Thursday, 1 December 2016

New article on the possibility of machines as moral agents online

One of the real perks of supervising PhD students is that they tend to force you outside your established academic comfort zone, and explore new territories of philosophical inquiry. This is what has happened when I have followed the footsteps and eventually joined the work of Dorna Behdadi, who is pursuing a PhD project in our practical philosophy group on the theme of Moral Agency in Animals and Machines. She has led the work on a new paper, where I am co-authour, that is now available online as a so-called preprint, while it is being considered for publication by a scientific journal. The title of the paper is "Artificial Moral Agency: Reviewing Philosophical Assumptions and Methodological Challenges", and deals with the notion of machines or any artificial entity (possibly a very advanced not yet existing one) could ever be ascribed agency of a moral sort, that might imply moral wrongdoing, responsibility for such wrongdoing (by the machine), or similar things.

Tts abstract runs thus:

The emerging field of "machine ethics" has raised the issue of the moral agency and responsibility of artificial entities, like computers and robots, under the heading of "artificial moral agents" (AMA). We analyze the philosophical assumptions at play in this debate and conclude that it is characterized by a rather pronounced conceptual and/or terminological confusion. Mostly, this confusion regards how central concepts and expressions (like agency, autonomy, responsibility, free will, rationality, consciousness) are (assumed to be) related to each other. This, in turn, creates a lack of basis for assessing either to what extent proposed positions and arguments are compatible or not, or whether or not they at all address the same issue. Furthermore, we argue that the AMA debate would benefit from assessing some underlying methodological issues, for instance, regarding the relationship between conceptual, epistemic, pragmatic and ethical reasons and positions. Lastly, because this debate has some family resemblance to debates on the moral status of various kinds of beings, the AMA discussion needs to acknowledge that there exists a challenge of demarcation regarding what kind of entities that can and should be ascribed moral agency.
 The paper can be viewed and downloaded for free here and here.


Friday, 25 November 2016

Come and Join our team in Practical Philosophy: One or more senior lecturers sought!

Our practical philosophy group at the Department of Philosophy, Linguistics and Theory of Science at the University of Gothenburg is hiring. We are presently seeking one or several senior lecturers in practical philosophy. This subjects includes all aspects of philosophy relating to human action and social practices, such as applied and general normative ethics, ditto political philosophy and philosophy of law, metaethics, philosophical esthetics, and the philosophy of religion and the social sciences.

Read more and submit your application here.


Saturday, 29 October 2016

New article on the ethics of risk online

Just a little heads-up that a few days ago I submitted a new article for a coming special issue on the ethics of risk, and has made the "preprint" (my msubmitted manuscript before peer review and editing) available for free reading and download. The article critically assesses the notion of basing an ethics of risk on the core assumption of "defeasible" basic individual moral rights against being exposed to risk by others, and the abstract runs like this:

This article critically assesses recent proposals that an ethics of risk developed independently of standard "factualistic" ethical theory should be based on the assumption of a basic moral right of individuals against being exposed to risks. I argue that core elements that have to be present if the notion of a moral right is to uphold the classic Rawlsian requirement of "taking seriously the distinction between persons" and of preserving the notion of waiving rights means that an ethics of risk based on this axiom will fail to address its most paramount issues. This, in turn, is due to the nature of the most ethically important risks to be collectively produced, and the subsequent consequence that an ethics of risk needs to be able to acknowledge the moral importance of security against risks as a public good. The article ends by charting three broad theoretical strategies that an ethics of risk may take to face up to this challenge, and discuss the place for rights within these respective theoretical landscapes with mostly skeptical results.
 The article itself can be accessed here and here.


Thursday, 13 October 2016

New article on prenatal screening online

 Yesterday I received word that the American Journal of Bioethics has accepted a so-called open peer commentary by myself on a coming so-called target-article that presents a seemingly drastic proposal regarding the ethics and policy of prenatal screening using non-invasive sample techniques and so-called whole genome sequencing technology for analysis. I am partly in sharp disagreement with this proposal, partly in full agreement, and rather critical of how the authors of the proposal have ignored crucial parts of the literature and linked complications. The response where I set out my reasons can now be accessed in its original form, before peer review or editing here and here.


