Molecular medicine and concepts of disease: the ethical value of a conceptual analysis of emerging biomedical technologies

Although it is now generally acknowledged that new biomedical technologies often produce new definitions and sometimes even new concepts of disease, this observation is rarely used in research that anticipates potential ethical issues in emerging technologies. This article argues that it is useful to start with an analysis of implied concepts of disease when anticipating ethical issues of biomedical technologies. It shows, moreover, that it is possible to do so at an early stage, i.e. when a technology is only just emerging. The specific case analysed here is that of ‘molecular medicine’. This group of emerging technologies combines a ‘cascade model’ of disease processes with a ‘personal pattern’ model of bodily functioning. Whereas the ethical implications of the first are partly familiar from earlier—albeit controversial—forms of preventive and predictive medicine, those of the second are quite novel and potentially far-reaching

The Ethics of Empowerment

Background: Being empowered has to do with having control over the determinants of one’s quality of life (including health) (Tengland 2007). Many things can be changed, on many levels, to increase empowerment in this sense and increasing the empowerment of individuals and groups can be seen as a goal for many kinds of social interventions, e.g. health promotion (WHO 1986). Empowerment can also be seen as the process of facilitating increased control. This process involves fully engaging the person or group concerned in the change process, so that they controls as much of this process as possible. The professional supports this process, and has no agenda of her own other than to facilitate the individual or group in achieving their aims (Tengland 2007). Empowerment has a positive ethical ring to it. It is supposedly superior to other ways of working towards health and social change – better than top-down interventions and behavior change projects. But is this so? Objectives: The aim of the paper is to critically discuss the ethical pros and cons of empowerment and relate it to other kinds of goals and interventions within health promotion and public health. Underlying values and principles: Ethical principles and theories, such as utilitarianism, deontology, principalism, virtue ethics and theories of justice are used throughout the discussion. Knowledge base/ Evidence base: The ethical analysis starts from a conceptual theory of empowerment (Tengland 2008) in relation to health promotion (Tengland 2007). Context of intervention/project/work: The general context of the project are the ethical aspects of health promotion and public health (Holland 2007). Methods: Ethical analysis (ethical theories and principles) is used when discussing and evaluating the goals and means of the empowerment approach, and relating it to other approaches (see underlying values and principles). Results and Conclusions: A first conclusion is that empowerment as a process is superior to many behavior change projects, since a) it reduces persuasion, manipulation and coercion of the subjects involved, something that is common in other approaches, b) it (thus) enhances autonomy, rather than reducing it, and c) it is founded on a more accurate theory of human nature, humanistic theory, rather than cognitive theory. Another conclusion is that many top-down projects are ethically compatible with most empowerment goals (i.e. increased control), e.g. literacy projects in poor countries, although not with all such goals, e.g. requiring drivers to wear seat-belts. However, other ethical concerns are also important, e.g. social justice, equal opportunity, and positive freedom, some of which might not necessarily lead to empowerment of individuals or groups. References: Holland, S 2007. Public Health Ethics. London: Polity. Tengland, Per-Anders 2007. Empowerment: A Goal or a Means for Health Promotion? Medicine, Health Care and Philosophy, Vol. 10, No 2 (2007), 197-207. Tengland, Per-Anders 2008. Empowerment: A Conceptual Discussion. Health Care Analysis vol 16, no 2, 77-96. WHO (1986) Ottawa Charter for Health Promotion. WHO: Geneva

Health and Morality : Two Conceptually Distinct Categories?

When seeing immoral actions, criminal or not, we often deem the people who perform them (mentally) unhealthy or disordered. This is especially so if the actions are of a serious nature, e.g., involving murder, rape, or other kinds of violence. That is, we translate our moral evaluation into an evaluation about (mental) health and illness. The question is, how analytically sound is such a move? In this paper I will scrutinize the most common theories of health (and illness) in order to see if they, or any one of them, support the claim that immoral acts are by definition unhealthy? When seeing immoral actions, criminal or not, we often deem the people who perform them (mentally) unhealthy or disordered. This is especially so if the actions are of a serious nature, e.g., involving murder, rape, or other kinds of violence. That is, we translate our moral evaluation into an evaluation about (mental) health and illness. The question is, how analytically sound is such a move? In this paper I will scrutinize the most common theories of health (and illness) in order to see if they, or any one of them, support the claim that immoral acts are by definition unhealthy? The psychological theory of Carl Rogers and the holistic theory of Lennart Nordenfelt are used to frame the issue and show how morality can, in Roger’s case, and cannot, in Nordenfelt’s case, be seen as conceptually related to health. Several versions of a pluralistic holistic theory then are discussed in order to see if, and if so, how, morality can be conceptually related to health. It is concluded that moral abilities and, perhaps also, moral virtues can be seen as being part of the individuals health. It is harder to incorporate moral actions into such a theory. If immoral actions are typical, or cluster, in the individual, or/and if they are of a severe kind, causing serious harm, it is more likely that the person can be deemed unhealthy

What kind of power is biopower, and can the notion help us settle normative issues within public health?

