Thursday, 11 August 2016

New and forthcoming work (soon) available: conscientious refusal of pofessionals, hate crime philosophy, responsibility and priority-setting in health care, and the ethics of patient education

Just kicking off the autumn term after some well-needed weeks of complete holiday, summing up some recent and very soon available or forthcoming work in a few different areas:

1. Conscientious objection or refusal of professionals (in health care and elsewhere)
This is an area, i have been posting about before (here, and here).

a) As I flagged earlier in one of these posts, there is one article on this topic, co-authored by myself and Morten Ebbe Juul Nielsen, entitled "The Legal Ethical Backbone of Conscientious Refusal", forthcoming in a special issue of the Cambridge Quarterly of Healthcare Ethics, now formally accepted and with a so-called "postprint" (our finally submitted manuscript after peer review) avialable for free online reading and download here and here. In short, me and Morten argues that the idea of a legal right to conscientious refusal is either  incompatible with basic legal ethical principles (equal treatment, rule of law etc), or indefensible by undermining core societal values. Here's the abstract:

This paper analyses the idea of a legal right to conscientious refusal for health care professionals from a basic legal ethical standpoint, using refusal to perform tasks related to legal abortion (in cases of voluntary employment) as a case in point. The idea of a legal right to conscientious refusal is distinguished from ideas regarding moral rights or reasons related to conscientious refusal, and none of the latter are found to support the notion of a legal right. Reasons for allowing some sort of room for conscientious refusal for health care professionals based on the importance of cultural identity and the fostering of a critical atmosphere might provide some support, if no countervailing factors apply. One such factor is that a legal right to health care professionals conscientious refusal must comply with basic legal ethical tenets regarding the rule of law and equal treatment, and this requirement is found to create serious problems for those wishing to defend the idea under consideration. We conclude that the notion of a legal right to conscientious refusal for any profession is either fundamentally incompatible with elementary legal and ethical requirements, or implausible because it undermines the functioning of related professional sector (healthcare) or even of society as a whole.

b) In the same post, I also mentioned a workshop on this topic at the Brocher Foundation in Geneva, which took place as planned in June. The slides to my presentation there, "All or nothing! The legal, ethical and jurisprudential basis of legal rights to conscientious objection of voluntarily employed professionals" (building on and somewhat extending the argument of mine and Morten's article above), are available here and here.

c) At the same workshop, a wide range of presenters with opposing views on many issues nevertheless found themselves to agree on a number of core positions, and a consensus statement is currently being drafted for speedy publication, soon to be available in an as yet unnamed professional journal.

d) The workshop organisers, Alberto Giubilini, Julian Savulescu and Sharyn Milnes, moreover invited participants to submit to a further special issue on the topic, now in the Journal of Medical Ethics. As mine and Morten's article was already placed, I wrote a brief note on the Swedish way of dealing with conscientious objection in health care, entitled "Conscientious Refusal in Healthcare: The Swedish Solution", which is now accepted for publication, and available in its "preprint" (original submitted manuscript) form for free reading and download here and here. This is the abstract:

The Swedish solution to the legal handling of professional conscientious refusal in health care is described. No legal right to conscientious refusal for any profession or class of professional tasks exist in Sweden, regardless of the religious or moral background of the objection. The background of this can be found in strong convictions about the importance of public service provision and related civic duties, and ideals about rule of law, equality and non-discrimination. Employee requests to change work tasks are handled case by case within the frames of labour law, ensuring full voluntariness, but also employer privilege regarding the organisations and direction of work, and duties of public institutions to provide services. Two complicating aspects of this solution related to the inclusion of "alternative medical" service providers in a national health service, and professional insistence on conscientious refusal rights to accept legalised assisted dying are discussed. The latter is found to undermine the pragmatic reasons behind recent attempts by pro-life groups to challenge the Swedish solution related to legal abortion in courts.