Sunday, 9 October 2016

New article online: Conscientious Refusal in Healthcare: The Swedish Solution

Indeed, as flagged before, I have a new article published online in the Journal of Medical Ethics on the topic of the Sweden's longstanding policy on conscientious objection by health professionals. I briefly describe the policy and its background and chart some recent challenges to it.

The published article, which is to be included in a coming special issue on conscientious objection, is here.

Preprints for free reading and download those of you who lack institutional access to the JME are here and here.


Celebrating 400 000 reads.

Yep, sometime tonight, Philosophical Comment, passed 400 000 reads. Thanks to everyone!

Saturday, 8 October 2016

New paper on precaution and existential risk online for free reading and download

 Some time back, I had two posts here, with a slightly tongue-in-cheek comment on some ongoing academic campaigns and discussions for attending to small or very unclear risks with potentially very serious negative outcomes - so-called existential risks: here, and here. As reported later, this led to an invitation to debate the issue with Olle Häggström (mathematician and crossdisciplinary futurist), author of this new book on the existential risk issue, at The Institute of Future Studies in Stockholm, and Olle used a number of pages in his book to comment on the points I made in the blog posts. Parallel to all of this, I was invited by Sune Holm at the University of Copenhagen, who's been coordinating a nice series of international workshops on the ethics and philosophy of risk, to contribute to a coming special issue of the research journal Ethics, Policy and the Environment on the theme of the ethics of precaution, an area that readers of this blog know that I'm deeply engaged in since many years. Happy to accept, I took the opportunity to start off from the blogposts and the ensuing debates to clarify what existential risks means for the ethics of precaution, and to attend to some quite difficult theoretical issues left hanging in my own theory of the ethics of precaution and risk, published 5 years ago. I have now submitted my contribution, and the so-called preprint, that is my submitted manuscript before peer review, etc. can be freely read and downloaded here and here.


Friday, 16 September 2016

Four Positions in Financial Ethics open at my University

A quick repost of this splendid opportunity for any early carreer philosophy/ethics/economics student or academic with an interest in the ethics and philosophy of finance and economic systems. 4 positions (research fellow, postdoc and PhD's) and a chance to work with my former PhD student, now stellar researcher in his own right, Joakim Sandberg. Joakim has landed a bunch of grants to suppot his creation of a new research environment in his field of expertise, so do check out what it's all about and learn how to apply here.

Tuesday, 30 August 2016

Consensus statement on conscientious objection in healthcare

Just a very brief pointer to this post at the Oxford Practical Ethics blog, showcasing a consensus statement on how states and health systems should handle the phenomenon of healthcare staff conscientiously objecting to practices included in medical practice that comes out of the symposium on this very topic that I related in a recent post.


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.


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.


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.


Saturday, 30 April 2016

Is it a good idea for academics to keep track of their failures?

In the recent weeks there has been some buzz over the academic corner of the internet and social media about the "CV of failures", made public by Johannes Haushofer, assistant economics professor at Princeton. He writes:  

"Most of what I try fails, but these failures are often invisible, while the successes are visible. I have noticed that this sometimes gives others the impression that most things work out for me. As a result, they are more likely to attribute their own failures to themselves, rather than the fact that the world is stochastic, applications are crapshoots, and selection committees and referees have bad days. This CV of Failures is an attempt to balance the record and provide some perspective."

VOX picked up the story and made it larger, but Haushofer himself attributes the notion of a CV of failures to neurobiology researcher Melanie Stefan, who voiced the idea in Nature already 2010:

"So here is my suggestion. Compile an 'alternative' CV of failures. Log every unsuccessful application, refused grant proposal and rejected paper. Don't dwell on it for hours, just keep a running, up-to-date tally. If you dare — and can afford to — make it public. It will be six times as long as your normal CV. It will probably be utterly depressing at first sight. But it will remind you of the missing truths, some of the essential parts of what it means to be a scientist — and it might inspire a colleague to shake off a rejection and start again."