Power relations seem to exist everywhere: between men and women, teachers and students, doctors and patients, employers and employees, authorities and refugees, and between the state and its citizens. These relations can take many forms, from violence and coercion to more subtle influences in the shape of rewards, persuasion, authority, and manipulation. Power can be visible, as well as invisible, as is the case of some structural forms of power. Certain norms and values appear to be important forms of power, not least those that are ideological and political. Even scientifically produced knowledge can be seen as a kind of power, in that it creates new “forms of life” that categorize the world in ways that make people behave and see themselves in new ways. Some of these forms of power appear legitimate, as when a democratically elected government creates new laws, whereas others seem to be illegitimate and immoral, as when minorities are prevented from practicing their religions. Biopower seems to be a particular form of power, one that concerns the whole population and that emanates from the government and its civil servants. It is not completely clear, however, how this kind of power relates to other kinds of power, or even if it should count as a kind of power. The aim of the paper is, thus, to try to disentangle this issue by, first, specifying what biopower is usually taken to mean, and then comparing it to other conceptions of power, such as “power to”, “power over”, “social power”, “structural power”, and “discursive power”, and investigating in what forms it might manifest itself, that is, if it is “exercised”, as, for example, influence, coercion, manipulation, incentive, or persuasion. Finally, since biopower is claimed to be related to the health of populations, a few cases from public health practice and health promotion interventions will be discussed in order to try to determine if, and how, they might be examples of biopower, as “defined” in the text. This will give us a possibility to evaluate the normative utility of the idea of biopower, and to determine if it adds anything valuable to the critical discussions of these kinds of interventions

Att bedöma arbetsförmåga : ett kvalitativt tillvägagånssätt

Kapitlet utgår från några problem som många kvantitativa instrument lider av, nämligen bristande validitet samt att de är onödigt omfattande, vilket även illustrerades i föregående kapitel. Huvudsyftet med kapitlet är att visa hur man utifrån en noggrant konstruerad definition av begreppet “arbetsförmåga” kan skapa ett kvalitativt frågeformulär ämnat att utvärdera en individs specifika arbetsförmåga och samtidigt erhålla information relevant för att kunna lösa, minska, eller kompensera för, problemet ifråga. Lärdomar: De flesta kvantitativa instrument har problem med validiteten, då den begreppsliga grunden för dem är svag. Många instrument är även omständliga eftersom de innehåller många irrelevanta frågor. Validiteten kan öka om man skapa instrumentet utifrån en noggrant konstruerad definition som avser fånga fenomenet man är intresserad av, t.ex. arbetsförmåga. Det bästa sättet att försöka fånga det komplexa fenomenet arbetsförmåga är genom en kvalitativ intervjuundersökning som utgår ifrån den framtagna definitionen. En individs arbetsförmåga kan endast utvärderas i relation till ett konkret arbete, inte till en abstrakt arbetsmarknad

Does amphetamine enhance your health? On the distinction between health and “health-like” enhancements

It seems that we all have a moral obligation to restore, preserve and enhance health, our own and that of others, e.g. that of our children or parents. It is also an imperative within health care, medicine and public health, to support and enhance people’s health. Health is, furthermore, thought to be a human right. In its most ambitious formulation health is not only "a fundamental human right”, but “the attainment of the highest possible level of health” is “a most important worldwide social goal” (WHO 1986). These ethical imperatives make it important to discuss what health is, and what kinds of enhancement are increases in health and what kinds are not. This paper presents different attempts to draw a demarcation line between processes and states that we believe should belong to the concept of health, and processes and states which we believe should not belong to it. Since all we can expect to produce is a nominal definition, some initial criteria for the explication of health are presented. On the basis of these criteria, a holistic, pluralistic theory is suggested. The theory defines health in terms of basic abilities and well-being. A distinction is also made between manifest health, i.e. the ability and well-being here and now, and basic or fundamental health, i.e. the internal foundations for manifest health. Given these conceptual starting points, the remainder of the paper discusses various ways of trying to differentiate between enhancement that is an increase in (the various aspects of) health, and enhancement that is not, e.g. if there is a distinction between reducing ill health, and promoting positive health, or between “normal” and “supernormal” enhancement. It also discusses if the means used matter, e.g. if wheel-chairs, implants, medicine, narcotics, or genetic manipulation enhance health, if they only compensate for the lack of it, or if they enhance something else, such as non-health-related abilities, capacities or competences. Finally, the paper makes some suggestions towards distinguishing substances that are health-enhancing and those that are non-health-enhancing, e.g. those that are normal to humans, or normal in the culture, those which individuals need in order to live and to flourish, and those that can be tolerated in the long run by the human body and mind

Health and capabilities : a conceptual clarification

There are great health disparities in the world today, both between countries and within them. This problem might be seen as related to the access to various kinds of capabilities. It is not fully clear, however, what the exact relation is between health and capabilities. Neither Amartya Sen nor Martha Nussbaum has explicitly formulated a theory of health to go with their theories of capabilities. This paper attempts to present a clarification of the conceptual relation between health and capabilities. Health, it is argued, should be seen as a holistic multi-dimensional phenomenon, made up of basic abilities and subjective well-being, and of fundamental states and processes. Using this theory, the paper shows how health is related to Nussbaum's ten capabilities. It is argued that health, in the senses described, is a necessary part of all ten capabilities. Moreover, some of the capabilities on Nussbaum's list, such as thinking and imagining, and practical reasoning, refer to health. Finally, it is shown that even though health is part of all capabilities, health cannot itself primarily be seen as a capability. An acceptable degree of health is required as a functioning for any theory of human flourishing to be reasonable