New Swedish Guidelines for ICU Priority Setting in Exceptional Circumstances

This post was updated March 30, 2020 with criteria for rationing outside ICU!

During the last two weeks, I have, together with a bunch of philosophy and bioethics colleagues specialised on these kinds of questions not only in theory but also in practice, contributed to a speedy development of of new central guidelines on ICU priority setting and resource allocation from the National Board of Health and Welfare (one of the central governing authorities of the Swedish healthcare system). The guidelines address exceptional circumstances, such as an unusual high pressure of cases that exceeds normal capacity, and are, of course, prompted by the Covid19 pandemic. Lars Sandman, head of the national Center for healthcare priority setting, led the work, and it took a little less than two weeks to go from zero to end product. Besides philosophers, the National Council for Medical Ethics, representatives of the Ethics Delegation of the Swedish Society of Medicine, and ICU specialist consultants have contributed.

As the legal language of Swedish public documents is Swedish, this is also the language of the guidelines. This full version can be read and downloaded here. But, as there has been quite a bit of international interest, here is a short English summary by myself (ie. this is not an official translation from NBHW):

BACKGROUND

Health care priority setting is already regulated by special laws, where non-instrumentality, equal treatment and non-discrimination, priority based on patient need only, and ban on unnecessary waste of resources are the key principles decided by the Swedish Parliament since before.

APPLICATION IN THE GUIDELINES

First of all, ICU capacity should be strengthened by rationing less acute or important care, or care than can be postponed without severe consequences (and without disturbing management of the pandemic), so that an exceptional ICU situation is avoided as far as is practically possible. There is a specific appendix in the full guidelines setting out rationing principles to this effect (see below).

In exceptional circumstances, ICU should focus on patients where the treatment can do the most good, thus focusing more on the prognosis of the treatment than the severity of the condition (both dimensions of patient need). This means that indication for ICU may be strengthened to exclude some patients with severe conditions that are given ICU in normal circumstances to give extra time for planning and family contact.

While the legal regulation excludes chronological age as priority basis in its own right, it allows for life expectancy (if given successful care) to be part of the assessment of the patient need for a resource (besides the severity of the condition and the immediate prognosis of the treatment). Factors to assess life expectancy in the clinic are:

• Extent and severity of vital organ failure
• Extent and severity of pre-existring co-morbidities
• High chrononological age in combination with a bad prognosis after intensive care

Priority groups are patients with:

Priority 1

Severe condition or injury with >12 months life prognosis, otherwise meet indication for ICU, and don't suffer severly decreased life expectancy (see above). If there is necessary to make a choice between patients in this group, patients with a general longer life expectancy (higher biological age) should be given priority.

Priority 2
(a) One or several serious systemic diseases with extensive functional impact, and/or (b) expected survival of 6-12 months based on pre-existing underlying disease.

Priority 3

Bad prognosis in ICU, and where ICU is normally undertaken only to provide time for planning, or family contacts.

These priority groups should ground resource allocation both when assessing new patients, and when reassessing patients admitted to ICU care, and may therefore also ground discontinuation of ICU care, to free resources for new patients with a higher priority.

Patients who are denied or taken off ICU should receive best possible palliative and other care to manage their care need given the ICU resource allocation.

There are also some sections on management of staff ethical stress, and of how to involve patients and family in the decisions.

COMMENTS BY MYSELF

In the preparatory stage, it was discussed whether or not the guidelines should include the feature of being crucial for life saving societal functions as a further item to sort among those in priority group 1. There seems to have been agreement that the requirement of equal treatment for all patients with similar need of care could support this idea if the circumstances are extremely prolonged (as loss of critical staff could then undermine the treatment prospects for future patients). However, the general assessment was that the crisis possibly caused by the Covid19 pandemic for Swedish ICU care would probably not be of this nature, especially in view of the time it would take for someone to return to work after a very critical ICU episode. Should the situation change, the guidelines may be amended to this effect.

RATIONING OUTSIDE OF ICU
These are the rationing criteria for healthcare outside ICU, in order to free capacity for ICU in an Covid19 crisis, mirroring the priority setting criteria above, and based on the same legal principles. They apply on the condition that rationing can free resources/capacity for ICU, and that the rationing does not impede communicable disease control work: 
RATIONING GROUP 1: Elective procedures that may be postponed without deterioratiuon of the condition; 
GROUP 2: Elective procedures that may be postponed without threat to life, abeit with negative effect on QoL: 
GROUP 3: Elective or acute procedures that are unlikely to restore health and likely to lead to prolonged care with risk of ICU need; 
GROUP 4: Acute procedures where postponement will affect QoL during the delay, but not lead to a worse longterm prognosis; 
GROUP 5: Acute procedures where postponement will affect QoL also in the longterm, but not be a threat to survival. 

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New article on the ethics of risk online

Just a little heads-up that a few days ago I submitted a new article for a coming special issue on the ethics of risk, and has made the "preprint" (my msubmitted manuscript before peer review and editing) available for free reading and download. The article critically assesses the notion of basing an ethics of risk on the core assumption of "defeasible" basic individual moral rights against being exposed to risk by others, and the abstract runs like this:

This article critically assesses recent proposals that an ethics of risk developed independently of standard "factualistic" ethical theory should be based on the assumption of a basic moral right of individuals against being exposed to risks. I argue that core elements that have to be present if the notion of a moral right is to uphold the classic Rawlsian requirement of "taking seriously the distinction between persons" and of preserving the notion of waiving rights means that an ethics of risk based on this axiom will fail to address its most paramount issues. This, in turn, is due to the nature of the most ethically important risks to be collectively produced, and the subsequent consequence that an ethics of risk needs to be able to acknowledge the moral importance of security against risks as a public good. The article ends by charting three broad theoretical strategies that an ethics of risk may take to face up to this challenge, and discuss the place for rights within these respective theoretical landscapes with mostly skeptical results.

 The article itself can be accessed here and here.

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Four Positions in Financial Ethics open at my University

A quick repost of this splendid opportunity for any early carreer philosophy/ethics/economics student or academic with an interest in the ethics and philosophy of finance and economic systems. 4 positions (research fellow, postdoc and PhD's) and a chance to work with my former PhD student, now stellar researcher in his own right, Joakim Sandberg. Joakim has landed a bunch of grants to suppot his creation of a new research environment in his field of expertise, so do check out what it's all about and learn how to apply here.

Addendum Re. Using Medical Methods to Determine the Age of Unaccompanied Refugee Children

After my post on this issue a few days ago, I've debated the issue with a number of people from within medicine and also bioethics in different fora.

