'Empathy counterbalancing' to mitigate the 'identified victim effect'? Ethical reflections on cognitive debiasing strategies to increase support for healthcare priority setting.

Priority setting is inevitable to control expenditure on expensive medicines, but citizen support is often hampered by the workings of the 'identified victim effect', that is, the greater willingness to spend resources helping identified victims than helping statistical victims. In this paper we explore a possible cognitive debiasing strategy that is being employed in discussions on healthcare priority setting, which we call 'empathy counterbalancing' (EC). EC is the strategy of directing attention to, and eliciting empathy for, those who might be harmed as a result of one-sided empathy for the very ill who needs expensive treatment. We argue that governments have good reasons to attempt EC because the identified victim effect distorts priority setting in ways that undermine procedural fairness. We briefly outline three areas of application for EC and suggest some possible mechanisms that might explain how EC might work, if at all. We then discuss four potential ethical concerns with EC. First, EC might have the counterproductive effect of reducing overall citizen support for public funding of expensive medical treatments, thereby undermining solidarity. Second, EC may give rise to a 'competition in suffering', which may have unintended side effects for patients who feature in attempts at EC. Third, there may be doubts about whether EC is effective. Fourth, it may be objected that EC comes down to emotional manipulation, which governments should avoid. We conclude that insofar these concerns are valid they may be adequately addressed, and that EC seems a promising strategy that merits further investigation.

[Uncertainties around the current gender care: five problems with the clinical lesson 'Youth with gender incongruence']. / Onzekerheden rond de huidige genderzorg.

The clinical lesson 'Youth with gender incongruence' by Dutch gender clinicians aims to describe Dutch adolescent gender care and its dilemma's. This commentary discusses five serious objections. First, the lesson fails to draw the implications from its acknowledgement of the paucity of evidence: puberty blockers and cross-sex hormones most likely do not meet the requirements for standard care. Second, it does not make the crucial distinction between childhood and adolescent onset gender dysphoria. Third, its claim that from those children that continue from GnRHa to cross-sex hormones '98% continues to use these hormones in the long term' is unfounded. Fourth, it does not acknowledge the dilemma that puberty blockers may impede, rather than facilitate, time for reflection. Fifth, it inaccurately represents the literature on the potential detrimental effects of GnRHa on brain development. The commentary concludes with a call to reform Dutch gender care, following the examples of Sweden and Finland.

[Prioritisation in health care: An ethical perspective]. / Keuzes maken in tijden van schaarste.

Scarcity is an increasingly pressing problem currently in health care. To help address growing waiting lists, some hospitals in the Netherlands have begun applying triage of referrals for specialist care by primary care physicians: Which patients must be seen in the hospital, and which patients may just as well be treated in primary care settings? Does this new practice of more stringent triage fall within the scope of normal good care provision, or is something else - such as implicit rationing - at play? This paper analyses decision-making about care from an ethical perspective, using various justice theories, including utilitarianism, egalitarianism, sufficientarianism, and prioritarianism.

Can Voluntary Health Insurance for Non-reimbursed Expensive New Treatments Be Just?

Public healthcare systems are increasingly refusing (temporarily) to reimburse newly approved medical treatments of insufficient or uncertain cost-effectiveness. As both patient demand for these treatments and their list prices increase, a market might arise for voluntary additional health insurance (VHI) that covers effective but (very) expensive medical treatments. In this paper, we evaluate such potential future practices of VHI in public healthcare systems from a justice perspective. We find that direct (telic) egalitarian objections to unequal access to expensive treatments based on different ability to afford VHI do not stand up to scrutiny. However, such unequal access might lead to loss of self-respect among individuals, or loss of fraternity within society, rendering it more difficult for citizens to interact on equal moral footing. This would be problematic from a relational egalitarian perspective. Moreover, the introduction of VHI might turn out to have negative consequences for the comprehensiveness and/or the quality of the public healthcare services that are offered to all patients equally through basic health insurance. These consequences must be weighed against potential health gains and the value of liberty. We conclude that governments should be careful when considering the introduction of VHI in public healthcare systems.

Access to effective but expensive treatments: An analysis of the solidarity argument in discussions on funding of medical treatments.

The development of new effective but expensive medical treatments leads to discussions about whether and how such treatments should be funded in solidarity-based healthcare systems. Solidarity is often seen as an elusive concept; it appears to be used to refer to different sets of concerns, and its interrelations with the concept of justice are not well understood. This paper provides a conceptual analysis of the concept of solidarity as it is used in discussions on the allocation of healthcare resources and the funding of expensive treatments. It contributes to the clarification of the concept of solidarity by identifying in the literature and discussing four uses of the concept: (1) assisting patients in need, (2) upholding the solidarity-based healthcare system, (3) willingness to contribute and (4) promoting equality. It distinguishes normative and descriptive uses of the concept and outlines the overlap and differences between solidarity and justice. Our analysis shows that the various uses of the concept of solidarity point to different, even conflicting, ethical stances on whether and how access to effective, expensive treatments should be provided. We conclude that the concept of solidarity has a role to play in discussions on the accessibility and funding of newly approved medical treatments. It requires, for instance, that healthcare policies promote and maintain both societal willingness to contribute to the care of others and the value of providing care to vulnerable patients through public funding.

