There are several strategies to promote health in individuals and populations. Two general approaches to health promotion are behavior change and empowerment. The aim of this article is to present those two kinds of strategies, and show that the behavior-change approach has some moral problems, problems that the empowerment approach (on the whole) is better at handling. Two distinct ‘ideal types’ of these practices are presented and scrutinized. Behavior change interventions use various kinds of theories to target people’s behavior, which (...) they do through information, persuasion, coercion and manipulation. Empowerment is a collaborative method where those ‘facilitated’ participate in the change process. Some ethical problems with the behavior-change model are that it does not sufficiently respect the right to autonomy of the individuals involved and risks reducing their ability for autonomy, and that it risks increasing health inequalities. Empowerment, on the other hand, respects the participant’s right to autonomy, tends to increase the ability for autonomy, as well as increasing other coping skills, and is likely to reduce inequalities. A drawback with this approach is that it often takes longer to realize. (shrink)

The concept of ‘empowerment’ is used frequently in a number of professional areas, from psychotherapy to social work. But even if the same term is used, it is not always clear if the concept denotes the same goals or the same practice in these various fields. The purpose of this paper is to clarify the discussion and to find a plausible and useful definition of the concept that is suitable for work in various professions. Several suggestions are discussed in the (...) paper, for example control over life or health, autonomy, ability, self-efficacy, self-esteem, and freedom, and it is concluded that there are two plausible complementary uses, one as a goal and one as a process or approach. Empowerment as a goal is to have control over the determinants of one’s quality of life, and empowerment as a process is to create a professional relation where the client or community takes control over the change process, determining both the goals of this process and the means to use. (shrink)

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled to (...) publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues. (shrink)

In recent years, a growing discussion about how we should design our cities has emerged, particularly for the more controversial modes of design such as “defensive,” “hostile,” or “disciplinary” architecture (i.e., benches on which one cannot sleep, or metal studs on which one cannot skate). Although this debate is relatively mature, many studies have argued that these design notions are undertheorized and are, thus, challenging to study from an empirical and normative perspective. In this paper, I will defne the most (...) common terms used in the literature and show how they are interconnected by utilizing a set of “conditions of adequacy” from philosophy to facilitate a more transparent and well-grounded discussion of them. Terms such as “hostile” and “defensive” design are underlined by several diferent phenomena, not just one as is sometimes commonly assumed. I will also show that these phenomena and their conceptualizations require—and sometimes force us to use—diferent moral reasons when justifying the utilization of diferent designs. (shrink)

Trust is often perceived as having great value. For example, there is a strong belief that trust will bring different sorts of public goods and help us preserve common resources. A related concept which is just as important, but perhaps not explicitly discussed to the same extent as “trust”, is “reliance” or “confidence”. To be able to rely on some agent is often seen as a prerequisite for being able to trust this agent. Up to now, the conceptual discussion about (...) the definition of trust and reliance has been rational in the sense that most people involved have offered arguments for their respective views, or against competing views. While these arguments rely on some criterion or other, these criteria are rarely explicitly stated, and to our knowledge, no systematic account of such criteria has been offered. In this paper we give an account of what criteria we should use to assess tentative definitions of “trust” and “reliance”. We will also offer our own well-founded definitions of “trust” and “reliance”. Trust should be regarded as a kind of reliance and we defend what we call “the accountability view” of trust, by appealing to the desiderata we identify in the first parts of the paper. (shrink)

One important ethical issue for health promotion and public health work is to determine what the goals for these practices should be. This paper will try to clarify what some of these goals are thought to be, and what they ought to be. It will specifically discuss two different approaches to health promotion, such as, behavior change and empowerment. The general aim of this paper is, thus, to compare the behavior-change approach and the empowerment approach, concerning their immediate goals or (...) aims, and to morally evaluate the strengths and weaknesses of these two goal models, in relation to the ultimate goal of health promotion. The investigation shows that the behavior-change approach has several moral problems. First of all, it is overly paternalistic and often disregards the individual’s or group’s own perception of what is important—something that also increases the risk of failed interventions. Furthermore, it risks leading to ‘victim blaming’ and stigmatization, and to increased inequalities in health, and it puts focus on the ‘wrong’ problems, i.e., behavior instead of the ‘causes of the causes’. It is thereafter shown that the empowerment approach does not have any of these problems. Finally, some specific problems for the empowerment approach are discussed and resolved, such as, the idea that empowering some groups might lead to power over others, the objection that the focus is not primarily on health, and the fact that empowered people might choose to live lives that risk reducing their health. (shrink)