Due to the presence of significant uncertainties of the methods debated, my suggestion was that use of this methods should be amended by the following methodological rule (assuming 18 to be the age of adulthood, if it is different we may simply insert another variable for that):

... for any method, M, for the assessment of the age of a person, P, with a margin of error +/- X years, M is taken to indicate adulthood if, and only if, its result is 18+X years or higher, and otherwise taken to indicate childhood

Here are a few points that may be added to the complexities of this particular issue:

1. The nature of the uncertanties
Some have argued to me that the methods are not only uncertain in a way possible to describe in terms of a margin of error. One reason for this put to me is that besides the usual margin of error within the dimension of a variable, there is also the background confidence interval behind this margin, and the known effect of having this confidence deteriorate considerably when aggregated population probabilities are projected onto individual cases. I, of course, do not deny that there is also this source of uncertainty, but as far as I can see, my formula above can easily include that: X can be the aggregation of both these uncertainties (this was my original thought as well). This probably means that X becomes considerably larger than 4 (the number used in the example in the original post, based on claims by critics of the model). However, this in no way undermines my suggestion, as this will probably mean that all unaccompanied refugee children will most likely be determined to be children (and, if there are any people like that, in addition a number of refugee adults who falsely claim to be children). That is, the best interest of children, as well as the proper priority of legal provisions is upheld. Suppose, for instance, that the margin of error, accounting for all sources of uncertainty, becomes +/- 15 years. Then my rule says that P is to be considered an adult if, and only if, M finds P to be 33 years or more.

Another claim has been that some of the methods depend on the existence of relevant tables and charts or background data, and that such are missing in this case, meaning that the methods are not really uncertain, there is no method at all. The bewildering thing is that the same people are at the same time officially repeating the argument that the methods are uncertain and have unacceptably wide margins of error. These two claims are, of course, inconsistent; if it's not possible to have any result at all, there is no margin of error, and if there is a margin of error there is some results that create this margin. If it turns out that, in fact, the variable X (accounting for all kinds of sources of uncertainty), cannot be given any empirically based numerical estimate, I concede that my rule is inapplicable. However, if even an interval numerical estimate can be grounded, my rule can be used, by simply adding (supported by the same basic principles as before) that, the high extreme of this interval should be used to define X (in order to err in the right direction). Again, this may mean that the method will determine all tested as children, but, as already argued, it is difficult to see what the ethical or legal problem with that would be.

2. Professional Health Care Ethics and Ethics
Another aspect that has been raised is the fact that my suggestions means that health care professionals pragmatically accommodate to flawed public policies in the best interest of concerned parties (i.e. the children). This is wrong, some say, health care professionals should demand to regulate themselves and never do anything they themselves collegially don't find suitable to do, not even if this is harming third parties. Some have even gone so far at to claim that it is irresponsible of a health care professional to ever act the slightest in any other interest than his or her patient's.

The latter would, of course, mean that we would have to abandon all public health practices, communicable disease management, forensic medicine, large segments of insurance and sports medicine, and not least the involvement of doctors in issuing certificates underlying decisions by public authorities, such as sick leave or work-related disability benefits, and so on. Since health care professional organisations have as yet made no move whatsoever in such directions, I trust that this is not the line underlying the criticism in the present case. In other words, formalised professional health care ethics already accepts a number of cases where medical methods are used to other ends than the best interest of patients and many of these uses are being pragmatically accommodated to still make the best out of an imperfect thing. A very clear illustration is the assessment of "ability to work" nowadays made routinely by medical doctors in many countries, strategically adapted not to harm their patients while still abiding by required formalities.

It is thus unclear to what extent the principle of never doing anything to right the wrongs of public policies is a part of professional health care ethics. Even more unclear is if, had it been such a part, it would have been ethically defensible. To illustrate with the issue at hand, suppose that the health care professional community was to refuse to participate in the practice decided by the Swedish government. This may have three outcomes: (a) the government and parliament creates a legal room for some other class of officials to use the methods (not using my rule), (b) no method is used, (c) alternative suggested methods based on psychological models are used.

• If (c) is the outcome, the issue reappears, as also these methods can be expected to have margins of error, sources of uncertainty and so on. Then my rule can be used to secure that determinations err in the right direction.

• If (a) is the outcome, the results for the persons concerned, namely the children, is worse than if the profession had chosen to participate, using my rule to secure that they act solely in the best interest of the children, although also accommodating societal requests.

• If (b) is the outcome, the situation stands that unaccompanied refugee children where there is uncertainty as to whether or not they are children, will not be given their rights as children.

Now, compare this with (d): health professionals decide to pragmatically accommodate, and use the methods, amended by my rule.

• If (d) is the outcome, the concerned children's interests and Sweden's legal needs are better served than if any of (a) and (b). If these children are seen as patients, it would then be in their best interest to go for (d) rather than (a) or (b). If there is an option (c), this is even better, provided that my rule is used, but if not it may be better for the patients to go for (d).

3. The Ethics of Clean Hands, Politics of Power and Professional Integrity as Strategic Tool
Against this form of reasoning, some debaters I've talked to have claimed that the downsides for refugee children of the options (a) and (b) (as well as (c) without my rule) cannot be laid at the door of health professionals, but is the sole moral responsibility of the government. That is, they apply the standard of an "ethics of clean hands", denouncing responsibility for bad outcomes they could have avoided by acting differently just because the same is true of some other acting party (here, the government). This is like when the car driver, displeased with the rule that gives pedestrians priority at crosswalks, blames the government while electing to run people over, who cross motivated by the rule. Not very splendid ethics, I'd say.

Another version of this reasoning instead comes in the form of a political power bidding in the name of professional autonomy. It is simply the claim that health professionals should insist on the right to decide for themselves what standards they act on. While this is understandable (we all would like the privilege not to give a damn about the opinions of others, don't we?), it either comes without any underlying defense, or is compatible with sometimes choosing to compromise with other parts, interests and powers in society. As mentioned, the latter seems what in fact is happening in a number of areas, so then the question moves to what reasons pro or contra are present in the area at hand. Here, I have argued that (d) is the superior position.

The same outcome seems to ensue when analysing a final (and, to my view, better) variant of this sort of argument. Instead of an empty insistence on professional autonomy at all cost, this argument points to the political importance of professional integrity as a strategic tool in certain areas. The most obvious of these are torture, capital punishment and military interrogation. Here, the profession has adopted zero tolerance policies, which are thought to have an accumulated preventive effect, as these practices in various ways "need" the participation of doctors. However, this point does not demonstrate that age determination of unaccompanied refugee children belongs to this set of absolutely prohibited practices. As those who criticise the presently proposed methods also say that they could accept methods with a better degree of precision and exactness, it doesn't seem that they are trying to argue this in the present case. Which is understandable, as that would mean arguing against any claim to special considerations of the interests and rights of children.

In sum, therefore, unless it is demonstrated that there is no method at all that could produce any sort of empirically grounded numerical estimate (even in the form of a wide interval) in this area, my suggestion holds up to scrutiny. In fact, it is better supported by both professional health care ethics and more general ethical analysis, than alternative suggestions.