Ethics of access to newly approved expensive medical treatments: multi-stakeholder dialogues in a publicly funded healthcare system.

Background: Due to rising healthcare expenditures, countries with publicly funded healthcare systems face challenges when providing newly approved expensive anti-cancer treatments to all eligible patients. In the Netherlands in 2015, the so-called Coverage Lock (CL), was introduced to help safeguard the sustainability of the healthcare system. Since then, newly approved treatments are no longer automatically reimbursed. Previous work has shown that as policies for access to CL treatments are lacking, patient access to non-reimbursed treatments is limited and variable, which raises ethical issues. The ethics of access were discussed in a series of multi-stakeholder dialogues in the Netherlands. Methods: Three dialogues were held in early 2023 and included physicians, health insurers, hospital executives, policymakers, patients, citizens, and representatives of pharmaceutical companies, patient and professional organizations. In advance, participants had received an 'argument scheme' featuring three models: 1) access based on third-party payment (e.g., by pharmaceutical companies, health insurers or hospitals) 2) access based on out-of-pocket payments by patients 3) no access to CL treatments. During the dialogues, participants were asked to discuss the merits of the ethical arguments for and against these models together, and ultimately to weigh them. The discussions were audio-taped, transcribed, coded, and thematically analyzed. Results: Generally, most stakeholders were in favour of allowing access-at least when treatments are clearly beneficial-to treatments in the CL. When discussing third-party payment, stakeholders favoured payment by pharmaceutical companies over payment by health insurers or hospitals, not wanting to usurp collective funds while cost-effectiveness assessments are still pending. Largely, stakeholders were not in favour of out-of-pocket payments, emphasizing solidarity and equal access as important pillars of the Dutch healthcare system. Recurrent themes included the conflict between individual and collective interests, shifting attitudes, withholding access as a means to put pressure on the system, and the importance of transparency about access to CL-treatments. Conclusion: Policies for access to non-reimbursed treatments should address stakeholders' concerns regarding transparency, equal access and solidarity, and loss of potential health benefits for patients. Multi-stakeholder dialogues are an important tool to help inform policy-making on access to newly approved (too) expensive treatments in countries facing challenges to the sustainability of healthcare systems.

Danaher's Ethical Behaviourism: An Adequate Guide to Assessing the Moral Status of a Robot?

This paper critically assesses John Danaher's 'ethical behaviourism', a theory on how the moral status of robots should be determined. The basic idea of this theory is that a robot's moral status is determined decisively on the basis of its observable behaviour. If it behaves sufficiently similar to some entity that has moral status, such as a human or an animal, then we should ascribe the same moral status to the robot as we do to this human or animal. The paper argues against ethical behaviourism by making four main points. First, it is argued that the strongest version of ethical behaviourism understands the theory as relying on inferences to the best explanation when inferring moral status. Second, as a consequence, ethical behaviourism cannot stick with merely looking at the robot's behaviour, while remaining neutral with regard to the difficult question of which property grounds moral status. Third, not only behavioural evidence ought to play a role in inferring a robot's moral status, but knowledge of the design process of the robot and of its designer's intention ought to be taken into account as well. Fourth, knowledge of a robot's ontology and how that relates to human biology often is epistemically relevant for inferring moral status as well. The paper closes with some concluding observations.

Can a Robot Be a Good Colleague?

This paper discusses the robotization of the workplace, and particularly the question of whether robots can be good colleagues. This might appear to be a strange question at first glance, but it is worth asking for two reasons. Firstly, some people already treat robots they work alongside as if the robots are valuable colleagues. It is worth reflecting on whether such people (e.g. soldiers giving "fallen" military robots military funerals and medals of honor) are making a mistake. Secondly, having good colleagues is widely regarded as a key aspect of what can make work meaningful. In discussing whether robots can be good colleagues, the paper compares that question to the more widely discussed questions of whether robots can be our friends or romantic partners. The paper argues that the ideal of being a good colleague has many different parts, and that on a behavioral level, robots can live up to many of the criteria typically associated with being a good colleague. Moreover, the paper also argues that in comparison with the more demanding ideals of being a good friend or a good romantic partner, it is comparatively easier for a robot to live up to the ideal of being a good colleague. The reason for this is that the "inner lives" of our friends and lovers are more important to us than the inner lives of our colleagues.