Many people in the academic sphere have been sharing this idea, and Haushofer's actual CoF with appreciating comments, but my reaction is a bit different. It is this: why on earth keep track of your failures at this level of granularity and meticulousness? I totally get the point that handling failures is a very important core skill of academics (as of artists and many other professional groups). I also completely emphatise with the notion that having young students and early career academics see that well established seniors have had and still have their hard time too, and that rejection is not a proof of uselessness. All hail to that! But, then again, all of this assumes that CVs of failures would be floating around without the kind of personality one would nurture by being disposed to write them up, and my reflection is about whether or not nurturing that kind of personality is a good idea for young aspiring academics, or even for academia in general. I actually don't think so, and I think our positive reactions to this piece of news of our dear colleague at Princeton, as for Stefan's original idea, have us confuse keeping track of one's failures with being open about one's attempts

What would be very beneficial for academic culture as a whole, as for seniors and juniors alike, were if we had a more open culture about our attempts to have acceptance (for papers, for grants, for jobs, etc.). Then our failures would be exposed too, as a side-effect, but we needn't spend energy on keeping track of them to document for the rest of the world to see. Or even focus on it, or success for that matter. The importance is the honest attempt, including the struggle to endlessly improve it. That would be a real improvement of the academic culture and landscape.

Thursday, 14 April 2016

Awesome Resource for Public Health Ethics Scholarship and Training Available Online for Free!

Yes indeed! Super kudos to the editorial team of Drue H. Barrett, Leonard H. Ortmann, Angus Dawson, Carla Saenz, Andreas Reis and Gail Bolan – and the sponsor CDC – for putting together this freely available, pioneering and one of a kind collection of case studies and background texts for global public health ethics study, research and training. With contribution by a pack of high octane scholars, such as Ruth Gaare Bernheim, Jo A. Valentine, Lisa M. Lee , Kayte Spector-Bagdady, Maneesha Sakhuja, Norman Daniels, Michael J. Selgelid, Janani Suraksha Yojana, Harald Schmidt, Bruce Jennings, Anthony Wrigley, Eric M. Meslin, Ibrahim Garba, Natalie Brown and Barbara R. DeCausey. 

Available for free download as PDF wherever you are. Just go here.

Tuesday, 12 April 2016

New paper online: Ethical Hazards in Monitoring and Addressing Patient Decision Capacity in Clinical Practice

Just a little heads-up about a new research paper now being online (free to read and download). This one is lead by my Ph.D. student, Thomas Hartvigsson (presently visiting at Queen's University, Canada) and addresses aspects of his thesis topic about the normative roles of decision competence, for instance, in areas such as law or health care.

Together with Gun Forsander, chief senior clinical consultant at a childhood diabetes clinic, we use studies made in the area of teenage diabetes care, to argue that patient educational interventions meant to monitor and promote patients' intellectual understanding of general facts about their disease and the treatment brings ethical hazards likely to undermine some patient's decision-making capacities rather than enhancing or safeguarding them. At the same time, we find a strong general case for the idea of monitoring and addressing decision competence in patient groups where there is good reason to suspect especially fragile decision capacities, and sketch some challenges regarding staff competence and care organisation related to that.

The paper is freely available online for reading and download here.

Wednesday, 23 March 2016

Come and Work with Us on Moral and Legal Responsibility and Agency!

The practical philosophy group at my department has for many years been working on building a research environment focusing broadly on responsibility as a topical theme. This theme encompasses all aspects of moral and legal responsibility and agency, and ranges from the applied and practice oriented (related to different areas and institutions), to the most general and fundamental issues in philosophy, moral and legal theory. It also contains openings for cross-disciplinary collaborations, e.g., with psychology, psychiatry, neuroscience, law, politics and economics. Last year, thanks to a major 10-year grant from the Swedish Research Council, we could welcome Paul Russell as new professor within this theme, who now leads the resulting Gothenburg Responsibility Project (GRP), and also a first round of post docs.

Now the GRP is opening its second call for post docs, and we are, of course, very keen on having applications from people in the postdoctoral phase of their careers, who feel that their field of research fits the GRP theme, and that spending a few years at our department is an attractive prospect. If that's you, please go here for more practical details!