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New Article Presenting Framework for Identifying Ethical Aspects in Health Technology Assessment

I'm happy to announce the publication of a new article, available for free download and reading online, that presents a novel framework for systematic identification of ethical aspects in so-called Health Technology Assessment (HTA). This is the organised and systematiced discipline of assessing the evidence for the value of new treatments and methods for health care purposes (pharmaceuticals, new procedures, technical tools, diagnostic tests, and so on). The idea of having ethical issues integrated into such assessment has been seriously discussed for about ten years, and I have the last two of these been fortunate to take part in a project to this effect, organised by the Swedish national health technology assessment agency, SBU. This work produced a new guideline in Swedish and an update of the ethics section of the SBU method handbook. We then continued to develop a presentation of what we think are both novel and useful results also in an international perspective, which can increase the ambition and quality of attempts to integrate ethical aspects in HTA work, into an international publication, which we are now happy to have out in the International Journal of Technology Assessment in Health Care:

And the abstract runs:

Objectives: Assessment of ethical aspects of a technology is an important component of health technology assessment (HTA). Nevertheless, how the implementation of ethical assessment in HTA is to be organized and adapted to specific regulatory and organizational settings remains unclear. The objective of this study is to present a framework for systematic identification of ethical aspects of health technologies. Furthermore, the process of developing and adapting the framework to a specific setting is described.
Methods: The framework was developed based on an inventory of existing approaches to identification and assessment of ethical aspects in HTA. In addition, the framework was adapted to the Swedish legal and organizational healthcare context, to the role of the HTA agency and to the use of non-ethicists. The framework was reviewed by a group of ethicists working in the field as well as by a wider set of interested parties including industry, interest groups, and other potential users.
Results: The framework consists of twelve items with sub-questions, short explanations, and a concluding overall summary. The items are organized into four different themes: the effects of the intervention on health, its compatibility with ethical norms, structural factors with ethical implications, and long term ethical consequences of using the intervention.
Conclusions: In this study, a framework for identifying ethical aspects of health technologies is proposed. The general considerations and methodological approach to this venture will hopefully inspire and present important insights to organizations in other national contexts interested in making similar adaptations.

The article is so-called open access, meaning that it can be freely downloaded and read online by anyone. You are also free to re-use, distribute, and reproduce in any medium, provided the original work is properly cited. Find out more here or download the pdf directly here!

American Psychology Profession and Speciality and Its Central Association Completely Disgraced By Independent Report on Complicity in and Abetting of Military Torture

This post was slightly added to July 12, 2015.

Big news today on an issue within the US psychology profession and academic speciality that has been bubbling for quite some time – I posted about some of the brave and persistent activism that has been driving it a few years back, here. It is thus all about the completely disgraceful role of the American Psychological Association (APA) in actively aiding and abetting both the practice itself of so-called enhanced interrogation techniques – retrospectively declared even by the US government itself to be torture – in military and intelligence operations post 9/11, and the actual complicity of professional psychologists in these practices.

In an independent report (online readable here, and downloadable here), specially commissioned by the APA, former federal prosecutor David Hoffman reveals the APA involvement not only to be quite extensive, but also involving outrageous manipulation of internal processes and skewed application of guidelines and regulation of several high ranking APA officers and representatives. One of these, the director of ethics Stephen Behnke, has already been fired. Besides the pointing out of several individuals besides Behnke, whose heads deserve to be set rolling with equal enthusiasm, a central recommendation coming out of the report is that APA should adopt the same policy as the American Medical Association and ban members from participating in military interrogations, and this suggestion is reported to have been quickly picked up by the APA board of directors. Most fitting, and let us all hope that bill carries all the way through. Not least in the light of an independent comment in The Guardian by long-standing anti-torture activist, medical doctor and bioethicist Steve Miles – who among other things run the Doctors Who Torture Accountability Project – that the APA complicity with the US torture policies has been a general impediment for the general fight against torture practices globally. An extensive public apology and list of actions, among these the mentioned ban, has been published by the APA on its website, although it also contains some seemingly desperate attempts to flee responsibility by highlighting some less important findings, e.g., that the motive seems not to have been outright support of the torture program or US policy in this area, but "to curry favors" with the federal government and its agencies. That is: "we only did it for the money and the glory, not at all because we thought it was the right thing to do". As if that would make any difference for the better!

A less partial, extensive and popularised summary of the essentials of the report by New York Times reporter James Risen, who has helped push the uncovering of the heinous APA practices with his book Pay Any Price, can be found here.

The Ethics of Pharmaceutical Pricing

I don't think I'm alone in having noticed in my own country – as well as throughout that part of the developed world where states run reasonably expansive publicly financed health service schemes – an increased political and general societal problematisation of the costs of new pharmaceuticals.* The background to this increased focus is doubtlessly complex, but four aspects stand out as especially relevant explanatory factors. First, there is the generally splendid public health situation in these countries, with ever increasing average life expectancy and declining morbidity rates at the population level,** but with the side-effect of more and more of this increase being effected by reparative treatment of chronic, aging-related health problems, rather than primary prevention of basic health problems. Second, there is the next step in pharmacological development strategy, whith drugs targeting more and more specific and limited groups of patients and conditions, as a side-effect also providing treatment for extremely rare and serious diseases which have before been a dire fate to bear, with very limited treatment opportunities (many of these monogenic diseases which have been virtually untreatable). Third, there is the increased focus on rationality and ethics of public spending and the organisation of health services, effecting a greater transparency, control and regulation of the assessment, introduction and prioritarisation of new treatments. Fourth, there is the pricing policies of pharmaceutical companies, in extension reflecting the chosen expectations of return on investments of their owners. This post is about the fourth of these factors.

In most discussions of public policy in this area, this fourth factor is and has for a long time been treated as an immovable state of nature. There are three basic reasons usually presented in favour of that stance: First, commercial businesses have to be assumed to act as commercial businesses and strive to maximise profit for their owners, and are – in fact – in most jurisdictions required by law to do so. Second, if pharmaceutical companies would not be allowed to act in this way, they would soon be deprived of investor capital (as this would move to more profitable areas), and this would cripple the development of new drugs. Third, states are not capable of taking on the task performed by pharmaceutical businesses today; if they would, the result would soon be either an even worse cost crisis, or declining development and production. I think that the third argument is worth some critical discussion, especially in some areas of particular societal importance – such as vaccines – but in the present context, I will let it stand unquestioned for the sake of discussion. That is, I assume in the following that states are indeed dependent on private business solutions to have an effective development and production of pharmaceuticals.

But what about the other two arguments? Lately, these have been questioned in the context of debates in several countries about the pricing of a drug called Soliris by its manufacturer Alexion, targetting the rare and very serious hereditary disease Atypical hemolytic-uremic syndrome, or aHUS. In several countries, agencies responsible for assessing the evidence base, cost-efficiency and priority of new drugs have expressed serious complaints about the high price (here, here, here, here). In several of these cases, the national health services have eventually chosen to introduce this drug any way, in order not to have heavily burdened patients caught in the fight between health institutions and drug companies. But the change of tune with regard to pharmacological companies is notable, and raises the more general question of the plausibility and validity of the two arguments above.

I will claim that, given that the thesis supposed to be backed up by the arguments is that national health services, governments and related agencies have no reason to apply normative (ethical or political) judgement regarding the pricing of pharmaceuticals, my assessment is that while both arguments are plausible (as in likely to be true), they are invalid (as in not supporting the conclusion). I will support that claim with two arguments, one ethical and one political, and then sign off by pointing to some complicating factors that I think are mostly overlooked in health policy debates.