2. The ethics of responsibility and priority-setting in shared decision-making
This is work undertaken in an ongoing research programme on the ethics of person centred care, of which I'm a part, but also linked to my work in the Gothenburg Responsibility Project. It builds further on earlier collaborative analyses by myself and Lars Sandman of the notion of so-called shared decision-making in health care. Together with Erik Gustavsson, we have an article that has just been published online in the Journal of Medical Ethics, where we penetrate the idea that increased patient involvement in and empowerment over clinical decisions would strengthen the case for the idea of holding them responsible for lack of adherence to agreed care plans (and the resulting ill-health) through a less favourable priority-setting of their health needs. We also discuss whether or not the ideas behind shared decision-making constitute an argument in favour of applying some such principle of individual responsibility for ill-health. Basically, our answer is yes to the first query and no to the second, although we also note several limitations and complications. "Preprints" of this article are available for free reading and download here and here. This is the abstract:

Given health care resource constraints, voices are raised to hold patients responsible for their health-choices. In parallel, there is a growing trend towards shared decision-making, aiming to empower patients and give them more control over health care decisions. More power and control over decisions is usually taken to mean more responsibility for these. The trend of shared decision-making would therefore seem to strengthen the case for invoking individual responsibility in health care priority setting.
Objective and Design
The objective was to analyze whether the implementation of shared decision-making would strengthen the argumentative support for invoking individual responsibility in health-care priority setting, using normative analysis.
Results and Conclusions
Shared decision-making does not constitute an independent argument in favor of employing individual responsibility since these notions rest on different underlying values. However, these theoretical tensions do not constitute a problem for combining these phenomena in practice. If a health system employs shared decision-making, individual responsibility may be used to limit resource implications of accommodating patient preferences outside of professional standards and goals. If a health care system employs individual responsibility, high level dynamic shared decision-making may disarm common objections to the applicability of individual responsibility, in virtue of making them more likely to exercise adequate control of their own actions. However, if communication strategies applied in the shared decision-making are misaligned to the patient's initial capacities, the result may be the opposite. Non high-level dynamic types of shared decision-making would not seem to affect the applicability of individual responsibility at all.
3. The ethics of patient education
This work, entitled "Errorthrawling and Fringe Decision Competence: Ethical Hazards in Monitoring and Addressing Patient Decision Capacity in Clinical Practice" utilises some material and builds partly on earlier analyses of studies of the communication and ethics of pediatric diabetes care, e.g., this one, but mostly presents fresh analytical results from my Ph.D. student Thomas Hartvigsson, who works on a thesis on the normative roles of decision competence. The article describes and discusses the ethical, emotional and professional dymamics of an extreme variant of patient education, especially risky to occur when common patient education strategies are applied to what we call "fringe decision competent patients", i.e. people who are in a grey area between obvious decision competence and incompetence. The article is still in the submission phase, so it is due to be revised a number of times, and if you have comments or suggestions, don't hesitate to contact Thomas. His email is found in the original "preprint", available for free reading and download here and here. The current abstract runs like this:

In this article we discuss how health professionals should monitor and safeguard patients' abilities to take part in clinical decisions and their implementation. Such a task is essential e.g. in self-care situation where patient is responsible for most regular care. Here, argue that a common fact-oriented strategy of patient education in practice tends to take the form of what we call errorthrawling. Illustrated by empirical findings from a video study of consultation meetings in adolescent diabetes care, we argue that this strategy both tends to miss significant capacity weaknesses, and even undermine capacities. In effect, this strategy for clinically monitoring and addressing the decision capacities of patients where these are fragile seems to be incomplete and actually hazardous. We close by suggesting complementary and alternative strategies, and comment on how these may actualise a need of a broadened competence of clinical health professionals.
Being work in progress there's bound to be further news ahead on this front, which will be relayed here as it appears.

 4. Hate crime philosophy and moral psychology: forthcoming 3 volume book series
Before going on holiday, me and David Brax, with whom I have been working on the philosophy of hate crime for some years now, submitted the final versions of three chapters contributing to a coming 3 volume book series published by Preager, of which we are also associate editors, entitled The Psychology of Hate Crimes as Domestic Terrorism: U.S. and Global Issues, and edited by Edward Dunbar, Amalio Blanco and Desirée A. Crèvecoeur-MacPhail. Me and David contribute two co-authoured chapters, one briefly summarising the basic philosophical issues actualised by the phenomenon of hate crime and related policy, and one on the relationship between hate crime and terrorism from a conceptual, ethical and moral psychological standpoint. In addition, I contribute a chapter on my own, where I problematise the relationship between underlying assumptions about criminal responsibility related to the moral psychological assumptions around hate criminality and crimes committed by mentally disordered offender. The series is currently in its final production stage and is due for publication in November this year.