Sunday, 6 March 2016

Personalised, Individualised or Precision Medicine: Three Unaddressed Socio-economic Hurdles

After the BRAIN initiative of 2013, in 2015 US president Obama announced another large scale government funding scheme for biomedical science, on so-called Precision Medicine. Just recently this initiative announced its first pilot study. Leaving the unfortunate terminological analogue of "precision bombing" (eventually known precisely for its lack of precision) to a side, precision medicine is basically nothing new compared to what's already been known among medical scientists as individualised or personalised medicine, except that the Obama initiative has added large scale so-called Big Data methodology to the mix. The vision (described in these reports by the European Science Foundation in 2012) is that of a new strategy in pharmacological treatment consisting of two broad dimensions:

  • Individually designed choice and style of medication (types of drug, dosage scheme, etc), based on complex analyses of pretests of genetic and other factors of relevance.
  • Vastly increased use of presymptomatic screening of people to pick up possible early fragilities disposing for or signs of illness, to then attack with the mentioned new treatment strategies in early stages.
I'll call these dimensions treatment and screening respectively below. Both offer tremendous scientific challenges, still mostly to be overcome. But in this post I'll be assuming that the science has been worked out and instead point to three seemingly rather difficult socio-economic hurdles for the personalised, individualised or precision medicine ultimate agenda to ever be realised. For, naturally, the endpoint is not about the science as such, but to take significant additional steps in bettering human health and the fighting of disease. For that to occur, the existence of scientifically demonstrated natural mechanisms and technological solutions is far from enough. There also has to be a realistic socio-economic production and delivery system with a potential to make the mechanisms and technologies further the ultimate aim.

Hurdle 1: Practical inconsistency and the societal costs of screening
The first hurdle becomes visible when appreciating that the two dimensions are bound to partly work against each other. This as the screening dimension, due to elementary features of statistics and scientific measurement, will most probably mean increased imprecision; the more potential signs of conditions that are picked up in more people, the more likely it will be that signals for possible disease are what is known as false positives, and the more likely it will be that any signal is untrue due to weak predictive value. This, in turn, is especially likely the more the screening dimension addresses conditions as these will be defined in the treatment dimension: these condition will then be increasingly rare (due to the increased precision and individualisation in characterising them), a factor well-known to decrease the precision of screening programmes. This, in turn, will mean that the screening dimension is very likely to boost two well-known problems in medical screening, overdiagnosis and overtreatment, both of which cost both money and suffering. That is, whatever possible increased effectiveness in the fight for health and against disease brought by the treatment dimension is likely to be undermined – overrun even – by these expected outcomes of the screening dimension of precision medicine. Anyone wanting to dig deeper into these kinds of problems are welcome to treat themselves to the wider and deeper explorations of Niklas Juth and myself in our book on the ethics of screening.

Hurdle 2: The medicalisation of life and the exponential increase of health care costs
The next hurdle is linked to the one just described and connects to the concept of medicalisation, which is the process through which we start to view aspects of our life as suitable for biomedical interventions. Medicalisation is partly driven by a well-known socio-psychological tendency of pathologisation of the previously normal, i.e. our tendency of starting to view negative aspects of life or society as seriously problematic to warrant practical attention (rather than merely generally pesty aspects of life as it happens to be, to be reckoned with as part of the normal variation) as they become increasingly rare. One example of this is how we now view the death of a person in Europe at the age of 60 a tragedy warranting serious concern about something having gone wrong, while only 3-4 decades back it wouldn't have raised many eyebrows, even less prompting any probing of fault. But medicalisation is also driven by other mechanisms, two of which are the increasing tendency of viewing risk and indirect indicators of possible future disease as equal to disease, and the increasing tendency of viewing the consumption of a biomedical product or service as the apt response to an increasingly wider sector of perceived problems in life. Especially the latter two mechanisms are bound to be driven by the screening dimension, meaning that increasingly many people can be expected to view an increasing amount of states of their lives as either equivalent to disease or fit for a biomedical response, or both. This forceful increase of consumer demand can then, by ordinary economic mechanisms, be expected to effect a surge in health care costs. However, this surge will at the same time undermine the ultimate aim of precision or personalised medicine, since the surging costs makes it less likely that people, insurers or public health systems can afford meeting the demand and at the same time take up the new treatments from the treatment dimension.

