Sunday, 21 August 2016

Substantially updated blogroll



Just a quick note that I have finally gotten around to updating the Philosophical Comment blogroll, that is the list of linked blogs promoted on this page further down in the left hand side margin. I have basically taken off all old blogs that either has closed down since I listed them some years back, or that when I checked had not posted anything for a year or more. In addition the URLs for some of the still active blogs had been changed, so this has been updated as well. Among the new entries are:

Three general purpose collectively run philosophy blogs that have appeared since I compiled my original list, which mix news, commentary and academic debate with substantial philosophical discussion in various areas: The Daily Nous, Feminist PhilosophersA Philosopher's Take. Other additions are individual philosophy blogs dedicated to substantial philosophical debate in selected topical areas. Two of these have become well established and highly regarded since the last update, Philosophical Disquisitions and The Splintered Mind.

But I would like to push a little bit extra for a very recently started blog by my dynamic colleague and good friend Richard Ashcroft, professor of bioethics at the School of law of the Queen Mary University of London: Utopian Biofutures. One of the most broadly conceiving and farsighted of philosophical bioethicists I know (being a scholar law and social science besides philosophy, applied ethics and political theory), this blog is dedicated to his latest project, where he sets out to combine his diverse scholarship with his astute knowledge and affinity for futuristic and SF fiction in an analysis that is to address what technological utopias for humanity and human societies we, where we stand now, have reason to consider and what we should think and do about them.

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Thursday, 11 August 2016

New and forthcoming work (soon) available: conscientious refusal of pofessionals, hate crime philosophy, responsibility and priority-setting in health care, and the ethics of patient education

 
 
Just kicking off the autumn term after some well-needed weeks of complete holiday, summing up some recent and very soon available or forthcoming work in a few different areas:

1. Conscientious objection or refusal of professionals (in health care and elsewhere)
This is an area, i have been posting about before (here, and here).

a) As I flagged earlier in one of these posts, there is one article on this topic, co-authored by myself and Morten Ebbe Juul Nielsen, entitled "The Legal Ethical Backbone of Conscientious Refusal", forthcoming in a special issue of the Cambridge Quarterly of Healthcare Ethics, now formally accepted and with a so-called "postprint" (our finally submitted manuscript after peer review) avialable for free online reading and download here and here. In short, me and Morten argues that the idea of a legal right to conscientious refusal is either  incompatible with basic legal ethical principles (equal treatment, rule of law etc), or indefensible by undermining core societal values. Here's the abstract:

This paper analyses the idea of a legal right to conscientious refusal for health care professionals from a basic legal ethical standpoint, using refusal to perform tasks related to legal abortion (in cases of voluntary employment) as a case in point. The idea of a legal right to conscientious refusal is distinguished from ideas regarding moral rights or reasons related to conscientious refusal, and none of the latter are found to support the notion of a legal right. Reasons for allowing some sort of room for conscientious refusal for health care professionals based on the importance of cultural identity and the fostering of a critical atmosphere might provide some support, if no countervailing factors apply. One such factor is that a legal right to health care professionals conscientious refusal must comply with basic legal ethical tenets regarding the rule of law and equal treatment, and this requirement is found to create serious problems for those wishing to defend the idea under consideration. We conclude that the notion of a legal right to conscientious refusal for any profession is either fundamentally incompatible with elementary legal and ethical requirements, or implausible because it undermines the functioning of related professional sector (healthcare) or even of society as a whole.

b) In the same post, I also mentioned a workshop on this topic at the Brocher Foundation in Geneva, which took place as planned in June. The slides to my presentation there, "All or nothing! The legal, ethical and jurisprudential basis of legal rights to conscientious objection of voluntarily employed professionals" (building on and somewhat extending the argument of mine and Morten's article above), are available here and here.

c) At the same workshop, a wide range of presenters with opposing views on many issues nevertheless found themselves to agree on a number of core positions, and a consensus statement is currently being drafted for speedy publication, soon to be available in an as yet unnamed professional journal.

d) The workshop organisers, Alberto Giubilini, Julian Savulescu and Sharyn Milnes, moreover invited participants to submit to a further special issue on the topic, now in the Journal of Medical Ethics. As mine and Morten's article was already placed, I wrote a brief note on the Swedish way of dealing with conscientious objection in health care, entitled "Conscientious Refusal in Healthcare: The Swedish Solution", which is now accepted for publication, and available in its "preprint" (original submitted manuscript) form for free reading and download here and here. This is the abstract:

The Swedish solution to the legal handling of professional conscientious refusal in health care is described. No legal right to conscientious refusal for any profession or class of professional tasks exist 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 requests to change work tasks are handled case by case within the frames of labour law, ensuring full voluntariness, but also employer privilege regarding the organisations 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 pro-life groups to challenge the Swedish solution related to legal abortion in courts.

