Contemporary Political Philosophy: An Introduction

considerations. Biomedical Research Involving Animals is a report of the proceedings of the 1983 conference which discussed a draft of the Guiding Principles for Research using Animals presented at the conference and which it was hoped would provide widely applicable criteria for establishing codes of practice or legislation concerning the use of laboratory animals for scientific purposes. Whilst no one could fault the intention, the list of participants emphasises the rather one-sided nature of the proceedings. Of some 200 participants, scientists outnumbered animal welfarists by more than 20 to 1. The sooner those involved in any of the scientific disciplines accept that responsible lay opinion in all areas where the welfare of man or animal is at stake must be given equal weight with scientific opinion, the better. The attitude expressed by one scientist at the round table conference that those who are not in favour of experiments with animals simply do not understand what basic scientific method is about, is no longer true or acceptable. Nevertheless, Biomedical Research InvolvingAnimals is a useful selection of papers and discussions on this controversial and contentious issue. The conference was divided into three sessions, each of which included three or four papers followed by discussion: Scientific Progress and Research Involving Animals; Determinants of Future Policy Regarding Research Involving Animals, and Care and Protection of Laboratory Animals. The book ends with reports and summaries by the session chairmen. I found the most interesting and useful paper was that of Dr Zimmermann, of the International Association for the Study of Pain, on Ethical Considerations in Relation to Pain in Animal Experimentation. In discussion, Dr Zimmermann makes the point which should give pause for thought to all those involved in experimental research:

https://jme.bmj.com/content/medethics/12/1/50.full.pdf

Just Health Care.

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Punishment and responsibility: essays in the philosophy of law

Setting limits fairly: can we learn to share medical resources?

1. References to solidarity are currently on the increase in public discourse. In the UK and beyond, during economic crises and in a political climate where many feel that mutual assistance has lost currency, calls for a new and forceful emphasis on the meaning of solidarity are increasingly heard. Such appeals to solidarity are inevitably linked to ideas about how societies function, and about how and where the boundary between individual, familial, communal and societal spheres of responsibilities should be drawn.

Solidarity: Reflections on an emerging concept in bioethics

Unhealthy lifestyle contributes significantly to the burden of disease. Scarce medical resources that could alternatively be spent on interventions to prevent or cure sufferings for which no one is to blame, are spent on prevention or treatment of (the risk of) disease that could be avoided through individual lifestyle changes. This may encourage policy makers and health care professionals to opt for a criterion of individual responsibility for medical suffering when setting priorities. The following article asks whether responsibility-based reasoning should be accepted as relevant for fair and legitimate healthcare rationing. The luck-egalitarian argument that inequalities in health expectancies that derive from unchosen features of people’s circumstances are unjust and should be compensated, while inequalities that reflect personal choices of lifestyle may not, is discussed. It seems that while a backward-looking interpretation of individual responsibility cannot be relevant as a criterion of priority setting, a forward-looking conception of responsibility may be approved.

Within all modern societies healthcare authorities are facing difficult priority setting problems. Various criteria for rationing medical intervention have been proposed due to scarcity of resources. Until now, individual responsibility for medical suffering has been given little attention in the public or in academic debate. This is about to change. As Alexander Cappelen and Ole Norheim have pointed out in a recent article in this journal, unhealthy lifestyle contributes increasingly to the burden of disease. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge.1 In this article the following question is addressed: should responsibility-based arguments be accepted as relevant to meeting healthcare rationing fairly and legitimately? I will argue that while a backward-looking conception of individual responsibility should not be endorsed, a forward-looking notion of responsibility may be approved.

There are both empirical and theoretical reasons for …

https://jme.bmj.com/content/medethics/34/1/33.full.pdf

Lifestyle, responsibility and justice

The use of involuntary admission in psychiatry may be necessary to enable treatment and prevent harm, yet remains controversial. Mental health laws in high-income countries typically permit coercive treatment of persons with mental disorders to restore health or prevent future harm. Criteria intended to regulate practice leave scope for discretion. The values and beliefs of staff may become a determinating factor for decisions. Previous research has only to a limited degree addressed how legal criteria for involuntary psychiatric admission are interpreted by clinical decision-makers. We examined clinicians’ interpretations of criteria for involuntary admission under the Norwegian Mental Health Care Act. This act applies a status approach, whereby involuntary admission can be used at the presence of mental disorder and need for treatment or perceived risk to the patient or others. Further, best interest assessments carry a large justificatory burden and open for a range of extra-legislative factors to be considered.

