Care of the older person and the value of human dignity.

As the world population is rapidly aging, stakeholders must address the care of the elderly with great concern. Also, loss of dignity is often associated with aging due to dementia, mobility problems and diminished functional autonomy. However, dignity is a polysemic term that is deemed useless by some ethicists. To counter this claim, we propose four concepts to define it better and make use accurately of this notion. These are human dignity, dignity of identity, dignities of excellence and attributed dignities. Finally, we explain the importance of solicitude and human dignity in the care of the elderly. This will ensure the respect, friendship and dignity of the elderly in providing geriatric ethical care.

Dignity at stake: Caring for persons with impaired autonomy.

Dignity, usually considered an essential ethical value in healthcare, is a relatively complex, multifaceted concept. However, healthcare professionals often have only a vague idea of what it means to respect dignity when providing care, especially for persons with impaired autonomy. This article focuses on two concepts of dignity, human dignity and dignity of identity, and aims to analyse how these concepts can be applied in the care for persons with impaired autonomy and in furthering the practice of respect and protection from harm. Three vignettes were designed to illustrate typical caring situations involving patients with mild to severely impaired autonomy, including patients with cognitive impairments. In situations like these, there is a risk of the patient's dignity being disrespected and violated. The vignettes were then analysed with respect to the two concepts of dignity to find out whether this approach can illuminate what is at stake in these situations and to provide an understanding of which measures could safeguard the dignity of these patients. The analysis showed that there are profound ethical challenges in the daily care of persons with impaired autonomy. We suggest that these two concepts of human dignity could help guide healthcare professionals to develop practical skills in person-centred, ethically grounded care, where the patient's wishes and needs are the starting point.

Simplified bipartite concepts of functioning and disability recommended for interdisciplinary use of the ICF.

PURPOSE: To argue for and propose bipartite concepts of functioning and disability, to tally with the structure of the ICF classification list, concepts of social models and clinical needs. METHOD: The ICF concepts are discussed in relation to the history of ideas regarding disability concepts and the needs for such concepts in interdisciplinary rehabilitation. RESULTS: Bipartite concepts are presented; they refer to actual functioning, simply body functions/structures and participation, including functioning in standardized environments. Participation refers to actually performed "activities", with "activities" simply denoting things that people may do. Bipartite concepts are congruent with the ICF classification and the structure of social models of disability, suitable for clinical and interdisciplinary use and easy to understand. The issue of standardized environments represents a methodological issue rather than the conceptual issue of defining functioning and disability. An individual perspective on activity and activity limitations, i.e. the middle part of the tripartite ICF concept, is somewhat similar to concepts of traditional language that were regarded as too generalizing already in 1912, when the interactional concept of "disability in a social sense" was introduced in rehabilitation practices. CONCLUSION: Bipartite concepts of functioning and disability are recommended for interdisciplinary use of the ICF. IMPLICATIONS FOR REHABILITATION: The ICF classification is useful, but the ICF concept of activities in an individual perspective is confusing. We suggest a use of the term "activities" simply to denote things that people may do and "participation" to denote actually performed activities. Estimations of ability should be explicit about how they are related to environmental factors.

What is a sports injury?

Current sports injury reporting systems lack a common conceptual basis. We propose a conceptual foundation as a basis for the recording of health problems associated with participation in sports, based on the notion of impairment used by the World Health Organization. We provide definitions of sports impairment concepts to represent the perspectives of health services, the participants in sports and physical exercise themselves, and sports institutions. For each perspective, the duration of the causative event is used as the norm for separating concepts into those denoting impairment conditions sustained instantly and those developing gradually over time. Regarding sports impairment sustained in isolated events, 'sports injury' denotes the loss of bodily function or structure that is the object of observations in clinical examinations; 'sports trauma' is defined as an immediate sensation of pain, discomfort or loss of functioning that is the object of athlete self-evaluations; and 'sports incapacity' is the sidelining of an athlete because of a health evaluation made by a legitimate sports authority that is the object of time loss observations. Correspondingly, sports impairment caused by excessive bouts of physical exercise is denoted as 'sports disease' (overuse syndrome) when observed by health service professionals during clinical examinations, 'sports illness' when observed by the athlete in self-evaluations, and 'sports sickness' when recorded as time loss from sports participation by a sports body representative. We propose a concerted development effort in this area that takes advantage of concurrent ontology management resources and involves the international sporting community in building terminology systems that have broad relevance.

Ill health or illness: a reply to Hofmann.

In this article I respond to Björn Hofmann's criticism of some elements in my theory of health. Hofmann's main objective is to question "Nordenfelt's basic premise that you can be ill without having negative first-person experiences, and to investigate the consequences of abandoning the premise." One of Hofmann's critical points is that my theory of health does not lend voice to the individual. My response is essentially conducted in four steps: (1) I question the aim of conceptual analysis that Hofmann proposes for the analysis of the notion of health. (2) I maintain that my analysis, in spite of Hofmann's contention, lends voice to the individual. It does so via my notion of subjective illness but also via my notion of vital goal. (3) I argue that conditions, such as coma, paralysis and mania are salient instances of ill health and that these may become neglected if the use of the terms "ill" and "illness" is restricted to instances where negative subjective experiences are present. (4) I rehearse my main arguments for selecting disability as the core element of ill health and respond to Hofmann's contention that persons who are in great pain can sometimes nevertheless perform perfectly.

Food and health: individual, cultural, or scientific matters?

