Measuring the effectiveness of medical interventions faces three epistemological challenges: the choice of good measuring instruments, the use of appropriate analytic measures, and the use of a reliable method of extrapolating measures from an experimental context to a more general context. In practice each of these challenges contributes to overestimating the effectiveness of medical interventions. These challenges suggest the need for corrective normative principles. The instruments employed in clinical research should measure patient-relevant and disease-specific parameters, and should not be sensitive (...) to parameters that are only indirectly relevant. Effectiveness always should be measured and reported in absolute terms (using measures such as 'absolute risk reduction'), and only sometimes should effectiveness also be measured and reported in relative terms (using measures such as 'relative risk reduction')-employment of relative measures promotes an informal fallacy akin to the base-rate fallacy, which can be exploited to exaggerate claims of effectiveness. Finally, extrapolating from research settings to clinical settings should more rigorously take into account possible ways in which the intervention in question can fail to be effective in a target population. (shrink)

Evidence hierarchies are widely used to assess evidence in systematic reviews of medical studies. I give several arguments against the use of evidence hierarchies. The problems with evidence hierarchies are numerous, and include methodological shortcomings, philosophical problems, and formal constraints. I argue that medical science should not employ evidence hierarchies, including even the latest and most-sophisticated of such hierarchies.

In this paper we discuss the hypothesis that, ‘moral agency is distributed over both humans and technological artefacts’, recently proposed by Peter-Paul Verbeek. We present some arguments for thinking that Verbeek is mistaken. We argue that artefacts such as bridges, word processors, or bombs can never be (part of) moral agents. After having discussed some possible responses, as well as a moderate view proposed by Illies and Meijers, we conclude that technological artefacts are neutral tools that are at most bearers (...) of instrumental value. (shrink)

In the field of health technology assessment, there are several approaches that can be used for ethical analysis. However, there is a scarcity of literature that critically evaluates and compares the strength and weaknesses of these approaches when they are applied in practice. In this paper, we analyse the applicability of some selected approaches for addressing ethical issues in HTA in the field of complex health interventions. Complex health interventions have been the focus of methodological attention in HTA. However, the (...) potential methodological challenges for ethical analysis are as yet unknown.Six of the most frequently described and applied ethical approaches in HTA were critically assessed against a set of five characteristics of complex health interventions: multiple and changing perspectives, indeterminate phenomena, uncertain causality, unpredictable outcomes, and ethical complexity. The assessments are based on literature and the authors’ experiences of developing, applying and assessing the approaches.The Interactive, participatory HTA approach is by its nature and flexibility, applicable across most complexity characteristics. Wide Reflective Equilibrium is also flexible and its openness to different perspectives makes it better suited for complex health interventions than more rigid conventional approaches, such as Principlism and Casuistry. Approaches developed for HTA purposes are fairly applicable for complex health interventions, which one could expect because they include various ethical perspectives, such as the HTA Core Model® and the Socratic approach.This study shows how the applicability for addressing ethical issues in HTA of complex health interventions differs between the selected ethical approaches. Knowledge about these differences may be helpful when choosing and applying an approach for ethical analyses in HTA. We believe that the study contributes to increasing awareness and interest of the ethical aspects of complex health interventions in general. (shrink)

The widespread application of technology in health care has imposed a broad range of challenges. The field of health technology assessment (HTA) is developed in order to face some of these challenges. However, this strategy has not been as successful as one could hope. One of the reasons for this is that social and ethical considerations have not been integrated in the HTA process. Nowadays however, such considerations have been included in many HTAs. Still, the conclusions and recommendations of the (...) HTAs are not followed. The reason for this may be that the methods for integrating ethics for HTA are not sufficiently developed, or that they are not adequate. This article presents a supplementary approach to the ethical inquiry in HTA. It is argued that a value analysis is crucial in order to address the ethical issues of health care technology in a fruitful way and to make viable decisions about such technology. (shrink)

Obesity has generated significant worries amongst health policy makers and has obtained increased attention in health care. Obesity is unanimously defined as a disease in the health care and health policy literature. However, there are pragmatic and not principled reasons for this. This warrants an analysis of obesity according to standard conceptions of disease in the literature of philosophy of medicine. According to theories and definitions of disease referring to internal processes, obesity is not a disease. Obesity undoubtedly can result (...) in disease, making it a risk factor for disease, but not a disease per se. According to several social conceptions of disease, however, obesity clearly is a disease. Obesity can conflict with aesthetic, moral, or other social norms. Making obesity a “social disease” may very well be a wise health policy, assuring and improving population health, especially if we address the social determinants of obesity, such as the food supply and marketing system. However, applying biomedical solutions to social problems may also have severe side effects. It can result in medicalization and enhance stigmatization and discrimination of persons based on appearance or behavior. Approaching social problems with biomedical means may also serve commercial and professionals’ interests more than the health and welfare of individuals; it may make quick fix medical solutions halt more sustainable structural solutions. This urges health insurers, health care professionals, and health policy makers to be cautious. Especially if we want to help and respect persons that we classify and treat as obese. (shrink)

