Hymenoplasty is a surgical procedure requested by women who are expected to remain virgins until marriage. In this article, I assess the ethical and legal challenges raised by this request, both for the individual physician and for the health care system. I argue that performing hymenoplasty is not always an unethical practice and that, under certain conditions, it should be provided by the health care system.

In this article we critically examine the principle of equivalence of care in prison medicine. First, we provide an overview of how the principle of equivalence is utilized in various national and international guidelines on health care provision to prisoners. Second, we outline some of the problems associated with its applications, and argue that the principle of equivalence should go beyond equivalence to access and include equivalence of outcomes. However, because of the particular context of the prison environment, third, we (...) contend that the concept of “health” in equivalence of health outcomes needs conceptual clarity; otherwise, it fails to provide a threshold for healthy states among inmates. We accomplish this by examining common understandings of the concepts of health and disease. We conclude our article by showing why the conceptualization of diseases as clinical problems provides a helpful approach in the delivery of health care in prison. (shrink)

Während der größte Teil der Bevölkerung die kieferorthopädische Therapie, also die Veränderung der Zahn- bzw. Kieferstellung, als eine Behandlung betrachtet, die vor allem auf eine Verbesserung des Erscheinungsbildes zielt, sehen der kieferorthopädische und zahnärztliche Berufsstand sowie auch private und öffentliche Kostenträger in bestimmten Abweichungen von Zahn- oder Kieferstellungen eine Gefährdung der oralen Gesundheit und der Funktionsfähigkeit des Gebisses. Letztere Auffassung bestimmt das ärztliche Handeln in der Kieferorthopädie und begründet auch die Übernahme zumindest bestimmter Leistungen durch die gesetzlichen Krankenkassen. Anhand aktueller (...) wissenschaftlicher Erkenntnisse lassen sich jedoch in vielen Fällen keine (akuten oder potentiellen) gesundheitlichen oder essentiellen funktionellen Beeinträchtigungen und Risiken abweichender Zahnstellungen nachweisen. Ziel dieses Aufsatzes ist es, diesem Widerspruch nachzugehen. Im Folgenden werden wir aufzeigen, welche Faktoren die Anbieter kieferorthopädischer Leistungen beeinflussen, welches die entscheidenden Gründe und Grundlagen für die Behandlung sind und an welchen Kriterien sich die Leistungsübernahme durch die Krankenkassen orientiert. Dabei wird deutlich werden, dass die formalen Kriterien von Behandlung und Kostenübernahme, die tatsächliche Behandlungs- und Kostenerstattungspraxis, die Erwartungen derjenigen, die Behandlungsleistungen in Anspruch nehmen und der aktuelle Stand der Forschung zu erwartbaren Funktionsbeeinträchtigungen durch Zahnstellungsvariationen nicht zwanglos zu vereinbaren sind. Erforderlich erscheint ein interdisziplinärer normativer Diskurs über die Frage, wie die diagnostizierten Spannungen aufzulösen wären. Als Anregung für einen solchen Diskurs werden wir im Ausblick alternative Lösungsstrategien vorstellen. (shrink)

This paper critically discusses two areas of Sahotra Sarkar’s recent work in environmental philosophy : biodiversity and conservation biology and roles for decision theory in incorporating values explicitly in the environmental policy process. I argue that Sarkar’s emphasis on the practices of conservation biologists, and especially the role of social and cultural values in the choice of biodiversity constituents, restricts his conception of biodiversity to particular practical conservation contexts. I argue that life scientists have many reasons to measure many types (...) of diversity, and that biodiversity metrics could be value-free. I argue that Sarkar’s emphasis on the limitations of normative decision theory is in tension with his statement that decision theory can “put science and ethics together.” I also challenge his claim that multi-criteria decision tools lacking axiomatic foundations in preference and utility theory are “without a rational basis,” by presenting a case of a simple “outranking” multi-criteria decision rule that can violate a basic normative requirement of preferences and ask whether there may nevertheless be contexts in which such a procedure might assist decision makers. (shrink)

This paper is a revalidation of Oliver Sacks's role in the development of medicine's narrative turn and, as such, a reinterpretation of the history of narrative in medicine. It suggests that, from the late 1960s, Sacks pioneered in his ‘Romantic Science’ a new medical mode that reunited the seemingly incommensurable art and science of medicine while also offering a way for medical humanities to shape clinical reasoning more effectively.