1. Even if commercial companies lack moral obligations, their owners don't
It may be debated to what extent commercial companies have moral obligations and, if so, which these are. Most countries have set up a system where, in Milton Friedman's famed words, 'the business of business is business' – that is, beyond keeping to the limits of criminal and necessary civil, and administrative law, commercial companies are not to mind about anything else than meeting the profit expectations of its owners. Based on this, a company may, of course, chose to abide by one or the other moral judgement, but only to the extent that it is thought to be a sound commercial strategy as defined above. Also, while thus using business only for its expected good outcomes of business (usually increased productivity of goods and services), a state may take political action to compensate for its bad side-effects, e.g., with regard to public health. In recent decades, this 'separation thesis' regarding the obligation of commercial companies (to maximise profits for its owners inside the realm of the law) has been questioned as both increasingly irrelevant (due to globalisation, which enables companies to move freely between jurisdictions in an amoral manner, thus emptying the content of the requirement to abide by the law) and for its inability to reply to increased arguments coming from the area of business ethics, corporate social responsibility and political philosophical observations that the separation thesis assumes a demarcation between the realms of business and that of basic public concerns which is simply not to be had.

However, even if we would grant the idea that companies have no other moral obligations than meeting the profit expectations of their owners inside the realm of the law, it doesn't follow that national health services, governments and related agencies have no reason to apply normative (ethical or political) judgement regarding the pricing of pharmaceuticals. This since the separation thesis does not in any way undermine the claim that owners of businesses have moral obligations and ethical reasons to behave considerate towards other people beyond what the law may require. Or, it may do so in the first instance, as many owner's are institutional business parties (banks, funds, and so on), but at the end of the day, there will be actual and quite ordinary people, and these have the same moral obligations as anyone else. In fact, it would seem that the whole idea of the separation thesis rests on the assumption of a well-functioning society within which businesses may operate, and a core part of such a society is that people act decently towards one another. This implies, e.g., the recognition  of basic and reciprocal civic obligations of due diligence, duty of care and general consideration to other people – all stretching beyond what is strictly required by law. Just start to imagine what walking along a street in a city would be like absent such basic cultural arrangements in place. Likewise, imagine a society were no individual assisted another in need according to such principles. I take it that no one would disagree that we hold these sort of moral obligations to one another. However, if we do, these don't just magically disappear if we happen to open a shop or purchase some company stock. Even if not required by law, as owners of businesses, we are still bounded by ethical considerations to other people, e.g., to care for those in dire and undeserved circumstances.***

So how does one discharge these moral obligations in the role as owner of commercial enterprise? Well, since the enterprise itself – a company – works according to the main principle of realising the profit expectations of the owners, the lever available to an owner seems to be exactly these expectations. That is, the material outcome of the duty of the company towards its owners being discharged can be manipulated by the owners' communication into the company structure of what level and rate of return on invested capital is being expected. This creates ample room for an owner to have ethical reasons to adjust such expectations in view of reasons beyond those of "pure business". Transferred to the case of pharmaceuticals, this line of reasoning results in the conclusion that, to the extent that this is required by our normal set of ethical reasons to be considerate towards each other, an owner of such a company has a reason to decrease his or her expectation of return on invested capital, whether in terms of level or rate. In both cases, such an adjustment will enable the company to adjust its pricing downwards without defaulting what it owes its owners. To be true, such a reason need not always be available, but in the case of drugs for very serious diseases, it seems quite reasonable to claim that it does. Note also, that the reasoning can be applied also to argue against withdrawing investment, thus diffusing the argument that reducing profit margins to enable lower pricing would effect investment flight. Maybe it would, but it still holds that investors should not thus flee a slightly less profitable investment that would mean meeting one's general moral obligations to other people. I made this argument myself, in the Swedish debate around Soliris.

In conclusion, the idea that there are sound and valid normative (ethical) claims to make with regard to the pricing of effective drugs for very serious diseases holds up to scrutiny. The (assumed) facts that "the business of business is business" and that (potential and actual) owners of pharmaceutical companies do as a matter of fact not currently seem to act in accordance with their moral obligations (maybe partly because these have not been recognised) do nothing to undermine this claim. Owners of pharmaceutical companies owe it to very sick people to adjust their profit expectations to enable more modest pricing, and potential owners owe the same people not to withdraw from investment due to this obligation.  

2. States owe their citizens not to be money pumps
The second argument does not target individual people in their role as (potential) owners and investors, but rather state institutions in their roles as counterparties in business negotiations. This argument is entirely independent of the first one, and will hold up even if the former would be shown to be somehow faulty. The argument does, however, assume that pharmaceutical companies are behaving more or less according to "the business of business is business" pattern, with owners who as a matter of fact do not moderate their expectations on return on invested capital as they should. Should owners start to behave more in line with their moral obligations, the validity of the present argument will be undermined (although it is still sound).

The behaviour of pharmaceutical companies with regard to pricing of drugs as just sketched means that they try in every instance to find an optimal equilibrium between the price per sold item and the number of items sold. This is the reasons why the so-called "list price" of new drugs is in most cases much higher than the price eventually paid by public health services; the company sets an exaggerated price as it expects a negotiation where the price will be decreased in light of consumer demand, as expressed by the public agencies doing the state's bidding. In my own country, where up till recently, this bargaining has been undertaken by each single county government (responsibly for its health care service region), companies have thus been very savvy at, insisting on commercial secrecy around the agreed price, play all these counties against the middle to maximise bargaining outcome. From a political ethical standpoint, to have state or county agencies – and ultimately tax payers – thus being allowed to be played for suckers is simply unacceptable. For what it means is that the state – in view of the never ever ending demand for health care – allows commercial parties to milk its treasure chest dry. In more technical sense, the state thus allows itself to be what experts on economic bargaining rationality and game theory call a money pump – someone who applies a bargaining or game theoretical choice strategy that systematically leads to a losing position, albeit each single move may appear winning, given the circumstances.**** The argument that one should avoid such strategies (technically, to avoid dutch book strategies) has given raise to the discipline of dynamic choice theory, and is a standard motivation, e.g., for why it is irrational to apply decision strategies that make one succumb to blackmail – as each concession of a black mailer's demands (no matter of well motivated in the single instance) makes it rational for the blackmailer to continue the blackmail and increase the demands. In the case of negotiations about the price of pharmaceuticals, the state or responsible public agency becomes a money pump by being overwhelmed by the reason to accept the offered price presented by needs of single patients, and thus not considering the option of declining the offered product as a live option. Just as the blackmailer in the analogous situation receives increased reasons to continue the blackmail and up the stakes, the pharmaceutical companies are thereby reinforced in their reasons in terms of business logic to increase prices even more, and thus increasingly bleed the public health services budget.