New technologies facilitate the enhancement of a wide range of human dispositions, capacities, or abilities. While it is argued that we need to set limits to human enhancement, it is unclear where we should find resources to set such limits. Traditional routes for setting limits, such as referring to nature, the therapy-enhancement distinction, and the health-disease distinction, turn out to have some shortcomings. However, upon closer scrutiny the concept of enhancement is based on vague conceptions of what is to be (...) enhanced. Explaining why it is better to become older, stronger, and more intelligent presupposes a clear conception of goodness, which is seldom provided. In particular, the qualitative better is frequently confused with the quantitative more. We may therefore not need “external” measures for setting its limits – they are available in the concept of enhancement itself. While there may be shortcomings in traditional sources of limit setting to human enhancement, such as nature, therapy, and disease, such approaches may not be necessary. The specification-of-betterment problem inherent in the conception of human enhancement itself provides means to restrict its unwarranted proliferation. We only need to demand clear, sustainable, obtainable goals for enhancement that are based on evidence, and not on lofty speculations, hypes, analogies, or weak associations. Human enhancements that specify what will become better, and provide adequate evidence, are good and should be pursued. Others should not be accepted. (shrink)

HTA and TA institutions at national parliaments (PTA) both share the same origin and of course have objectives and some of their methods in common. Nevertheless both TA branches developed in some distance during the 1970s and 1980s. Drawing on the case of biomedicine this paper outlines the differences between HTA and PTA, highlighting the “clinical perspective” of HTA and the “societal perspective” of PTA. It is shown that biomedicine which has developed rapidly during the last decade has hardly been (...) dealt with by HTA, whereas it ranked quite prominent on the agendas of PTA institutions. Biomedical technologies became a subject of policy making beyond the boundaries of health care politics since biomedicine is perceived as an ethical challenge to society and not only as a medical innovation that has to be assessed by clinical experts. It is argued that there may however be good reasons to integrate the HTA and the PTA perspective in future TA on biomedical technologies. (shrink)

Artificial agents (AAs), particularly but not only those in Cyberspace, extend the class of entities that can be involved in moral situations. For they can be conceived of as moral patients (as entities that can be acted upon for good or evil) and also as moral agents (as entities that can perform actions, again for good or evil). In this paper, we clarify the concept of agent and go on to separate the concerns of morality and responsibility of agents (most (...) interestingly for us, of AAs). We conclude that there is substantial and important scope, particularly in Computer Ethics, for the concept of moral agent not necessarily exhibiting free will, mental states or responsibility. This complements the more traditional approach, common at least since Montaigne and Descartes, which considers whether or not (artificial) agents have mental states, feelings, emotions and so on. By focussing directly on mind-less morality we are able to avoid that question and also many of the concerns of Artificial Intelligence. A vital component in our approach is the Method of Abstraction for analysing the level of abstraction (LoA) at which an agent is considered to act. The LoA is determined by the way in which one chooses to describe, analyse and discuss a system and its context. The Method of Abstraction is explained in terms of an interface or set of features or observables at a given LoA. Agenthood, and in particular moral agenthood, depends on a LoA. Our guidelines for agenthood are: interactivity (response to stimulus by change of state), autonomy (ability to change state without stimulus) and adaptability (ability to change the transition rules by which state is changed) at a given LoA. Morality may be thought of as a threshold defined on the observables in the interface determining the LoA under consideration. An agent is morally good if its actions all respect that threshold; and it is morally evil if some action violates it. That view is particularly informative when the agent constitutes a software or digital system, and the observables are numerical. Finally we review the consequences for Computer Ethics of our approach. In conclusion, this approach facilitates the discussion of the morality of agents not only in Cyberspace but also in the biosphere, where animals can be considered moral agents without their having to display free will, emotions or mental states, and in social contexts, where systems like organizations can play the role of moral agents. The primary cost of this facility is the extension of the class of agents and moral agents to embrace AAs. (shrink)