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)

A number of problems and uncertainties have been raised by this brief review. Although they are well-known in philosophical and social scientific circles they are otherwise consistently ignored. But I call for a wider debate about them. If medicine cannot come to terms with its own confusing terminology and methodology; if medicine cannot stop raising expectations it cannot fulfil; if medicine does not deliberately restrict its boundaries; and if medicine does not take serious steps to explain why it chooses to (...) call some conditions states of health and others states of disease; then the result must be that health policy (which medicine largely continues to direct) will either be simply an arbitrary matter, or will be implemented on the basis of economic arguments. Where everything else is imprecise the discipline that offers precision will triumph. And the evidence of the moment is that this is exactly what is happening. (shrink)

Many leading health economists hold misconceived ideas about central components of their work. In particular, they assume that their methods are in principle valueneutral. This belief is demonstrably false. Health economic investigations incorporate mainly unexpressed theories of health. Unless this fact is recognised health economics will shortly reach a conceptual and practical dead end. The way to avoid this dead end is to express implicit theories of health, and explicitly to base philosophically and economically justifiable policy proposals on them.

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)

Thomas Szasz, the radical critic of state-supported psychiatry, and root and branch sceptic about mental illness, died in September 2012. Based on the obituary1 and editorial comment in The Lancet2 and the response his work commonly elicits, it is evident that there will be mixed reviews of his impact and of the cogency of his position.Certainly, some have seen him as a notable figure from the past. There is a sense in which, as far as Szasz's critique of psychiatry goes, (...) it did not really change at all in its essence from the time it was first explicitly expressed in his writings of the 1960s right up to his last publications and talks in the 2010s. He started his 1960 paper The Myth of Mental Illness3 with the assertion that there is no such thing as mental illness, and this has been an underlying pedal note to all his many pronouncements in this area ever since. Personally, I have always found his written interventions in debates right up to the present to be highly readable and intellectually sharp; he was adept at creating variations on the Szaszian theme. In one of his earlier book length texts, The Manufacture of Madness,4 he likens the contemporary idea that people have mental illness to the historical idea that some people were witches, and he parallels the institutions of modern state-supported psychiatry to those of the Inquisition. In articles he later published in the Journal of Medical Ethics, he likened mental illness to ‘phlogiston’—the non-existent substance that supposedly explained combustion5 and claimed the term ‘mental …. (shrink)

This paper explores usage of the concept ofabnormality in medical genetics and proposesdirectives for more careful usage of this concept.The conceptual difficulties are first explored, thena model is developed to assess actual usage, followedby analysis of a sample of genetic textbooks andgenetics literature. It appears that fact andvaluation are often intermingled, that referencestandards used to define 'genetic abnormalities' areoften not clear and that the concept of abnormality isoften used independent of the degree of certainty withwhich the altered genetype develops into (...) a (seriously)harmful phenotype. On the basis of these findings itis argued that more restraint and more careful use ofthe concept of genetic abnormality of medical geneticsis appropriate as well as more agreement on the use ofreference standards. (shrink)

Theoretical accounts of health attempt to ground the concept in the relevant underlying biological facts. Discussions of such accounts have largely focused on whether they successfully identify necessary and sufficient conditions for a state to count as pathological. Correctly accounting for examples of pathology, however, is not the only basis for evaluating an understanding of disease. Here I argue that we should expect any understanding of health and disease to be consistent with the view that medicine’s central aim is health (...) promotion. I argue that the theoretical account of health offered by Christopher Boorse faces particular difficulties in this regard. (shrink)

Developments in biomedical science continue to transform our understanding of concepts such as health and disease. The creation of this expertise has also had a substantive role in changing the veterinary approach to animal diseases. Traditionally, companion animal veterinarians modelled their practices on developments in the diagnosis and treatment of human patients. As science and technology have realigned the boundaries between normalcy, intra-species variation and pathology in particular domains of expertise such as orthopaedic surgery, these patterns of knowledge translation have (...) changed. Not so long ago, treatments for the rupture of the cruciate ligament in human and canine patients were based on pathoanatomical comparison and designed to reestablish the stability of the joint by the functional restoration of ligament anatomy. Recently, a radically different characterization of the canine injury—with a corresponding alternative intervention—has been proposed within the field of veterinary orthopaedics. It views the normal anatomy of the canine knee as being in some way inherently pathogenic and proposes the surgical creation of an idealized structure as a remedy to dysfunction and disease. The veterinary focus on an ideal of patient performance, rather than a specific pathology, is now influencing how orthopaedists choose to approach analogous human injuries. In this article, I chart the history of canine ‘cruciate disease’ therapies as a means to map some of the epistemic assumptions, interplays of idealized and analogical reasoning and patterns of knowledge translation central to the biomedicalization of the science and practice of orthopaedic surgery. (shrink)