I take it that everyone agrees that a state and its agencies owe it to their people to avoid such positions. As a matter of fact, since the rationality of avoiding being a money pump is so basic, this would seem to hold even on the super-thin libertarian idea of the state as a security business enterprise of its citizens (which I take most people would want to go beyond). But to do that, the state has to create a bargaining situation where the counterparty counts a declining of its offer as a live option to be calculated with. And to create that situation, the state needs to actually decline offered services also when they are necessary to meet important needs.If they don't, the companies will not view such a declining as a live option, and will thus be motivated to increase the stakes. Now, this does not necessarily mean that it is in case of effective orphan disease products such as Soliris, where the most urgent need for such demonstration of actual bargaining power is called for. Rather, one would find it more acceptable to decline state subsidising of treatments for far less serious, albeit more widespread conditons, although that may not harvest much of political popularity. But if the state never says "no" to anything, the money pumping result will eventually affect the entire public health service supply, and it is not unlikely that before long the willingness of citizens to fund very expensive treatments for conditions that strike only very few will falter as a result. Moreover, as more and more drugs for all sorts of condition (many of which will not be as extreme as aHUS) can be expected to become "orphan" in the sense of targeting only very specific patient groups, or add only very minor therapeutic effects (and often considerable side-effects) to serious conditions which are inevitably killing patients very shortly (as is the case with many new cancer medications), the fact that the targeted condition is either rare or very serious cannot by itself be a disclaimer from applying a rational bargaining strategy that also takes into consideration therapeutic effect, cost and opportunity costs in terms of what other treatments to other conditions may may be funded by the same money.

In any case, however, the many difficult priority setting issues which follow from the state and responsible agencies thus taking its responsibility to citizens are handled, the fact remains that the state does have such responsibilities. As much as society has reasons to allocate resources to be able to offer its members publicly available health care services, it has strong obligations to the very same members not to unnecessarily waste these resources. Avoiding the money pump position in relation to pharmaceutical companies seems like an elementary part of performing that duty.

3. Where we are in all of this
In conclusion, there are two separate arguments for the existence of valid and sound normative reasons to apply to the pricing of pharmaceuticals by commercial companies. Both assume only a very minimal idea of ethical and political reasons, which should be acceptable across most otherwise competing ethical and political positions and ideologies. However, there is an interesting dialectic between the arguments, hinted at when I wrote above that the second argument gains in validity to the extent that the first argument is ignored by the acting parties – owners of and investors in pharmaceutical companies. But who are these owners? As pointed out, in the first instance they are probably mostly banks, investment and holding companies, funds and so on, but at the end of the line there will of course be actual people (who hold the ethical obligations claimed in section 1 above). Some of these will, of course, belong to the fabled 1% of repugnantly rich, but most of them won't. In fact, most of them will be like you and me, people who has a bit of insurance, a bank account, a small slice of a pension fund (no matter how modest), loans, maybe even some stock. And even if our possessions of this sort are very modest, we are benefiting from a public health services system, which include funds where the capital to pay for and subsidise pharmaceuticals and public health care investments is stored and managed, and we may even be due for a bit of minimal public pension from funds equally so taken care of to be able to deliver what was originally promised. In other words, we who gasp at the indecent pricing of pharmaceutical companies are the very same people who in section 1 above were claimed to have moral obligations to lower their expectations of return on invested capital. In view of the apparent fact that this seems to imply that most people have to lower their pension-, insurance, savings- and welfare demands, one may quite plausibly doubt our collective capacity to effect such an adjustment, no matter how persuaded we are of its rationale on a theoretical level.

Therefore, as in so many other cases, the most rational solution would seem to be the second one: to press the reasons for the state and involved public agencies to apply effective and rational bargaining strategies against the pharmaceutical companies. Of course, to have effective such systems, it is rational to abandon the subsidiarity system, where each county government make their own bargain, and centralise the process nationally. But that's only the first step, of course, as the same logic tells us to accept multinational bargaining cartels, possibly across the entire EU. That will probably have quite a bit of bite, although it will also necessitate difficult issues of health care policy priorities, due to the need of sometimes actually saying no to the offered goods. Moreover, it will, as in so many other cases where we are unable to do collectively what we should be doing together, force us to accept the concessions (in terms a lowered returns on investments, savings, pension fund, insurance benefits, what have you) we were obliged to accept by ourselves, but failed to do.
  

*) There is, of course, a comparably much more pressing issue about the cost of and access to pharmaceuticals in developing and/or economically deprived settings. This issue has attracted the attention of ethical reflection for a long time, and there is a rich debate addressing its many levels to dip into for whoever feels like it – just make some searches using "orphan drugs", "orphan disease", "ethics" and "access to healthcare in developing countries", and you're set.

**) Granted, there is also in many of these countries stark health inequalities. However, if we plot the curves from the start of these modern health policies at the beginning of the 20th century, even the worst of worst-off groups of today come out considerably better. This is not to say that inequalities of the present are unimportant or that it shouldn't be a priority to decrease them, and to lift the worst off even higher (it should!). But the point remains that also the worst off of today cannot be made much better by primary prevention, but will also need the same shift to expensive reparative treatment of basically incurable conditions and mere aging. 

***) The qualification of "undeserved" is inserted merely to silence objections based on considerations of desert.

****) The classic "money pump argument" regards only the case when such a strategy is the result of a choosing party entertaining intransitive or "cyclical" preferences, and used to motivate why a rational actor must avoid such preference structures. However, the argument apparently rests on the assumption that being "pumped of one's money", as may result in this instance, is a general fault to be avoided by a rational actor, no matter the explanation.

The Philosophy of Hate Crime: Special Section Edited by Myself And David Brax Published By The Journal of Interpersonal Violence

I have been posting a few times over the last couple of years about themes, events and media linked to my engagement in research on philosophical and ethical aspects of hate crimes, hate crime law, and policy relating to this. The engagement originates from my participation in the European Commission funded project When Law and Hate Collide, and I'm now happy to be able to announce the final publication of one of the main academic outputs of this project: A special section of the Journal of Interpersonal Violence on the theme of the philosophy of hate crime, guest-edited by David Brax (my main collaborator in the project) and myself:

The section features an unusually (for a philosophy publication) diverse collection of specialists, representing philosophy, ethics, law, sociology and criminology, writing on a wide selection of philosophical and ethical aspects of hate crimes and related policy. The table of content looks as follows:

David Brax's and my introduction, where the theme of the philosophy of hate crime, as well as the content of the individual contributions, are briefly explained, has been made "open access", that is freely available for reading or download by anyone. If you lack the access (through private subscription or your university library or other institutional link) to read the other contributions, please contact the individual authours to obtain copies of their respective articles!

Why Aren't Existential Risk / Ultimate Harm Argument Advocates All Attending Mass?