2. The ethics of responsibility and priority-setting in shared decision-making
This is work undertaken in an ongoing research programme on the ethics of person centred care, of which I'm a part, but also linked to my work in the Gothenburg Responsibility Project. It builds further on earlier collaborative analyses by myself and Lars Sandman of the notion of so-called shared decision-making in health care. Together with Erik Gustavsson, we have an article that has just been published online in the Journal of Medical Ethics, where we penetrate the idea that increased patient involvement in and empowerment over clinical decisions would strengthen the case for the idea of holding them responsible for lack of adherence to agreed care plans (and the resulting ill-health) through a less favourable priority-setting of their health needs. We also discuss whether or not the ideas behind shared decision-making constitute an argument in favour of applying some such principle of individual responsibility for ill-health. Basically, our answer is yes to the first query and no to the second, although we also note several limitations and complications. "Preprints" of this article are available for free reading and download here and here. This is the abstract:

Given health care resource constraints, voices are raised to hold patients responsible for their health-choices. In parallel, there is a growing trend towards shared decision-making, aiming to empower patients and give them more control over health care decisions. More power and control over decisions is usually taken to mean more responsibility for these. The trend of shared decision-making would therefore seem to strengthen the case for invoking individual responsibility in health care priority setting.
Objective and Design
The objective was to analyze whether the implementation of shared decision-making would strengthen the argumentative support for invoking individual responsibility in health-care priority setting, using normative analysis.
Results and Conclusions
Shared decision-making does not constitute an independent argument in favor of employing individual responsibility since these notions rest on different underlying values. However, these theoretical tensions do not constitute a problem for combining these phenomena in practice. If a health system employs shared decision-making, individual responsibility may be used to limit resource implications of accommodating patient preferences outside of professional standards and goals. If a health care system employs individual responsibility, high level dynamic shared decision-making may disarm common objections to the applicability of individual responsibility, in virtue of making them more likely to exercise adequate control of their own actions. However, if communication strategies applied in the shared decision-making are misaligned to the patient's initial capacities, the result may be the opposite. Non high-level dynamic types of shared decision-making would not seem to affect the applicability of individual responsibility at all.
3. The ethics of patient education
This work, entitled "Errorthrawling and Fringe Decision Competence: Ethical Hazards in Monitoring and Addressing Patient Decision Capacity in Clinical Practice" utilises some material and builds partly on earlier analyses of studies of the communication and ethics of pediatric diabetes care, e.g., this one, but mostly presents fresh analytical results from my Ph.D. student Thomas Hartvigsson, who works on a thesis on the normative roles of decision competence. The article describes and discusses the ethical, emotional and professional dymamics of an extreme variant of patient education, especially risky to occur when common patient education strategies are applied to what we call "fringe decision competent patients", i.e. people who are in a grey area between obvious decision competence and incompetence. The article is still in the submission phase, so it is due to be revised a number of times, and if you have comments or suggestions, don't hesitate to contact Thomas. His email is found in the original "preprint", available for free reading and download here and here. The current abstract runs like this:

In this article we discuss how health professionals should monitor and safeguard patients' abilities to take part in clinical decisions and their implementation. Such a task is essential e.g. in self-care situation where patient is responsible for most regular care. Here, argue that a common fact-oriented strategy of patient education in practice tends to take the form of what we call errorthrawling. Illustrated by empirical findings from a video study of consultation meetings in adolescent diabetes care, we argue that this strategy both tends to miss significant capacity weaknesses, and even undermine capacities. In effect, this strategy for clinically monitoring and addressing the decision capacities of patients where these are fragile seems to be incomplete and actually hazardous. We close by suggesting complementary and alternative strategies, and comment on how these may actualise a need of a broadened competence of clinical health professionals.
Being work in progress there's bound to be further news ahead on this front, which will be relayed here as it appears.

 4. Hate crime philosophy and moral psychology: forthcoming 3 volume book series
Before going on holiday, me and David Brax, with whom I have been working on the philosophy of hate crime for some years now, submitted the final versions of three chapters contributing to a coming 3 volume book series published by Preager, of which we are also associate editors, entitled The Psychology of Hate Crimes as Domestic Terrorism: U.S. and Global Issues, and edited by Edward Dunbar, Amalio Blanco and Desirée A. Crèvecoeur-MacPhail. Me and David contribute two co-authoured chapters, one briefly summarising the basic philosophical issues actualised by the phenomenon of hate crime and related policy, and one on the relationship between hate crime and terrorism from a conceptual, ethical and moral psychological standpoint. In addition, I contribute a chapter on my own, where I problematise the relationship between underlying assumptions about criminal responsibility related to the moral psychological assumptions around hate criminality and crimes committed by mentally disordered offender. The series is currently in its final production stage and is due for publication in November this year.