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Interpretations of legal criteria for involuntary psychiatric admission: a qualitative analysis

The debate on responsibility for health takes place within political philosophy and in policy setting. It is increasingly relevant in the context of rationing scarce resources as a substantial, and growing, proportion of diseases in high-income countries is attributable to lifestyle. Until now, empirical studies of medical professionals’ attitudes towards personal responsibility for health as a component of prioritisation have been lacking. This paper explores to what extent Norwegian physicians find personal responsibility for health relevant in prioritisation and what type of risk behaviour they consider relevant in such decisions. The proportion who agree that it should count varies from 17.1% (‘Healthcare priority should depend on the patient’s responsibility for the disease’) to 26.9% (‘Access to scarce organ transplants should depend on the patient’s responsibility for the disease’). Higher age and being male is positively correlated with acceptance. The doctors are more willing to consider substance use in priority setting decisions than choices on food and exercise. The findings reveal that a sizeable proportion have beliefs that conflict with the norms stated in the Norwegian Patient Act. It may be possible that the implementation of legal regulations can be hindered by the opposing attitudes among doctors. A further debate on the role personal responsibility should play in priority setting seems warranted. However, given the deep controversies about the concept of health responsibility and its application, it would be wise to proceed with caution. Design Nationally representative cross-sectional study. Setting Panel-data. Participants 1072 respondents, response rate 65%.

https://jme.bmj.com/content/medethics/37/6/357.full.pdf

On the relevance of personal responsibility in priority setting: a cross-sectional survey among Norwegian medical doctors

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)'s 2015 Health Survey (N = 2689), this study examined the public's attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities' responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of 'self-inflicted' conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.

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Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System.

New approaches to control healthcare expenditures and increase access to quality care are required by decision-makers in high-income countries. One strategy is to reallocate tasks from doctors to nurses. Evidence suggests that quality, effectiveness and efficiency of task shifting are context sensitive and affected by implementation. However, little is known about implementability of task shifting in specialised healthcare. We aimed to identify factors perceived to influence implementation of doctor-to-nurse task shifting in a hospital setting and improve understanding of task shifting implementability by using theory-based frameworks for analysing behaviour. Nurse-led bone marrow examination exemplified task shifting from the medical to the nursing domain. Doctors and nurses (n = 17) in a haematology department at a Norwegian university hospital were asked about factors perceived to influence implementation of nurse-led bone marrow aspirations and biopsies. Methods included in-depth semi-structured interviews (n = 11) and focus-group discussion (n = 6). Data were analysed using the Capability, Opportunity, and Motivation behaviour model and the Theoretical Domains Framework. Ten factors perceived to influence implementation were identified. Three factors were related to capability, including (1) knowledge and acceptability of task shifting rationale; (2) dynamic role boundaries; and (3) technical skills to perform biopsies and aspirations. Five factors were related to motivation, including (4) beliefs about task shifting consequences, such as efficiency, quality and patient satisfaction; (5) beliefs about capabilities, such as technical, communicative and emotional skills; (6) job satisfaction and esteem; (7) organisational culture, such as team optimism; and (8) emotions, such as fear of informal nurse hierarchy and envy. The last two factors were related to opportunity, including (9) project planning and leadership, and voluntariness; and (10) patient preferences. Task shifting from doctors to nurses in specialised healthcare requires not only development of technical skills but also complex changes in organisation, clinical routines and role identity. Educational and organisational interventions to build a team-oriented culture could potentially increase the possibility of successful task shifting and stimulate nurses to take on untraditional responsibilities. Environmental restructuring to support doctors using their time in activities only doctors can perform may be needed to realise potential efficiency gains.

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Eli Feiring

Papers

Lifestyle, responsibility and justice

Interpretations of legal criteria for involuntary psychiatric admission: a qualitative analysis

On the relevance of personal responsibility in priority setting: a cross-sectional survey among Norwegian medical doctors

Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System.

Factors perceived to influence implementation of task shifting in highly specialised healthcare: a theory-based qualitative approach.