According to Norman Daniels, the moral significance of health needs stem from their impact on the normal opportunity range: pathological conditions involve comparative disadvantage. In this paper I defend an alternative reading of the moral importance of healthcare, which focuses on non-comparative aspects of disease. In the first section I distinguish two contrasting perspectives on pathological conditions, viz a comparative versus a non-comparative. By using this distinction I introduce a related disparity regarding the moral importance of personal responsibility for disease. (...) I claim that people are usually prepared to disregard individual responsibility for disease, if it involves non-comparative harm, but not if it entails mere disadvantage. Since disadvantage means to have less than equal opportunities, Daniels’ conception of opportunity is vital for his theory. It is therefore scrutinised more closely. I try to show that he wavers between two interpretations of the notion of opportunity, which are again linked to the distinction between a comparative and a non-comparative point of view. Finally, I criticise Daniels’ supposition that persons have an interest in the normal opportunity range. (shrink)

This paper examines the most influential naturalist theory of health, Christopher Boorse’s ‘biostatistical theory’ . I argue that the BST is an unsuitable candidate for the rôle that Boorse has cast it to play, namely, to underpin medicine with a theoretical, value-free science of health and disease. Following the literature, I distinguish between “real” changes and “mere Cambridge changes” in terms of the difference between an individual’s intrinsic and relational properties and argue that the framework of the BST essentially implies (...) a Cambridge-change criterion. The examination reveals that this implicit criterion commits the BST to the troubling view that an individual could go from being diseased to healthy, or vice versa, without any physiological change in that individual. Two problems follow: the current framework of the BST is ill-equipped to formally embrace Cambridge changes and it is theoretically dubious. The arguments advanced here are not limited to the BST; I suggest they extend to any naturalist claim to underpin medical practice with a value-free theory of health and disease defined in terms of an evolutionary view of biological fitness. (shrink)

This article argues that there are neither moral considerations that in principle forbid the development or use of recom-binant DNA technology, nor grounds to hold that its application is likely to cause more harm than good. A defensible moral position would enjoin a prudent assessment of consequences, rather than an absolute prohibition. The technology may remain controversial because it presupposes the difference between being a person, an entity who can evaluate and manipulate its own biological structure, and human-ness as a (...) biological structure likely to be the subject of engineering over the long-range future. (shrink)

The prospect of germ-line genetic engineering, the ability to engineer genetic changes that can be passed on to subsequent generations, raises a wide range of moral and public policy questions. One of the most provocative questions is, simply put: Are there moral reasons that can be articulated in general secular terms for accepting human nature as we find it? Or, at least in terms of general secular moral restraints, may we reshape human nature better to meet our own interests, as (...) we define them? This question in turn raises the further question of whether human nature as it now exists has a moral standing akin to sacredness that can be understood in nonreligious terms. This essay will take as a given that it is not possible to show in general secular moral terms that human nature has a sanctity or special moral standing that should guide secular health-care policy. In addition, as this essay shows, it is not possible through appeals to considerations of authorizing consent or beneficence toward others to remedy this failure to establish a sanctity or special moral standing for human nature. Absent a religious or culturally normative understanding of human nature and given the availability of germline genetic engineering, there is a plurality of possibilities for refashioning our nature. The unavailability of substantive secular moral constraints on germ-line genetic engineering discloses a secularly licit plurality of possibilities for human nature. The likelihood that we will be able to refashion our human nature reveals how few general secular moral constraints there are to guide us. Paradoxically, the more we are able to reengineer our human nature, the less guidance is available. The plurality of possible conceptions of human well-being that can be pursued through germ-line genetic engineering challenges our self-understanding as humans. Given human freedom, and in the absence of taken-for-granted religious or cultural moral constraints, the likelihood of germ-line genetic engineering opens the possibility of human nature in the plural. (shrink)

This article isolates ten prepositions, which constitute the undercurrent paradigm of contemporary discourse of health disease and medicine. Discussion of the interrelationship between those prepositions leads to a systematic refutation of this paradigm. An alternative set is being forwarded. The key notions of the existing paradigm are that health is the natural condition of humankind and that disease is a deviance from that nature. Natural things are harmonious and healthy while human made artifacts are coercive interference with natural balance. It (...) is suggested that the current paradigm is influenced by the world of finances and by instrumental reason. The alternative model suggests that human nature cannot be delineated. Humans fashion their own selves and nature by artificial means, medicine among them. The article discusses the implications of the paradigm adapted in various scholarly and popular debates such as the use of sex hormones for contraception, the care of the elderly, holistic medicine and distributive justice in health care. Medicine is not an isolated or a privileged realm. There is no unique entitlement to health care. It is always part of a broader agenda of social values and institutions. A open view of human societies, values and practices as they are situated within concrete material conditions is the platform required for an integrative and creative discourse of health care. (shrink)