Hurdle 3: Exponential increase in treatment costs for uncertain value
This brings us to these very treatments and what I take to be the core of the vision of personalised, individualised or precision medicine, namely that a radically shrinking number of patients are to be subjected to selected treatments out of a radically increasing number of potential candidates, based on a new addition of test-batteries. As I pointed out not long ago in a post on the surge in drug prices in recent years,  the mere logic of ordinary business means that such a pattern of development will lead to drastic price increases of each personalised/precision product produced by the treatment dimension. Moreover, this effect will be stronger, the more that the treatment dimension turns out to be successful. Assuming full scientific success, it can safely be assumed to become exponential. The reason for this expectation is very simple: for any product it holds, that the fewer expected consumers, the more each product sale has to carry a larger part of covering the development and production costs and profit expectations making up the price necessary for commercial production to be at all viable. But, of course, this implies further scepticism as to whether the ultimate vision of precision medicine will ever be likely to be in sight. The treatment dimension will have to deliver huge increases of the effectiveness of treatments if this is ever to become even close to likely and even if we assume the scientific challenge to have been met it very much remains to be seen what this will mean in terms of actual effects, especially on common diseases such as auto-immune conditions (e.g., diabetes or arthritis), cancers, dementias and cardiovascular diseases. And, of course, the higher the target is set, the less likely becomes the scientific prospect.

In sum, both from the perspective of a private consumer, a health insurer or a state running a public health care system, the precision, personalisation or individualisation medicine visions, even if scientifically viable, look like potential dead ends from a socio-economic standpoint. At least as long as realistic strategies to remove or bypass the hurdles described above have not been presented. And then I haven't even started on such elementary health policy facts that most serious ill-health still depends on social determinants, quite possible to attack by political means, or that the brief historical paranthesis where we could stop worrying about ordinary infectious disease thanks to antibiotics is very close to come to and end rather soon. Political leaders would thus seem well advised to turn their gazes elsewhere than the currently unrealistic lure of a pharmacological industry that as always hunts a way to get us hooked, lined, sunk and landed for good in a trap of ever increasing consumption of ever increasingly unnecessary gadgets, while increasingly convinced of their utmost necessity. Instead tell them, sorry we can't afford it, but here's something we would really want, and maybe they will become more disposed to deliver something of actual social value and potential for promoting health. After all, the customer's always right. Right?

Saturday, 30 January 2016

On "Smykkeloven": The Danish Policy to Seize Personal Valuables and Money from Asylum Seekers

I suppose no one has missed the fast and radical transformation of European refugee and migration policy, following both the vast increase of refugees wishing to seek asylum in European countries during 2015, and the ongoing tragedy of people being killed while attempting to cross the the borders into the European fortress. In my earlier post on this, the focus has been on what occurs around the EU external borders and the inability of the EU to decide and enact a joint policy of sharing asylum seekers to defuse the problem. However, the transformations during the last year includes some rather drastic measures also inside EU itself. Not least by my own government, which has re-installed internal border controls between Sweden and Denmark, Germany, Poland, and so on, and the issuing of a transporter accountability legislation, leading to ID-controls akin those already routine at airports also at ports, train stations, etc. in Denmark and Germany. The Swedish turn-around rather quickly gave rise to a domino effect southwards within the EU, and quick changes of policy have occurred in Denmark, and are being announced in Germany as well. I predict that very soon we will be back at square one were we where when the horrific news of the mass deaths in the Mediterranean started to gain attention a few years back.

One of these changes, that have attracted a lot of negative attention, is the Danish so-called smykkelov; a statute prescribing Danish border police to seize and secure money and valuable assets (such as electronic equipment or jewelry), of asylum seekers, moving many people's minds to the well known Nazi-german organised robbery of Jewish assets, including the bending out of dental gold from people's teeth post slaughtering in the death camps. Thus, following the adoption of the law by parliament, The Guardian, published a satirical cartoon depicting the Danish PM, Lars Løkke Rasmussen, shown to the left. And another cartoon comment, published by The Independent, depicts the famous Havsfruen statue in the Copenhagen harbour thus:

As a tragicomical aside, these two pieces enraged the former leader of the Danish foremost anti-immigration party, now speaker of the parliament, Pia Kjeaersgaard – otherwise known as one the most fierce defenders of freedom of expression related to debates around the so-called Mohammed cartoons of Jyllandsposten – so that she publicly said they are "not fair" and that the newspapers would "have to withdraw them". And Swedish television aired a report on this, where also "ordinary danes" on the streets of Copenhagen exhibited similar crocodile tears when faced with the bitter taste of their own medicine.