There are many ways to avoid responsibility, for example, explaining what happens as the work of the gods, fate, society, or the system. For engineers, “technology” or “the organization” will serve this purpose quite well. We may distinguish at least nine (related) senses of “responsibility”, the most important of which are: (a) responsibility-as-causation (the storm is responsible for flooding), (b) responsibility-as-liability (he is the person responsible and will have to pay), (c) responsibility-as-competency (he’s a responsible person, that is, he’s rational), (...) (d) responsibility-as-office (he’s the responsible person, that is, the person in charge), and (e) a responsibility-as-domain-of-tasks (these are her responsibilities, that is, the things she is supposed to do). For all but the causal sense of responsibility, responsibility may be taken (in a relatively straightforward sense)—and generally is. Why then would anyone want to claim that certain technologies make it impossible to attribute responsibility to engineers (or anyone else)? In this paper, I identify seven arguments for that claim and explain why each is fallacious. The most important are: (1) the argument from “many hands”, (2) the argument from individual ignorance, and (3) the argument from blind forces. Each of these arguments makes the same fundamental mistake, the assumption that a certain factual situation, being fixed, settles responsibility, that is, that individuals, either individually or by some group decision, cannot take responsibility. I conclude by pointing out the sort of decisions (and consequences) engineers have explicitly taken responsibility for and why taking responsibility for them is rational, all things considered. There is no technological bar to such responsibility. (shrink)

The objective of this article is to analyse the value-ladenness of technology in the context of medicine. To address this issue several characteristics of technology are investigated: i) its interventive capacity, ii) its expansiveness and iii) its influence on the concept of disease, iv) its generalising character, v) its independence of the subjective experience of the patient. By this analysis I hope to unveil the double face of technology: Technology has a Janus-face in modern medicine, and the opposite of its (...) factual face is evaluative. (shrink)

Discusses the ethical implications of modern technology and examines the responsibility of humanity for the fate of the world.

Henry Richardson argues that we can determine our ends rationally. He constructs a rich and original theory of how we can reason about our final goals. Richardson defuses the counter-arguments for the limits of rational deliberation, and develops interesting ideas about how his model might be extended to interpersonal deliberation of ends, taking him to the borders of political theory. Along the way Richardson offers illuminating discussions of, inter alia, Aristotle, Aquinas, Sidgwick, and Dewey, as well as the work of (...) several contemporary philosophers. (shrink)

Subtitled "Studies in Ethical Analysis," this collection of eleven essays, most of which have previously appeared in journals, deals with a number of problems central to modern ethical theory: the emotive interpretation of ethical language, persuasive definitions and their role in ethical reasoning, the cognitive versus emotive conceptions of ethics: many of these problems were first raised and examined by Stevenson in his earlier book Ethics and Language. Other essays are of a less retrospective nature: studies on Moore and Dewey, (...) naturalism and relativism in ethics, and a general discussion of the relations of linguistic analysis to philosophy as a whole. Stevenson is mainly concerned with analytical, as opposed to descriptive, ethics; and he completely avoids the topics of normative ethics except for a brief survey. The approach to ethics is therefore restricted, but there is enough here to interest the philosopher whose main area lies outside of ethics; although it presupposes no acquaintance with the author's previous work, some of the questions on emotivism and persuasive language are more motivated when seen in the context of that work.—P. J. M. (shrink)

PURPOSE: The purpose of this paper is to consider some of the philosophical and bioethical issues raised by the creation of the draft social values framework developed to facilitate data collection and country-specific presentations at the inaugural workshop on "Social values and health priority setting" held in February 2011. -/- DESIGN/METHODOLOGY/APPROACH: Conceptual analysis is used to analyse the term "social values", as employed in the framework, and its relationship to related ideas such as moral values. The structure of the framework (...) (process and content values) is considered in light of current debate in philosophy and bioethics about the political and moral aims served by these kinds of values, and the extent to which they are either suited to, or sufficient for, the policy context. -/- FINDINGS: There is much to be gained by engaging with the arguments presented in the philosophical literature in order to further refine the framework. The framework should remain neutral in respect of the importance of procedural values in different contexts and should be as inclusive as possible in respect of the principles it includes. Further development would be best served by taking a multidisciplinary approach. The framework could provide a valuable space in which future debates about procedural/substantive values can be considered. -/- ORIGINALITY/VALUE: The paper brings philosophical and bioethics perspectives to bear on a new framework proposed for the analysis of social values in health priority setting. It identifies how such a practical, policy-focused framework might be informed by engagement with deeper, and often unresolved, questions or principle around resource allocation in health. (shrink)