Causal Responsibility and Rationing in Medicine

The article addresses the issue of rationing health care services, a topic currently being hotly debated in many countries. The author argues that the aspect of causal responsibility ought to play a decisive role in the allocation of limited medical resources. Starting out from Ronald Dworkin's distinction between option luck and brute luck, the appropriate and meaningful uses of the term causal responsibility are clarified first. A discussion of the conditions which might justify giving lower priority to patients whose illnesses are the result of unhealthy behavior, like e.g. alcohol abuse, follows. Causal responsibility is then viewed in the context of private health insurance and the club model of organ donation. It is argued that individuals themselves are basically responsible for their decisions regarding insurance coverage and membership in organ donors' clubs. Causal responsibility is shown to be a more suitable criterion for rationing scarce medical resources than other criteria which might alternatively be considered, such as patients' age.     

Care of the Self and Patient Participation in Genetic Discourse: A Foucauldian Reading of the Surgeon General's “My Family Health Portrait” Program

Critics of genetic discourse are concerned that deterministic and discriminatory views of genetics are increasingly becoming adopted. These views argue that current genetic discourse becomes a source of power whereby powerful institutions harm people with so-called “bad” genes. This essay argues that current analyses of the power of genetics discourse are grounded in an improper reading that disempowers patients. Deploying Michel Foucault's concept “care of the self,” this essay claims that genetics discourse is better understood as a way that patients take on power through rhetoric rather than a force that has power over patients. Through a close reading of the “My Family Health Portrait” program, this paper argues that patients experience a process of “subjection” wherein they become agents of and objects of genetics discourse both. This alternative mode of analyzing the power of genetics discourse has implications for our collective understanding of the operations of the care of the self and the uses of genetic information that we propose.     

The Nature and Significance of Behavioural Genetic Information

In light of the human genome project, establishing the genetic aetiology of complex human diseases has become a research priority within Western medicine. However, in addition to the identification of disease genes, numerous research projects are also being undertaken to identify genes contributing to the development of human behavioural characteristics, such as cognitive ability and criminal tendency. The permissibility of this research is obviously controversial: will society benefit from this research, or will it adversely affect our conceptions of ourselves and each other? When assessing the permissibility of this research, it is important to consider the nature and deterministic significance of behavioural genetic information. Whilst todate there has been much discussion and debate about the properties of genetic information per se and genetic determinism, this has not been applied to behavioural genetic research and its ethical implications. Therefore, this paper elucidates how behavioural genetic information can be distinguished from other types of genetic and non-genetic information and also synthesises the determinative significance of genetic factors for the development of human behavioural traits. Undertaking this analysis enables the ethical issues raised by this research to be debated in an appropriate context and indicates that separate policy considerations are warranted.

     

Metaphors in behavioral genetics

Behavioral geneticists sometimes use metaphorsto describe the role of genes in humanbehavior. In this paper, five sample texts areanalyzed: a popular book, a textbook, ascientific review article, and two originalscientific articles representing differentapproaches in behavioral genetics. Metaphorsare found in all the different kinds of sampletexts, not only in the popular book and thetextbook. This suggests that metaphors are usednot only for rhetorical or pedagogical purposesbut play a more fundamental role in scientificunderstanding. In the sample texts, themetaphors tend to be antideterministic, i.e.,they do not imply genetic determinism butstress the interaction of multiple genes andmultiple environmental factors. No conclusioncan be drawn, however, as to whetherantideterminism is representative ofpresent-day behavioral geneticists in general.Certain historically important metaphors thatmay imply genetic determinism are qualified,avoided, or explicitly rejected. There aretensions between some of the metaphors, makingthem difficult to combine. All the metaphorsthat are used appear empirically apt, howeversometimes only with certain qualifications.     