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Thursday, 12 May 2016

Is What's Going On in Brazil Politics A (Soft, Light, Parliamentary, Peaceful, Constitutional, Democratic) Coup?



Few, I assume, have missed the high level political developments in Brazil, where this night the Brazilian senate voted to impeach president Dilma Rousseff. Otherwise, some updates are here, here, here, here, to provide just a few. The process have been truly bizarre, as Dilma is ousted by and to the benefit of truly much more corrupt politicians than herself, for a sin which looks like a minor thing in context, not least the fact that the trick of hiding a budgetary deficit has been an accepted practice of Brazilian governments for a long time. In any case, the immediate result is that Dilma is now suspended from office for 180 days, while it will be determined if she is to be removed permanently. During that time, her selected vice president, Michel Temer steps up to head the government, and there he will remain if she is indeed removed by parliament.

Now, Temer is politically very far to the right of Dilma – who was once hailed as the heiress to the very popular political legacy of Lula da Silva but has then mismanaged the economy badly to lose popularity. Temer is accused of serious corruption and is probably correctly described as allied with the right wing forces (equally or worse corrupt) of parliament that want to have Dilma removed. This fact, together with a truly crazy roller coaster process of parliamentary decisions, courts and judges interfering at different levels, and a fresh speaker of parliament trying a last minute nullification of the whole shebang the other day, then making a 180° turn just a few hours later, have made commentators to the left side of typical conservative politics talk about a "coup". Not a military coup or a palace coup, of course, but nevertheless something truly undemocratic and fishy going on to remove a democratically elected political leader to the benefit of one representing a party that has performed weak to say the least in the last few general elections. This, not least, is Dilma's own main line. Some sources describing the same or very similar points are here, here, here, here, to name just a few. What's so interesting with this argument is that those who sing the coup line, do it with a long line of qualifiers. It's a "soft" coup, or a "light" one, it's not unconstitutional, but still a coup, neither is it against the democratic process of Brazil, but a coup nevertheless. And so on. So, one may wonder, with that definition of a coup, what's not a coup in the area of democratic states changing leaders?

Let's face it. Brazil is a constitutional democracy. One might prefer changes to its constitution, but that goes, of course, for all constitutional democracies. None of them are perfect. Within this constitution, Dilma has been elected for president by (strong!) popular vote, and it seems that none of the coup advocates complain about that, so Brazil democracy must be doing OK also by their light. Likewise, within this constitution, Dilma has selected Michel Temer as her vice prez, probably for reasons of the power politics of forming political alliances going on in any democratic state following a general election. That is, Michel Temer is as democratically selected as any vice president or vice PM of any country. Moreover, the role of a vice prez or PM is exactly to step in when the president or PM cannot perform their duties of office. This, once again, does not make Brazil an exception from other constitutional democracies. This alone settles the fact that there is nothing undemocratic or constitutionally dodgy of having a political mirror image taking over for Dilma. It's a consequence of her own democratic political moves to form a strong government to lead. This holds whatever the reason for her incapacity to execute her office, should it be illness, disappearance, death – or criminal charges. Moreover, the impeachment process seems to be perfectly constitutional, as the democratic constitution here gives the power to drive it to parliament rather than courts. Again, this may look unsatisfactory to some, but this solution to the issue of how to deal with (suspected) criminal political leaders, is far from unique among constitutional democracies around the world. At the end of the day, therefore, the 180 day removal of Dilma from office seems to be perfectly democratic and constitutional, and the consequence of this removal is that Temer now takes over, again (as we saw) perfectly in line with constitutional democratic rules and procedures.

My conclusion is that if the removal of Dilma and insertion of Temer as president is a coup, so is every constitutionally democratic (re)formation of government all over the world.

What we see in Brazil is nothing undemocratic or even a lack of democracy. It is about a deeply corrupt state and country, where political leaders sell themselves for money and form ideologically bizarre alliances for the mere reason of holding on to power, and the country's highest leader making serious political mistakes and not revising policies. This is something that needs to be highlighted much more: democracy is no guarantee for sound politics or well functioning states. It has other merits, of course, but to get at the deficiencies exposed by the latest mess in Brazil, we should look in other directions than the system for allocating formal political power, namely here.

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