An increasingly popular genre in the sort of applied philosophy and ethics of technology, which does not so much engage with actual technological development as more or less wild phantasies about possibly forthcoming ones is the notions of "existential risks" or "ultimate harms", or similar expressions. The theme is currently inspiring several research environments at world-leading universities, such as this one and this one (where you can find many links to other sources, articles, blog posts, and so on), and given quite a bit of space in recent scholarly literature on a topic often referred to as the ethics of emerging technology. Now, personally and academically, as it has actually proceeded, I have found much of this development being to a large extent a case of the emperor's new clothes. The fact that there are possible threats to human civilizations, the existence of humanity, life on earth or, at least, extended human well-being, is not exactly news, is it? Neither is there any kind of new insight that some of these are created by humans themselves. Also, it is not any sort of recent revelation that established moral ideas, or theories of rational decision making, may provide reason for avoiding or mitigating such threats. Rather, both these theses follow rather trivially from a great many well-established ethical and philosophical theories, and are well-known to do so since hundreds of years. Still, piece after piece is being produced in the existential risk genre making this out as some sort of recent finding, and exposing grand gestures at proving the point against more or less clearly defined straw-men.

At the same time, quite a bit of what is currently written on the topic strikes me as philosophically shallow. For instance, the notion that the eradication of the human species has to be a bad thing seems to be far from obvious from a philosophical point of view - this would depend on such things as the source of the value of specifically human existence, the manner of the imagined extinction (it certainly does not have to involve any sort of carnage or catastrophe), and what might possibly come instead of humanity or currently known life when extinct and how that is to be valued. Similarly, it is a very common step in the typical existential risk line to jump rather immediately from the proposition of such a risk to the suggestion that substantial (indeed, massive) resources should be spent on its prevention, mitigation or management. This goes for everything from imagined large scale geo-engineering solutions to environmental problems, dreams of outer space migration, to so-called human enhancement to adapt people to be able to handle otherwise massive threats in a better way. At the same time, the advocates of the existential risk line of thought also urges caution in the application of new hitherto unexplored technology, such as synthetic biology or (if it ever comes to appear) "real" A.I. and android technology. However, also there, the angle of analysis is often restricted to this very call, typically ignoring the already since long ongoing debates in the ethics of technology, bioethics, environmental ethics, et cetera, where the issue of how much of and what sort of such caution may be warranted in light of various good aspects of different the technologies considered. And, to be frank, this simplification seems to be the only thing that is special with the existential risk argument advocacy: the idea that the mere possibility of a catastrophic scenario justifies substantial sacrifices, without having to complicate things by pondering alternative uses of resources.

Now, this kind of argument, is (or should be) well-known to anyone with a philosophical education, since it seems to share the basic form of the philosophical classic known as Pascal's Wager. In this argument, French enlightenment philosopher and mathematician, Blaise Pascal offered a "proof" of the rationality of believing in God (the sort of God found in abrahamitic monotheistic religion, that is), based on the possible consequences of belief or non-belief, given the truth or falsity of the belief. You can explore the details of Pascal's argument, but the basic idea is that in the face of the immense consequences of belief and non-belief if God exists (eternal salvation vs. eternal damnation), it is rational to bet on the existence of God, no matter what theoretical or other evidence for the truth of this belief exists and no matter the probability of this truth. It seems to me that the typical existential risk argument advocacy subscribes to a very similar logic. For instance, the standard line to defend that resources should be spent on probing and (maybe) facilitating), e.g., possible extraterrestial migration for humanity, seems to have the following form:

1) Technology T might possibly prevent/mitigate existential risk, E

2) It would be really, really, very, very bad if E was to be actualised

3) Therefore: If E was otherwise to be actualised, it would be really, really, very, very good if E was prevented

4) Therefore: If E was otherwise to be actualised, it would be really, really, very, very good if we had access to a workable T

5) Therefore: there are good reasons to spend substantial resources on probing and (maybe, if that turns out to be possible) facilitating a workable T

That is, what drives the argument is the (mere) possibility of a massively significant outcome, and the (mere) possibility of a way to prevent that particular outcome, thus doing masses of good. Now, I'm sure that everyone can see that this argument is far from obviously valid, even if we ignore the question of whether or not premise 2 is true, and this goes for Pascal's Wager too in parallel ways. For instance, the existential risk argument above seems to ignore that there seems to be an innumerable amount of thus (merely) possible existential risk scenarios, as well as innumerable (merely) possibly workable technologies that might help to prevent or mitigate each of these, and it is unlikely (to say the least) that we have resources to bet substantially on them all, unless we spread them so thin that this action becomes meaningless. Similarly, there are innumerable possible versions of the god that lures you with threats and promises of damnation and salvation, and what that particular god may demand in return, often implying a ban on meeting a competing deity's demands, so the wager doesn't seem to tell you to try to start believing in any particular of all these (merely) possible gods. Likewise, the argument above ignores completely the (rather high) likelihood that the mobilised resources will be mostly wasted, and that, therefore, there are substantial opportunity costs attached to not using these resources to use better proven strategies with better identified threats and problems (say, preventing global poverty) - albeit maybe not as massive as the outcomes in the existential risk scenarios. Similarly, Pascal's Wager completely ignores all the good things one needs to give up to meet the demands of the god promising eternal salvation in return (for instance, spending your Sundays working for the allieviation of global poverty). None of that is worth any consideration, the idea seems to be, in light of the massive stakes of the existential risk / religious belief or non-belief scenarios.  

Now, I will not pick any quarrel with the existential risk argument as such on these grounds, although I do think that more developed ways to analyse risk-scenarios and the ethical implications of these already in existence and used in the fields I referred above will mean lots of troubles for the simplistic aspects already mentioned. What I do want to point to, however, is this: If you're impressed by the existential risk argument, you should be equally impressed by Pascal's Wager. Thus, in accordance with Pascal's recommendation that authentic religious belief can be gradually installed via the practice of rituals, you should – as should indeed the existential risk argument advocates themselves – spend your Sundays celebrating mass (or any other sort ritual demanded by the God you bet on). I very much doubt, however, that you (or they) in fact do that, or even accept the conclusion that you (or they) should be doing that.

Why on earth is that?

The Return of Lombroso? Free Access Article On the Ethics of the Scientific Vision of Screening for Risk of Criminality to Prevent Future Crime

One of my research interests is about the way in which medical science and technology may be used and misused for large-scale societal aims, and how that territory should be understood ethically. In Gothenburg, I am happy to be and have been part of the growing research environment of the Centre for Ethics, Law and Mental Health (CELAM), involving collaboration between forensic psychiatry, criminology, psychology, law, neuromedicine, political and care science, philosophy and ethics. In a freesh article coming out of this collaboration, by myself and CELAM director Susanna Radovic, a family of visionary and currently popular ideas – advocated not least by neurocriminology enthusiast Adrian Raine – about using the science of individual causes of crime for preventive screening programmes are analyzed from an ethical standpoint, connecting to the roots of such visions in the notorious ideas of 19th century Italian criminology pioneer Cesare Lombroso. The abstract runs:

The vision of legendary criminologist Cesare Lombroso to use scientific theories of individual causes of crime as a basis for screening and prevention programmes targeting individuals at risk for future criminal behaviour has resurfaced, following advances in genetics, neuroscience and psychiatric epidemiology. This article analyses this idea and maps its ethical implications from a public health ethical standpoint. Twenty-seven variants of the new Lombrosian vision of forensic screening and prevention are distinguished, and some scientific and technical limitations are noted. Some lures, biases and structural factors, making the application of the Lombrosian idea likely in spite of weak evidence are pointed out and noted as a specific type of ethical aspect. Many classic and complex ethical challenges for health screening programmes are shown to apply to the identified variants and the choice between them, albeit with peculiar and often provoking variations. These variations are shown to actualize an underlying theoretical conundrum in need of further study, pertaining to the relationship between public health ethics and the ethics and values of criminal law policy.

