This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

This is a major work in moral philosophy, the long-awaited follow-up to Parfit's 1984 classic Reasons and Persons, a landmark of twentieth-century philosophy. Parfit now presents a powerful new treatment of reasons and a critical examination of the most prominent systematic moral theories, leading to his own ground-breaking conclusion.

Challenging, with several powerful arguments, some of our deepest beliefs about rationality, morality, and personal identity, Parfit claims that we have a false view about our own nature. It is often rational to act against our own best interersts, he argues, and most of us have moral views that are self-defeating. We often act wrongly, although we know there will be no one with serious grounds for complaint, and when we consider future generations it is very hard to avoid conclusions (...) that most of us will find very disturbing. (shrink)

How should medical services be distributed within society? Who should pay for them? Is it right that large amounts should be spent on sophisticated technology and expensive operations, or would the resources be better employed in, for instance, less costly preventive measures? These and others are the questions addreses in this book. Norman Daniels examines some of the dilemmas thrown up by conflicting demands for medical attention, and goes on to advance a theory of justice in the distribution of health (...) care. The central argument is that health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly the distribution of health-care services. Access to care, preventive measures, treatment of the elderly, and the obligations of doctors and medical administrations are fully discussed, and the theory is shown to underwrite various practical policies in the area. (shrink)

What distinguishes preference utilitarianism from other utilitarian positions is the axiological component: the view concerning what is intrinsically valuable. According to PU, intrinsic value is based on preferences. Intrinsically valuable states are connected to our preferences being satisfied.

The concept of need is promising and alluring because of three factors.

To desire is to be in a particular state of mind. It is a state of mind familiar to everyone who has ever wanted to drink water or desired to know what has happened to an old friend, but its familiarity does not make it easy to give a theory of desire. Controversy immediately breaks out when asking whether wanting water and desiring knowledge are, at bottom, the same state of mind as others that seem somewhat similar: wishing never to (...) have been born, preferring mangoes to peaches, craving gin, having world conquest as one's goal, having a purpose in sneaking out to the shed, or being inclined to provoke just for the sake of provocation. These varied states of mind have all been grouped together under the heading of ‘pro attitudes’, but whether the pro attitudes are fundamentally one mental state or many is disputed. (shrink)

Desires move us to action, give us urges, incline us to joy at their satisfaction, and incline us to sorrow at their frustration. Naturalistic work on desire has focused on distinguishing which of these phenomena are part of the nature of desire, and which are merely normal consequences of desiring. Three main answers have been proposed. The first holds that the central necessary fact about desires is that they lead to action. The second makes pleasure the essence of desire. And (...) the third holds that the central necessary fact about desires is that they open us to reward-based learning. (shrink)

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (...) (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

In recent years the formerly quite strong interest in patient compliance has been questioned for being too paternalistic and oriented towards overly narrow biomedical goals as the basis for treatment recommendations. In line with this there has been a shift towards using the notion of adherence to signal an increased weight for patients’ preferences and autonomy in decision making around treatments. This ‘adherence-paradigm’ thus encompasses shared decision-making as an ideal and patient perspective and autonomy as guiding goals of care. What (...) this implies in terms of the importance that we have reason to attach to (non-)adherence and how has, however, not been explained. In this article, we explore the relationship between different forms of shared decision-making, patient autonomy and adherence. Distinguishing between dynamically and statically framed adherence we show how the version of shared decision-making advocated will have consequences for whether one should be interested in a dynamically or statically framed adherence and in what way patient adherence should be assessed. In contrast to the former compliance paradigm (where non-compliance was necessarily seen as a problem), using observations about (non-)adherence to assess the success of health care decision making and professional-patient interaction turns out to be a much less straightforward matter. (shrink)