Depression and Self-Esteem in Boys with Attention-Deficit/Hyperactivity Disorder: Associations with Comorbid Aggression and Explanatory Attributional Mechanisms

It was tested whether boys with attention-deficit/hyperactivity disorder (ADHD), subgrouped by aggressive status, would show higher rates of depressive symptomatology and lower levels of self-esteem than would comparison boys and, in a subsample, explored attributional mechanisms that may be related to such internalizing features. Study 1 utilized 114 boys with ADHD (all prior recipients of stimulant medication) and 87 comparison boys, aged 7–12 years. Aggressive boys with ADHD reported more symptoms of depression than did nonaggressive boys with ADHD, who, in turn, reported more depression than did comparison boys. Effect sizes were moderate to large and did not vary with a depression rating scale uncontaminated by ADHD-related items. For self-esteem, the most pronounced effect was that aggressive boys with ADHD showed lower levels than did nonaggressive ADHD or comparison boys; effects were again moderate to large. Study 2 participants were a subsample of boys with ADHD from Study 1 (N = 27). We probed causal attributions in ADHD-related domains through responses to hypothetical vignettes, in which the protagonist's medication status (medicated, not medicated) was crossed with type of outcome (good, bad). Medication-related attributions were frequent. In describing the protagonist's success in relation to medication treatment, the sample showed significant associations between (a) medication-related attributions and (b) increased depressive symptomatology as well as decreased self-esteem. We discuss attributional processes that may help to explain the variation in internalizing symptoms among children with ADHD.     

Karl Schmitz-Moormann: Our Intellectual Legacy From a Great Mind

Karl Schmitz-Moormann's thought as expressed in his last book exemplifies Catholic theology based on realism, flow, evolution, and free will. Categories of creation are reviewed: from nothing, continuous, called forth, informed, and free.     

Steep Cliff Arguments

In recent philosophical debates a number of arguments have been used which have so much in common that it is useful to study them as having a similar structure. Many arguments – Searle's Chinese Room, for example – make use of thought experiments in which we are told a story or given a narrative context such that we feel we are in comfortable surroundings. A new notion is then introduced which clashes with our ordinary habits and associations. As a result, we do not bother to investigate seriously the new notion any further. I call such an arrangement, which is perhaps a variation of the fallacy of presumption, a Steep Cliff argument. One remedy for the misdirection of a Steep Cliff argument is to tell a counterstory from the point of view of the rejected notion.     

Moral Responsibility, Determinism, and the Ability to do Otherwise

In his classic paper, The Principle of Alternate Possibilities, Harry Frankfurt presented counterexamples to the principle named in his title: A person is morally responsible for what he has done only if he could have done otherwise. He went on to argue that the falsity of the Principle of Alternate Possibilities (PAP) implied that the debate between the compatibilists and the incompatibilists (as regards determinism and the ability to do otherwise) did not have the significance that both parties had attributed to it -- since moral responsibility could exist even if no one was able to do otherwise. I have argued that even if PAP is false, there are other principles that imply that moral responsibility entails the ability to do otherwise, and that these principles are immune to Frankfurt-style counterexamples. Frankfurt has attempted to show that my arguments for this conclusion fail. This paper is a rejoinder to that reply; I argue that he has failed to show this.     

Faulty Judgment,Expert Opinion,and Decision-Making Capacity

An assessment of decision-making capacity is the accepted procedure for determining when a person is not competent. An inferential gap exists between the criteria for capacity specific abilities and the legal requirements to understand relevant information and appreciate the consequences of a decision. This gap extends to causal influences on a person'scapacity to decide. Using a published case of depression, we illustrate that assessors' uses of diagnostic information is frequently not up to the task of bridging this inferential gap in a justifiable way. We then describe cases of faulty judgement which challenge the understanding of diagnostic causal influences. These cases help to clarify the nature of the expertise required for capacity assessments. In practice, the requirements of decision-making capacity are often abandoned to other considerations due to a lack of requisite expertise. The legal policy supporting decision-making capacity as a means to protective intervention is justified only if the requisite expertise is developed. We propose the requisite expertise to be developed in the long term as a distinct multidisciplinary endeavour.