We have been fortunate to possess the funds of making the article so-called open access, meaning that it is now free for viewing and download by anyone – no need for subscription or the payment of any fees.

So if the topic of how medicine, science and technology can be used, for better of for worse, for preventing crime, and what are th ethical implications of such possibilities, feel free to sample our attempt at getting an initial grip on trhis topic, here. And should you want to share it along, or post it on a blog or a forum or in an archive, the open access license permits you to do so, as long as no commercial exploitation is involved.

Reproductive Public Health Ethics at the MANCEPT Workshops in Political Theory, 2014.

In a few hours, I'm off to Manchester, UK, for participation in a so-called panel ( ≈ special symposium) at the MANCEPT Workshops in Political Theory 2014. The panel is on the topic of Reproductive Public Health Ethics and has been conceived of and convened by myself. The topic itself is described thus, at the Mancept website:

Human reproduction and resulting population patterns is a classic concern of public policy, yet philosophical and ethical applications to this area remain imprecise, scattered and unsystematic. The point of this workshop is to stimulate a more integrated addressing of this area for social and political philosophical analysis from a public health standpoint. Reproductive bioethics hosts established interest in the regulation of reproductive technology, yet mostly ignoring overarching societal concerns to the benefit of a discourse focusing on individual reproductive liberty. This individualism has stimulated the emergence of public health ethics, where queries regarding health policy are put at a population level, but reproduction- and population issues have not been in focus, partly due to a common conflation in public health between reproductive and sexual health. In parallel, biopolitics subjects cultural layers of policy to critical scrutiny regarding “identities” and concepts central to laws across the world – e.g. parenthood and family – in light of, e.g., technological developments. Also here, public health ethical perspectives are scant, while dimensions of justice otherwise often ignored are addressed, making possible, e.g., explorations of hidden presumtions behind reproductive policies. More basic research on population ethics, while having somewhat informed reproductive bioethics, remains largely unexplored as to more conrete political and policy implications in either of the mentioned dimensions, e.g. in the face of environmental challenges and expected consequences in the form of resource scarcity and global migration. There are also theoretical conundrums which need attention, e.g. how justice-oriented discourses of biopolitics can be squared with the intricate problems of population ethics, or how the combination of these and a globalised public health ethical approach relates to the individualist assumptions of reproductive bioethics. The workshop assembles a selected group of presenters from the Netherlands, Romania, Sweden and the UK.

The same website also lists an, alas, not so up to date speaker list, as I've had a few cancellations and a few new people entering the program since it was initially presented to the Mancept organisation. The actual program looks like this:

• Session 1: Sept 8, 2 PM - 5:30 PM

Christian Munthe, University of Gothenburg: Reproductive Population Health and the Goals of Public Health: Exploring a Territory of Moral Unease

Angus Dawson, University of Birmingham: Public Health Reproduction: Defending the Very Idea

• Session 2: Sept 9, 9:30 AM - 1 PM

Daniela Cutas, Umeå University & University of Gothenburg: The Nuclear Family and Reproductive Policy: Ethical Challenges

Marian Verkerk, University of Groningen & Ulrik Kihlbom, Uppsala University: Preconception Genetic Testing and Reproductive Counselling as Challenge to the Family as Social Institution

Anca Gheaus, Sheffield University: Biological Parenthood: Gestational not Genetic – Implications for Reproductive and Family Law

• Session 3: Sept 9, 2 PM - 5:30 PM

Stephen Wilkinson, Lancaster University: The Public Health Ethics of Selecting Future Children

Anna Smajdor, University of East Anglia: Postponed Motherhood and the State

Rebecca Brown, University of Aberdeen: Incentives for Reproductive Public Health

• Session 4: Sept 10, 9:30 AM - 1 PM

Kalle Grill, Umeå University: Population Policy in the Face of Environmental Challenge: What Place for Reproductive Liberty?

General discussion on future developments and prospects of the topic in forthcoming endeavours


If you happen to be at the Mancept Workshops event, please don't hesitate to drop in on our panel, or approach about interest in the general topic!

Derek Parfit Wins the 2014 Royal Swedish Academy of Science Rolf Schock Prize in Logic and Philosophy

I'm happy to announce that this year's Rolf Schock prize in philosophy and logic has been awarded to University of Oxford All Souls College emeritus fellow Derek Parfit. The prize, which also is awarded in mathematics and the musical and visual arts is of a sizeable sum of 600 000 Swedish krona ≈ € 68 000 ≈ $ 93 000 and is one of, if not the, largest research prizes in philosophy. Former laureates include W.V.O. Quine, John Rawls, Hilary Putnam, Thomas Nagel, Saul Kripke and some other monumental names of 20th and 21th century Western academic and, let's be fair, anglophone philosophy. The list still waits to include a female receiver, I'm sorry to say.

But this takes nothing away from Derek Parfit, who has single-handedly transformed contemporary systematic moral philosophy more than anyone after John Rawls. Already his 1984 modern classic Reasons and Persons earned him the motivation of the selection committee that he receives the prize “for his ground-breaking contributions concerning personal identity, regard for future generations and analysis of the structure of moral theories”. This is a book that no even semi-serious scholar of ethics can avoid, as Parfit picks apart established ethical traditions and theories in to their bare bones, and further on into their marrow, to finally come out on the other side with a completely new research program for academic ethics scholars and moral philosophers, regarding, for instance, how to think about part-whole conflicts, personal identity and demarcation, future generations and population policy, the structure and role of theories of the good life, and the relationship between practical rationality, morality and the normativity of moral deliberation. He works in the very best of the British academic philosophical tradition, where Hume and Sidgwick are two of the most obvious influences, and has a now well-known style of writing that, as in the case of Quine, is imitated by many but mastered by only one. A few years back, he published the more synthetic and rather monumental work On What Matters, but to me R and P is what makes Parfit the giant he is, as his refusal of being content with any of the suggestions he contemplates there and the constant unfolding of new layers of paradox of human moral thought has produced fuel for philosophers to work on for, I'd say, at least a few centuries ahead.