The purpose of the article is to argue for the significance of a clarified goal of health care for the setting of priorities. Three arguments are explored. First, assessment of needs becomes necessary in so far as the principle of need should guide the priority-setting. The concept of health care need includes a goal component. This component should for rational reasons be identical with the goal of health care. Second, in order to use resources efficiently it is necessary to assess (...) the effects of health care. It is not, however, a question of assessing whether there is an effect but a question of assessing whether there is the right effect. And what constitutes the right effect can only be determined in relation to the goal of the enterprise. Third, the health sector involves several groups of actors such as politicians, administrators, doctors, nurses, physiotherapists, occupational therapists, educationists and patients. It is common knowledge that successful teamwork requires an understanding of a common goal. The article ends with an example of a goal chosen from ethics. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs must answer two (...) distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

One problematic aspect of the rationality of medical practice concerns the relation between expert knowledge and non-expert knowledge. In medical practice it is important to match medical knowledge with the self-knowledge of the individual patient. This paper tries to study the problem of such matching by describing a model for technological paradigms and comparing it with an ideal of technological rationality. The professionalised experts tend to base their decisions and actions mostly on medical knowledge while the rationality of medicine also (...) involves just as important elements of the personal evaluation and knowledge of the patients. Since both types of knowledge are necessary for rational decisions, the gap between the expert and the non-expert has to be bridged in some way. A solution to the problem is suggested in terms of pluralism, with the patient as ultimate decision-maker. (shrink)

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in determining the (...) relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others. (shrink)

abstract The argument that scarce health care resources should be distributed so that patients in ‘need’ are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, each of which focuses on separate intuitions. Although this (...) account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting‐point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs‐based priority setting to social welfare maximisation. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care need with a starting (...) point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

Derek Parfit presents the third volume of On What Matters, his landmark work of moral philosophy. Parfit develops further his influential treatment of reasons, normativity, the meaning of moral discourse, and the status of morality. He engages with his critics, and shows the way to resolution of their differences.

This book is a contribution to the general philosophy of action and the philosophy of welfare. The author makes separate analyses of concepts such as action, ability, interaction, action-explanation, happiness, health, illness and disability. At the same time he explores and substantiates the idea of a strong interdependence between the concept of action and some of the central concepts of welfare, in particular health and illness and related concepts.

Fred Feldman's fascinating new book sets out to defend hedonism as a theory about the Good Life. He tries to show that, when carefully and charitably interpreted, certain forms of hedonism yield plausible evaluations of human lives. Feldman begins by explaining the question about the Good Life. As he understands it, the question is not about the morally good life or about the beneficial life. Rather, the question concerns the general features of the life that is good in itself for (...) the one who lives it. Hedonism says (roughly) that the Good Life is the pleasant life. After showing that received formulations of hedonism are often confused or incoherent, Feldman presents a simple, clear, coherent form of sensory hedonism that provides a starting point for discussion. He then presents a catalogue of classic objections to hedonism, coming from sources as diverse as Plato, Aristotle, Brentano, Ross, Moore, Rawls, Kagan, Nozick, Brandt, and others. One of Feldman's central themes is that there is an important distinction between the forms of hedonism that emphasize sensory pleasure and those that emphasize attitudinal pleasure. Feldman formulates several kinds of hedonism based on the idea that attitudinal pleasure is the Good. He claims that attitudinal forms of hedonism - which have often been ignored in the literature -- are worthy of more careful attention. Another main theme of the book is the plasticity of hedonism. Hedonism comes in many forms. Attitudinal hedonism is especially receptive to variations and modifications. Feldman illustrates this plasticity by formulating several variants of attitudinal hedonism and showing how they evade some of the objections. He also shows how it is possible to develop forms of hedonism that are equivalent to the allegedly anti-hedonistic theory of G. E. Moore and the Aristotelian theory according to which the Good Life is the life of virtue, or flourishing. He also formulates hedonisms relevantly like the ones defended by Aristippus and Mill. Feldman argues that a carefully developed form of attitudinal hedonism is not refuted by objections concerning 'the shape of a life'. He also defends the claim that all of the alleged forms of hedonism discussed in the book genuinely deserve to be called 'hedonism'. Finally, after dealing with the last of the objections, he gives a sketch of his hedonistic vision of the Good Life. (shrink)