philosophical point of view.

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.

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'.

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 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.

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.

The notion of the best interest of children figures prominently in family and reproductive policy discussions and there is a considerable body of empirical research attempting to connect the interests of children to how families and society interact. Most of this research regards the effects of societal responses to perceived problems in families, thus underlying policy on interventions such as adoption, foster care and temporary assumption of custodianship, but also support structures that help families cope with various challenges. However, reference to the best interest of children can also be applied to a more basic issue in family policy, namely that of what is to be considered a family in the first place. This issue does not raise any questions regarding the proper conditions for when society should intervene in or change the family context of a child. Rather, it is about what social configurations should be recognized as a potentially fitting context for children to enter into and (if all goes well) eventually develop into adulthood within /.../ such that society’s default institutional arrangements allow it to have (by sexual and artificial reproduction, adoption, and combinations of these), care for and/or guard children. [This] will frame any further discussion of /.../ policies having further implications for, for example, the practices of adoption and reproductive technology, as well as regulation of custody in the event of separation or parental disagreement.

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?

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.