On of Parfit's exceptional qualities is his straightforward and simple way of moving effortlessly from highly technical exercises of intricate problems into the most engaging narrative examples, broadly fleshed out to provide humanity to the philosophical issues he engages with. This excerpt from Reasons and Persons, where the theme of personal identity is introduced is a well-known example:

When I started to get serious about philosophy and together with a friend, while still studying on the undergrad level, was invited to attend the "higher seminar" of practical philosophy in Stockholm, Reasons and Persons had just come out and was the topic for a term's discussions, and it was refreshing to watch how all of the seniors around were as shaken by the radical and far-reaching challenges presented by that book as I was. A term later, I wrote my B.A. thesis on 25 pages in the beginning of the book, where Parfit defends a theory of practical rationality that allows for "intrinsically irrational desires" (such as preferring suffering on tuesdays, while otherwise disliking suffering as much as any other one). I was critical of that theory, as I have been of much other of Parfit's own philosophical claims over the years, for instance in my extensive use of his seminal analysis of the morality of creating and influencing future people taking place in part four of the book for the purpose of explicating a consequentialist theory of the morality of abortion in my Ph.D. thesis. But the great thing about Parfit, is that he is not the sort of philosopher whose value is found in him "being right" (or, as is usually the case with such specimen – wrong) – it's rather the way in which he is often able to demonstrate that most of the things we have been taken for granted as obvious or unproblematic must, in fact, be rejected and new, hitherto unknown, answers must be sought out in a project forcing us to rethink just about everything.

Congrats!

Post Haiyan: A Very Brief Ethical Annotation Re. the Current Situation in the Philipines and Indonesia

In the aftermath of the monster typhoon Haiyan that hit especially hard in the Philipines and Indonesia recently, news have been continuing the past week of the tens of thousands of dead, many more injured and, of course long-term material and economic consequences which in turn will induce secondary and tertiary human harm, for instance through the social chaos emerging in the tracks of a destroyed civilisation. Reports are also coming, once again when catastrophes of this magnitude hit, of the willingness of nations and people all around the globe to help and assist in whatever way possible – acting on solidarity and compassion for the plight of others. Planes and ships with materials and competence are shuffled in the direction of need. This is how it should be, and the willingness to sacrifice masses of resources, time and own security for the sake of others makes me rejoice a bit over my own species in the middle of all the devastation.

However, one thing does not bring me joy, namely something that I in connection to the Haitian earth quake disaster in 2010 discussed in one of my earliest posts on this blog under the heading: How Our Compassion Reveals a Moral Abyss.

I point to it now, once again. Since it is relevant, since it is timely, since what now goes on shows how another order in this world could in fact have been possible – if it hadn't been for its weakest link: us.

Another Comment on Empirical Research Relating to Ethics and Morality: The Moral Behavior is not Necessarily so Moral at All

So, once again I have dared to post a small comment on an article in the mighty PLOS ONE open access science journal. Last time, as some of you may recall, it was a piece of psychology research claiming demonstrated predictive links (indeed!) between very particular emotional features and equally very particular types of moral judgements, to which I had some to my mind rather devastating comments based on the authors' apparent lack of insight into elementary ethical theory, quite besides the gap between the conclusion reached and the methodology applied. This time, it is once again psychology, albeit the thesis isn't quite as bold, but still interesting enough to probe. In Does “Science” Make You Moral? The Effects of Priming Science on Moral Judgments and Behavior, Christine Ma-Kellams and Jim Blascovich claim to have demonstrated through a series of experiments that people who think about (yes indeed, merely having in their thoughts) science are more likely to exhibit moral behaviour – the independently supported explanation of this being that science is regularly associated with positive moral features. Also here, however, the argumentation of the article is lacking and, in the end, deeply flawed due to lack of basic competence in ethical theory or moral philosophy. It is also flawed logically, independently of that, due to imprecise concepts being employed in the analysis. My conclusion is that while the study may confirm the rather trivial claim that people who think about moral features will engage more with (perceived) moral features in practical decision making and action, the engagement demonstrated in the studies may very well be immoral from the perspective of the moral features the subjects were aware of and/or engaged with. Read more here.

Slides to Two Recent Talks Connecting the Themes of Ethics, Crime and Psychiatry are Now Online

Just to inform that the slides to my two talks at the 33rd International Congress of Law and Mental Health, held in Amsterdam earlier this summer, are now available online for viewing, download and sharing via my Academia.edu site. Both talks represent work in progress, where I am in the beginning of combining thinking on different topics that I have been touching on in isolation before, but which are nevertheless related through their connection to certain aspects of criminal law policy connecting to medical views of human nature.

They are:

1. The Return of Lombroso? Ethical and Philosophical Aspects of  (Visions of) Forensic Screening

Abstract
Italian nineteenth century criminologist Cesare Lombroso is notorious for his seminal ideas about criminality and anti-social behaviour resulting from physiological anomalies that should be detected by society and used for forensic preventive purposes. After an extended period of disrepute following World War II, similar ideas have been resurrected in psychiatry, genetics, neurology and criminology in the past decade or two. In particular, there is a growing focus on early detection and application of preventive measures. This development actualizes a complex web of ethics and policy issues having to do with the well-known fact that screening and prevention in the health area are far from ethically clear-cut activities and actualize vivid prospects of doing extensive harm to individuals as well as society. Also, taken to its extreme, it actualizes the idea of using prenatal or preimplantation testing to preselect against children with a predisposition for criminal or antisocial behaviour. In the forensic case, such screening-prevention strategies will connect further to a complicated issue about the proper use of risk-assessment models for societal decision-making for precautionary purposes. Based on former work in all of these areas, this presentation will outline and analyze the basic issue of the defensibility of activities of this sort, with the perspective of forestalling unintentional harm to individuals and society.

And.....

2. Hate Crime, Mental Disorder and Criminal Responsibility

Abstract
Hate crimes are ordinary crimes committed in connection with a negatively prejudiced, biased, disparaging, or antagonistic attitude towards the victim in terms of a perceived membership of a social group. Some hate crimes are elaborate political acts of terror or elaborate persecution, some are so-called “hate speech”, but the overwhelming majority are instances of mundane criminality, involving everything from murder to theft and harassment. Hate crime policies rest on the idea that the bias or “hate”feature make such crimes worse, and that offenders for this reason should be held more firmly responsible. At the same time, the attitude of making a crime into a hate crime involves more or less distorted ideas about reality, together with a willingness to transgress social norms on that basis. In some cases, these views amount to major delusions, resistant to rational scrutiny. In other cases, we may move closer to a point where the belief-desire cluster can be seen as ordinary negligence. Thus, many hate crimes have features that may be argued acting to diminish responsibility according to standard ideas in the philosophy of punishment. The presentation maps underlying value conflicts, tensions, and incoherence in legal practice connected to this complexity of criminal law.

Enjoy for what it's worth!

Utilitarianism and Empathy, or: Are Kantians Abnormally Empathic?

I just made some comments on a new psychology research article on the topic of how moral judgement link to emotional features in the journal PLOS ONE, entitled Low Levels of Empathic Concern Predict Utilitarian Moral Judgment. As with other articles of this type, I am a bit concerned by the sloppy use of ethical theoretical terminology among psychology and cognitive science researchers, as well as biased reportings of results. The secondary title of this little post is meant as a well-meant and humorous wink to the authors of the article and other researchers in the field of moral psychology as to what they may be unwittingly assuming when reporting their findings....