This paper attempts to address the general questionwhether information technologies, as applied in thearea of medicine and health care, have or are likelyto change fundamental concepts regarding disease andhealth. After a short excursion into the domain ofmedical informatics I provide a brief overview of someof the current theories of what a disease is from amore philosophical perspective, i.e. the ``valuefree'' and ``value laden'' view of disease. Next, Iconsider at some length, whether health careinformatics is currently modifying fundamentalconcepts of disease. To (...) this question I will answerlargely in the negative, and I will provide the sketchof some arguments from current research programs inmedical informatics why I think this is the case. Thisargumentation is supported by a detailed account ofhow the disease profile for beriberi heart disease,used in one of the major medical informaticsdiagnostic programs, QMR (and its ancestorINTERNIST-1), was developed, and why at least thisprogram essentially follows received views oftraditional medicine.The one main exception to theconformity of this program to ``received'' views of adisease occurs when the program's designers need tofine-tune a disease definition. This fine-tuning is tocomport with the expert's perspective on the disease,including his or her epistemic values, as well as theprogram's other resources for diagnosing components ofa disease. (shrink)

The ways in which ethical issues arise in making clinical judgments are briefly discussed. By showing the topography of the role of value judgments in medical diagnostics it is suggested why clinical medicine remains inextricably a value-infected science.

Infectious diseases figure prominently as (counter)examples in debates on how to conceptualize “disease.” But crucial epidemiological distinctions are often not heeded in the debate, and pathological and clinical perspectives focusing on individual patients are favored at the expense of perspectives from epidemiology focusing on populations. In clarifying epidemiological concepts, this paper highlights the distinct contributions infectious disease epidemiology can make to the conception of “disease,” and the fact that this is at least tacitly recognized by medical personnel and philosophers. Crucially, (...) infectious disease epidemiology can help elucidate how carrying and transmitting infectious, communicable entities is a disease, even if the carriers themselves are not directly affected by symptoms detrimental to them. (shrink)

The definitions of disease proffered by philosophers and medical actors typically require that a state of ill health be linked to some known bodily dysfunction before it is classified as a disease. I argue that such definitions of disease are not fully implementable in current medical discourse and practice. Adhering to the definitions would require that medical actors keep close track of the current state of knowledge on the causes and mechanisms of particular illnesses. Yet, unaddressed problems in medical terminology (...) can make this difficult to do. I show that unrecognized misuse of “heterogeneous,” “biomarker,” and other important health terms—which I call index terms—can misrepresent the current empirical evidence on illness pathophysiology, such that unvalidated illness constructs become mistaken for diseases. Thus, implementing common definitions of disease would require closing this “loophole” in medical discourse. I offer a simple rule that, if followed, could help do just that. (shrink)

The authors of the articles in this issue of The Journal of Medicine and Philosophy address a wide variety of topics, from definitions of disease to bioenhancement. Each author, however, draws out the importance of careful use of language. Over the years, philosophers of medicine and bioethicists have debated questions such as what qualifies something as a disease, whether disease language is evaluative, whether the term “person” encompasses more than just human beings, and what language ought to be used to (...) best convey complex information to patients. Among a great deal of disagreement on these topics, one thing emerges distinctly: that clarity and careful attention to language is paramount in medicine. The articles in this issue contribute to that conversation, presenting complex arguments and illustrative examples of why it is so important to use clear and well-defined terms in medicine, and of the reality-altering power that our language carries. (shrink)

In this paper, I respond to commentaries on my book “Are Mental Disorders Brain Disorders?”. The topics I discuss are: accounts of function and dysfunction, constraints on the relationship between processes at the level of the brain and the mind, externalism in psychiatry, implications for moral responsibility and the question whether my account is a form of conceptual engineering. I defend my account and argue that the key criterion for whether mental disorders are brain disorders is whether we can map (...) dysfunctional psychological processes onto specific differences in brain function. I also acknowledge that my commentators have identified points where my account needs further development. (shrink)

In this article, I side with those who argue that the debate about the definition of “disease” should be reoriented from the question “what is disease” to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis (...) is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova’s account of social objectivity in the context of the definition of disease. (shrink)