Leaving such pathetic expressions of Danish nationalist hypocricy, however, a more serious accusation of possible hypocritical or double standard thinking has been wielded against those who criticise the Danish law. This since, first, apparently, most countries have various sorts of policies meaning that asylum seekers can be made to pay for things like housing, food, schooling of children, etc. during the trial of their application for asylum. This includes, for instance, Switzerland and, indeed, Sweden. Second, Danish politicians have argued that the Smykkelov is merely a case of applying a principle of equal treatment, as Danish residents (as the residents of most countries) are as a rule required to see to their own financial needs, and may only receive public welfare support when these have run out. I found these arguments interesting, as they basically rest on one sound idea: that there is no principal difference between residents and non-residents of a country. So let's have a closer look at how this way of looking at the issue relates to the Danish law.

1. Let's for starters leave out the option of challenging the principle that people should not receive public welfare support until their private assets have run out. Not because it cannot be challenged, it can for instance be argued that it is pragmatically stupid and inefficient, as it tends to lock people into dependency on public welfare. But only for the sake of the argument, let's leave that discussion to a side for now.

2. Let's also leave out the discussion whether or not it is OK for public agencies to demand payment for the processing of a request for what is a legal right (say applying for a tax subsidy, or requesting help by the police)). I would personally like to quarrel with that notion, but for the sake of argument, let's leave also this issue uncontested.

3. Let's then compare the policies of the mentioned examples, Denmark, Switzerland and Sweden.

  • In the Swedish case, the policy in question regards the daily welfare allowance that an asylum seeker may receive while waiting for a decision on asylum and is described here. In short, it means that in order to receive allowance, you have to demonstrate need, and that includes declaring your assets of economic value. If these are found to be sufficient, no allowance will be granted and the person in question will have to pay their own way. Included in this assessment is also an assessment regarding the need to provide housing, whether or not that should be covered by the allowance, etc. There is in this case also a right to appeal the decision. Of course, if someone lies or cheats in this process, this person acts illegally and can be penalised accordingly.  This makes the conditions of asylum seekers almost exactly on a par with Swedish residents applying for public welfare support, and thus in full compliance with the principle of equal treatment referred to in the Danish discussion.
  • In Switzerland, as reported in the news (here, here, here), the procedure is rather different. In this case, the system is that asylum seekers are required to "hand over" all money exceeding 1000 Swiss francs to the authorities, as a sort of security for the costs of the Swiss state for assessing their application for asylum and providing upkeep, and that these money are repaid to any asylum seeker deciding to abolish the process within 7 months. Thus, there is no active "search and seizure" by police, but a legal obligation (and I assume the asylum seeker can be penalised for breeches of it) where the individual is left to decide how to take this responsibility, and – in addition – the valuables are not necessarily lost, but within the 7 month window function more as a deposition. At the same time, the level of viewing asylum seekers as responsible people just like anybody else is slightly less than in the Swedish case, as the handover is obligatory and the valuables then managed by the state. Thus, asylum seekers are not treated as anyone else, as I doubt that Swiss policy for residents is that these have a legal obligation to give almost all their money to the state, so that the state can then pay their bills. Or, if that is preferred, it is handed over to be kept by the landlord, the telephone company, the electricty provider, the supermarket on the corner, and so on.
  • The Danish case, as I have understood the now decided policy (see links above), moves rather more far away from the idea of asylum seekers as actual people, even remotely on a par with residents of the country. Here the idea is exactly "search and seizure" – as I understand at the discretion of individual police officers and with no legally secured opportunity to get anything back, legal appeal, etc. Basically, the border policy is to take from you what you have if you apply for asylum, and then its gone; what we otherwise like to call robbery. I'm quite sure that this is not how residents' need to pay their way in various instances of Danish life is handled by the Danish state – if that were so, knowing quite a bit of Danish people, I think I'd heard about it by now. My impression is that this civic duty (which we accept for the sake of argument) is handled in Denmark as everywhere else: you receive a notification of payment, that can be challenged and for which you may apply for public support to handle, which you then are left to take responsibility for yourself, and if you don't take it you suffer the consequences. This basically also applies to taxes, although it's a bit of a complex process that proceeds via revenue, appeals, applications for subsidies, etc. The Danish resident is viewed as a person capable of taking responsibility for his or her own actions, with a basic right to dispose of his or her assets as she pleases (within what is lawful) and accountable for the ensuing upshots of his or her decisions. That is, the argument from equal treatment seems very far from supporting anything even remotely resembling the Smykkelov.