The starting point for the contemporary debate about theories of health should be the holistic theory of Lennart Nordenfelt, claims George Khushf, not the refuted theory of Christopher Boorse. The present paper is an attempt to challenge Nordenfelt and to present an alternative theory to his and other theories, including Boorse’s. The main problems with Nordenfelt’s theory are that it is relativistic, that it leads to counter-intuitive results as to what goals can count as healthy, that it focuses on the (...) wrong kind of abilities, that it makes measuring health extra difficult, and that it does not give us a sufficient account of health, at most a necessary one. The alternative theory proposed is two-dimensional. First, health is to have developed the abilities and dispositions that members of one’s culture typically develop, and be able to use them, in acceptable circumstances; and second, health is to experience positive moods and sensations, the kinds that have internal causes. The theory solves the problems attached to Nordenfelt’s theory by not being individual relativistic, by eliminating the goals in the definition, by giving an alternative interpretation of “ability,” by making health easier to measure, and by adding the dimension of well-being that, together with health as ability, not only gives us a necessary, but also a sufficient, account of health. (shrink)

There are great health disparities in the world today, both between countries and within them. This problem might be seen as related to the access to various kinds of capabilities. It is not fully clear, however, what the exact relation is between health and capabilities. Neither Amartya Sen nor Martha Nussbaum has explicitly formulated a theory of health to go with their theories of capabilities. This paper attempts to present a clarification of the conceptual relation between health and capabilities. Health, (...) it is argued, should be seen as a holistic multi-dimensional phenomenon, made up of basic abilities and subjective well-being, and of fundamental states and processes. Using this theory, the paper shows how health is related to Nussbaum’s ten capabilities. It is argued that health, in the senses described, is a necessary part of all ten capabilities. Moreover, some of the capabilities on Nussbaum’s list, such as thinking and imagining, and practical reasoning, refer to health. Finally, it is shown that even though health is part of all capabilities, health cannot itself primarily be seen as a capability. An acceptable degree of health is required as a functioning for any theory of human flourishing to be reasonable. (shrink)

The purpose of this article is to present a normative theory of the goals of medicine (a theory that tells us in what respects medicine should benefit the patient) that is both comprehensive and unified. A review of the relevant literature suggests that there are at least seven plausible goals that are irreducible to each other, namely to promote functioning, to maintain or restore normal structure and function, to promote quality of life, to save and prolong life, to help the (...) patient to cope well with her condition, to improve the external conditions under which people live, and to promote the growth and development of children. However, it seems that all these goals need to be qualified in different ways, e.g. it does not seem reasonable to improve physiological function or functional ability unless this is expected to have positive effects on quality of life and/or length of life, or to improve the quality of life in any respect, or by any means. These qualifications all suggest that the proposed goals are, as goals, conceptually, and not just causally, related to one another, and that they should therefore not be regarded in isolation. Instead, we should think of the medical enterprise as having a multidimensional goal structure rather than a single goal. In order to depict clearly how the different goals are related to one another, a multidimensional model is constructed. (shrink)

The terms “health promotion” and “disease prevention” refer to professional activities. But a “health promoter” has also come to denote a profession, with an alternative agenda compared to that of traditional public health work, work that by some is seen to be too medically oriented, too reliant upon prevention, risk-elimination and health-care. But is there really a sharp distinction between these activities and professions? The main aim of the paper is to investigate if these concepts are logically different, or if (...) they are just two extremes of one dimension. The central concepts, health promotion and disease prevention, are defined, and it is concluded that health promotion and disease prevention are logically distinct concepts, although they are conceptually related through a causal connection. Thus, logically, it is possible to promote health without preventing disease, even if this is not so common, in practice, but it is not possible to prevent disease without promoting health. Finally, most health promoting interventions target basic health, not manifest health, and often also thereby reduce future disease. (shrink)

Empowerment is a concept that has been much used and discussed for a number of years. However, it is not always explicitly clarified what its central meaning is. The present paper intends to clarify what empowerment means, and relate it to the goals of health promotion. The paper starts with the claim that health-related quality of life is the ultimate general goal for health promotion, and continues by briefly presenting definitions of some central concepts: “welfare” “health” and “quality of life”. (...) Several suggestions as to what empowerment is are then discussed: autonomy, freedom, knowledge, self-esteem, self-confidence, and control over health or life. One conclusion of this discussion is that empowerment can be seen as a complex goal which includes aspects of the three central concepts welfare, health and quality of life. To the extent that the empowerment goals aimed at are health-related, it is concluded that empowerment is a legitimate goal for health promotion. But empowerment is not only a goal, it can also be described as a process or as an approach. This process, or approach, in a fundamental way involves the participants in problem formulation, decision making and action, which means that the experts have to relinquish some of their control and power. (shrink)

