Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement (...) requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

This paper defends a distinctly liberal approach to public health ethics and replies to possible objections. In particular, I look at a set of recent proposals aiming to revise and expand liberalism in light of public health's rationale and epidemiological findings. I argue that they fail to provide a sociologically informed version of liberalism. Instead, they rest on an implicit normative premise about the value of health, which I show to be invalid. I then make explicit the unobvious, republican background (...) of these proposals. Finally, I expand on the liberal understanding of freedom as non-interference and show its advantages over the republican alternative of freedom as non-domination within the context of public health. The views of freedom I discuss in the paper do not overlap with the classical distinction between negative and positive freedom. In addition, my account differentiates the concepts of freedom and autonomy and does not rule out substantive accounts of the latter. Nor does it confine political liberalism to an essentially procedural form. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

This is the third in a series of five papers on the role, remit and function of research ethics committees which are intended to provide for REC members a broad understanding of the most important issues in research ethics and governance. This paper examines the role of ethics committees in balancing the social value of the research it reviews against the risks it imposes on those who take part. The ethics committee's role in assessing the social value of research goes (...) well beyond checking its scientific validity and this assessment may affect the risks ethics committees are prepared to ask of subjects not only for their own potential personal interests but importantly and inevitably in the name of science. However, their function is importantly restricted by the wider regulatory and governance environment in which they work. (shrink)

This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical Reasoning Discussion Tool—a dialogical (...) and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting. (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)

In this article the aurhtor explores the intimate connection between the concepts of ‘health’ and ‘normality’ in the fields of medicine and mental health by discerning Foucauldian themes in Peter Shaffer’s critically acclaimed drama Equus. Shaffer’s scrutiny of the mental health field pinpoints the same issue as Foucault does in his many works on medicine and psychiatry, namely, that operating behind any concept of ‘health’ in these fields is nothing other than the notion of ‘normality.’ By looking not only to (...) the acumen of Foucault’s research and critique, but also to the depiction of Foucauldian themes in Shaffer’s compelling dramatic work, this article is able to explore the implications of the relation between ‘health’ and ‘normality’ in concrete, human terms. In Equus, the effects of psychiatric discourse are written all over the face of a disturbed, young teenager, a fact which reminds us that the human beings subjected to the mental health care profession are all too real, precariously delicate, suffering individuals. (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)

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)

A biochemical pathway is a sequence of chemical reactions in a biological organism. Such pathways specify mechanisms that explain how cells carry out their major functions by means of molecules and reactions that produce regular changes. Many diseases can be explained by defects in pathways, and new treatments often involve finding drugs that correct those defects. This paper presents explanation schemas and treatment strategies that characterize how thinking about pathways contributes to biomedical discovery. It discusses the significance of pathways for (...) understanding the nature of diseases, explanations, and theories. (shrink)

This paper critically examines the volitional normative model of disease and its underlying nanotechnologic vision of medicine both defended by Robert Freitas. Having provided an account of this vision, we explicate the highlight of the model, which is a concept of disease based on individual values and preferences. The model’s normative positions are then critiqued based on our argument that the epistemic basis of Freitas’s vision of nanotechnologic medicine and, by extension, of his volitional normative model of disease is scientifically (...) flawed. An ethical and social critique of the model is then conducted on the basis of the model’s implicit ethical underpinnings. We argue that Freitas fails to justify the normativity of his model by not addressing the ethical issues that permeate it, one of which is the question of responsibility regarding the development of medical nanotechnology and the practice of new forms of medicine such as the one he envisions. We conclude that, due to its radically individualistic position, the model implies an unjustified view of nanoethics and relegates this field of ethics to the periphery of discussions of nanomedicine. (shrink)

Health and disease are core concepts in health care and have attracted substantial interest and controversy. In recent and interesting contributions to the debate it has been argued that the challenges with the concept of disease can be resolved by a prototype concept of disease. As a robin is a more prototypical of a bird than a penguin, some diseases are more prototypical than others. If disease is a prototype concept, it would change nosology, but also health care and the (...) study of health and disease. However, the statement that “disease is a prototype concept” forms an empirically testable hypothesis. Therefore, this study aims to test the hypothesis that health professionals have a prototype concept of disease. Two hundred twenty-three health care professionals in Norway were invited to participate in a survey where they were asked to rank a wide range of diseases according to how typical they considered them to be as diseases. Results were analysed with descriptive statistics. The response rate was 90%. Lung cancer, leukemia, colon cancer, myocardial infarction, and AIDS are the diseases ranged to be most typical, while homosexuality, pregnancy, drapetomania, dissidence, and nostalgia are considered to be the least typical diseases. The results also show that the answers to how typical various diseases are vary greatly, even amongst a relatively homogenous group of health professionals. This study falsifies the hypothesis that disease is a prototype concept for health professionals. This has implications for the debate on core concepts for health care. If health professionals do not have a prototype concept of disease, it is unlikely that there is a prototype concept of disease in general. Consequently, nosologies should not be based on prototypes. (shrink)