So how would the treatment of Danish residents have to look like for the Smykkelov to be supported by the appeal to equal treatment? I suppose something like this:

  • At the end of every month, the police scans you bank account and transfers all of the money there to a state account, used to pay for your rent, your food, your clothes, etc.
  • In this period, the police also breaks into your home and seizes all valuable assets for the same purpose.
  • In addition, there is the regularly seizure of tax for public services, but now at the discretion of individual police officers and no legal room for appeal, etc. 
So now, we all wait for this apparently generally desired reformation of danish civic life. As the title of the danish national anthem goes:

Der er et yndigt land!

Saturday, 16 January 2016

Conscientious refusal / objection in health care: new article draft online, and an upcoming symposium

A while back, I made a post with a number of critical remarks on the idea of a legal right of health care professionals to so-called conscientious refusal/objection. That is the idea that such professionals should enjoy a guaranteed exemption from the standard labour law rule, that employee's are obliged to carry out legal instructions of their employer, in cases when they object to the practice they are instructed to carry out, or its legal status. I made the post mainly to get some opinions of particular relevance to current health care policy off my chest, but as it turned out, these ideas have attracted attention within the international community of more systematic research undertaken in this area.

First, the post lead to an invitation to contribute to a coming special issue of the journal Cambridge Quarterly of Health Care Ethics, guest edited by Alberto Giubilini and Julian Savulescu, on the very subject of the ethics of conscientious objection/refusal in health care.

Second, I was invited to contribute to a symposium on the same topic at the Brocher Foundation in Geneva in  June this year, organised once again by Julian, now in collaboration with Sharyn Milnes. My contribution to the symposium is entitled "All or nothing: The legal, ethical and jurisprudential basis of legal rights to conscientious objection of voluntarily employed professionals", and the contribution to the special issue also focus on the combination of ethical and legal reasons in this area.

The work on this article has been undertaken in collaboration with my Danish colleague Morten Ebbe Juul Nielsen, who made contact almost immediately when the blog post was online to suggest that we collaborate, as he had been thinking along the lines of some of the central points of the post already, and had started to scan the relevant literature in more detail. Said and done, the first result of our efforts, the submitted draft manuscript to the mentioned special issue, entitled "The Legal Ethical Backbone of Conscientious Refusal",  can now be viewed online here and here. As this submitted manuscript is undergoing review and will almost certainly be subject to revision, me and Morten are happy to receive any sort of constructive comments.

Friday, 15 January 2016

New article published: The counseling, self-care, adherence approach to person-centered care and shared decision making: Moral psychology, executive autonomy, and ethics in multi-dimensional care decisions

A few days ago, an article by myself and three colleagues from philosophy, psychological safety research and pediatrics that's been accepted for a long time finally came online at the journal Health Communication's website. The article explores how standard accounts of how models for increased interaction and collaboration between patients and health care professionals – often termed patient or person centred care, and shared decision-making – fit badly to a broad group of patients; namely those whose care are mostly self-administered, who suffer vulnerable decision capacities and who exhibit a weakening adherence to decided care plans. In the article we illustrate the point with a study of adolescent diabetes care, based on video-taped consultation meetings between patients and health care professionals, and develop a general argument based on broadly recognised research in decision-making and moral psychology to revise the standard approach to person centredness and shared decision-making for this group of patients, focusing less on making shared rational autonomous decisions in health care meetings, and more on emotionally empowering patients and help them to develop virtues necessary to take responsibility for the self-care they agree on in collaboration with health professionals. Here is the abstract:

This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy.

The article itself can be found here. For those who lack access to university libraries or subscriptions, a so-called postprint of the article – i.e. the author's finally submitted manuscript after peer review, but before editorial and type setting changes, pagination and so on – can be found here. Or you can contact me, to request a pdf of the published version.