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

This article investigates five kinds of vagueness in medicine: disciplinary, ontological, conceptual, epistemic, and vagueness with respect to descriptive-prescriptive connections. First, medicine is a discipline with unclear borders, as it builds on a wide range of other disciplines and subjects. Second, medicine deals with many indistinct phenomena resulting in borderline cases. Third, medicine uses a variety of vague concepts, making it unclear which situations, conditions, and processes that fall under them. Fourth, medicine is based on and produces uncertain knowledge and (...) evidence. Fifth, vagueness emerges in medicine as a result of a wide range of fact-value-interactions. The various kinds of vagueness in medicine can explain many of the basic challenges of modern medicine, such as overdiagnosis, underdiagnosis, and medicalization. Even more, it illustrates how complex and challenging the field of medicine is, but also how important contributions from the philosophy can be for the practice of medicine. By clarifying and, where possible, reducing or limiting vagueness, philosophy can help improving care. Reducing the various types of vagueness can improve clinical decision-making, informing individuals, and health policy making. (shrink)

In his influential theory of health Nordenfelt bases the concepts of health and illness on the notions of ability and disability. A premise for this is that ability and disability provide a more promising, adequate, and useful basis than well-being and suffering. Nordenfelt uses coma and manic episodes as paradigm cases to show that this is so. Do these paradigm cases (and thus the premise) hold? What consequences does it have for the theory of health and illness if it they (...) do not? These are the key questions in this article, which first presents the relationship between pain and disability in Nordenfelt’s theory and the paradigm cases he uses to argue for the primacy of disability over pain. Then, Nordenfelt’s concepts of illness are outlined, highlighting its presumptions and arguments. The main point is that if you do not have an action-theoretical perspective, it is not obvious that disability is the core concept for illness. The compelling effect of the paradigm cases presupposes that you see ability as the primary issue. To those who do not share this presumption, people in coma may not be ill. There are alternative well founded arguments for the primacy of first person experiences for the concept of illness. Hence, we need better arguments for the primacy of disability over first person experiences in illness, or first-person experience should be more primarily included in the concept of illness. (shrink)

In this paper we explore the relation between health-care needs and patients’ desires within shared decision-making in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out and discuss a number of queries which seem to (...) arise due to the double focus on a patient’s need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine. (shrink)

The interest in "social sustainability" has recently increased in the field of urban development. We want societies, cities, and neighborhoods to be economically and environmentally sustainable, but we also want urban areas that are safe, diverse, walkable, and relaxing, just to mention a few examples. Strikingly, however, there is no consensus regarding what definition of "social sustainability" should be employed. Additionally, some people are skeptical about the prospect of finding a useful definition at all and claim it is impossible to (...) satisfactorily define the concept for various reasons, such as its complexity. A potential first step towards navigating this conceptual maze is to provide desiderata for a definition of social sustainability. We defend a list of nine desiderata and thereby create a theoretical framework for analyzing and constructing a definition of "social sustainability". We also examine the skeptical arguments and find that it is premature to conclude that the goal of finding a useful definition is hopeless. With the criteria in place, the future debate can proceed by assessing definitions of "social sustainability" in a more structured and transparent manner. This activity is of upmost importance if we want to create just cities. Keywords: Social Sustainability, Definition, Purposes and Aims, Conditions of Adequacy. (shrink)

This study is a contribution to the bioethical debate about new and possibly emerging reproductive technologies. Its point of departure is the intuition, which many people seem to share, that using such technologies to select non-disease traits – like sex and emotional stability - in yet unborn children is morally problematic, at least more so than using the technologies to avoid giving birth to children with severe genetic diseases, or attempting to shape the non-disease traits of already existing children by (...) environmental means, like education. The study employs philosophical analysis for the purpose of making this intuition intelligible and judging whether it is justified. Different ways in which the moral problems posed by reproductive technologies are often framed in bioethical debates are criticised as inadequate for this task. In particular, it is argued that the intuition cannot fully be made sense of in terms of harm to the children that such technologies help create. The study attempts to elaborate an alternative to that broadly consequentialist approach, by drawing on Martin Heidegger’s philosophy of technology, Hans Jonas’s ethics, and Aristotle’s practical philosophy, as it has been received and developed in the hermeneutical tradition. It is suggested that reproductive choices, unlike decisions for already born children, are characterised by a peculiar one-sidedness: the future child appears to the parents as something wholly theirs to decide about, not as a concrete other with whom they must interact in a responsive and attuned way. This is problematic because it means that such choices cannot call upon the particularised moral understanding only gained in interpersonal encounters. In particular, it makes them easily shaped by various tendencies, to which parents are always susceptible, to relate to children in instrumentalising ways, and at risk of reinforcing such tendencies. However, this does not mean that all uses of reproductive technologies are equally troubling. When selecting against severe disease the parents can rely on a widely shared illness experience to escape the dangers that one-sidedness involves. It is concluded that the intuition under discussion, thus explicated and in some ways qualified, makes sense morally. (shrink)