In personalized nutrition, food is a tool for good health, implying an instrumental relationship between food and health. Food receives a secondary value, while health would appear to be a descriptive biological concept. This article gives an introduction to cultural understandings of food and health. The wider definition of food and health is explored in relation to the commonly used scientific approach that tends to take a more reductionist approach to food and health. The different discourses on food and health are being discussed in relation to ethical aspects of personalized nutrition. The success of personalized nutrition is likely dependent upon the ability to integrate the scientific approach with everyday cultural, emotional, ethical, and sensual understandings of food. Health theories can be divided into two principal rival types-biostatistical and holistic. Biostatistical focuses on survival, while holistic focuses on ability as a precondition for health. Arguments in favor of a holistic and individualistic theory of health and illness are presented. This implies a focus on the ability of the individual to realize his or her "vital goals." A holistic and individualistic health concept may have a reinforcing effect on the individualized approach in personalized nutrition. It allows focus on individual health premises and related dietary means of health promotion, as well as an individualized perspective on the objectives of health promotion. An individualistic notion of health also indicates that people with high levels of vital goals benefit more easily. To reach beyond these groups is likely difficult. This potential injustice should be balanced with global preventive medical programs.

Standard circumstances and vital goals: comments on Venkatapuram's critique.

This article is a reply to Venkatapuram's critique in his article Health, Vital Goals, Capabilities, this volume. I take issue mainly with three critical points put forward by Venkatapuram with regard to my theory of health. (1) I deny that the contents of my vital goals are relative to each community or context, as Venkatapuram claims. There is no conceptual connection at all between standard circumstances and vital goals, as I understand these concepts. (2) Venkatapuram notes that I stop short of filling the framework of vital goals with any content and thereby make my concept of health less concrete. I reply that some vital goals are indeed universal, viz. the ones which are necessary conditions for survival. Many other vital goals are individual and cannot therefore be included in a universal list. (3) Venkatapuram claims that my definition of vital goals is too broad, since it entails that some persons without any disease can be regarded as ill. However, in my understanding health is a relational concept from a state of complete health to a state of maximal illness. In this framework, a minor reduction of a state of complete health does not entail illness. This article also contains a comparison between my theory of health and Martha Nussbaum's theory of capabilities for dignity.

Policy and practice of work ability: a negotiation of responsibility in organizing return to work.

PURPOSE: In welfare policy and practical work it is unclear what the concept of work ability involves and assessments may be different among involved actors, partly due to a lack of theoretical research in relation to regulations and practice. Based on theoretical and legal aspects of work ability the aim of the study is to analyze stakeholders' perspectives on work ability in local practice by studying multi-stakeholder meetings. METHODS: The material comprises nine digitally recorded multi-stakeholder meetings. Apart from the sick-listed individual, representatives from the public Social Insurance Agency, health care, employers, public employment service and the union participated in the meeting. The material was analyzed using qualitative content analysis. RESULTS: Three perspectives on work ability were identified: a medical perspective, a workplace perspective and a regulatory perspective. The meetings developed into negotiations of responsibility concerning workplace adjustments, rehabilitation efforts and financial support. Medical assessments served as objective expert statements to legitimize stakeholders' perspectives on work ability and return to work. CONCLUSIONS: Although the formal goal of the status meeting was to facilitate stakeholder collaboration, the results demonstrates an unequal distribution of power among cooperating actors where the employers had the "trump card" due to their possibilities to offer workplace adjustments. The employer perspective often determined whether or not persons could return to work and if they had work ability.

Health and welfare in animals and humans.

This paper contains a brief comparative analysis of some philosophical and scientific discourses on human and animal health and welfare, focusing mainly on the welfare of sentient animals. The paper sets forth two kinds of proposals for the analysis of animal welfare which do not appear in the contemporary philosophical discussion of human welfare, viz. the coping theory of welfare and the theory of welfare in terms of natural behaviour. These proposals are scrutinized in the light of some similar theories dealing with human health and quality of life. My conclusion is that the coping theory and the natural behaviour theory are not in themselves adequate for the characterization of welfare, either for humans or for sentient animals. I contend, finally, that, in the light of the previous discussion, there are good arguments for a particular set of analyses of both animal and human welfare, viz. the ones that are based on the notions of preference satisfaction and positive subjective experiences.

The association of immigrant- and non-immigrant-specific factors with mental ill health among immigrants in Sweden.

BACKGROUND: It has often been shown that immigrants are particularly at risk for mental ill health. The aim of the study was to investigate the association of immigrant- and non-immigrant-specific factors with mental ill health within a diverse immigrant population. METHOD: An extensive questionnaire was sent out to a stratified random sample of three immigrant populations from Finland, Iraq and Iran. The 720 respondents completed a Swedish, Arabic or Farsi (Persian) version of the questionnaire including the WHO (10) Well-Being Index and the HSCL-25. RESULTS: The results indicate that mental ill health among immigrants is independently associated with non-immigrant-specific factors (i.e. high number of types of traumatic episodes, divorced/widowed, poor social network, economic insecurity and being female) and immigrant-specific factors (i.e. low level of sociocultural adaptation). These results were obtained regardless of whether mental ill health was operationalized as low subjective well-being or a high symptom level of anxiety/depression. CONCLUSIONS: These findings support the notion that mental ill health among immigrants is a multi-faceted phenomenon that needs to be tackled within a wide range of sectors - e.g. the healthcare system, the social service sector and, of course, the political arena.

Dignity as experienced by nursing home staff.

Aims and objectives. To explore nursing home staff members' experiences of what dignity in end of life care means to older people and to themselves. Background. Dignity is a concept often used in end-of-life care, but its meaning is rarely clarified. Design. Qualitative descriptive study. Methods. Content analysis. This study is based on interviews with 21 staff members in four different nursing homes in Sweden. Findings. The results show that staff members balanced between providing for the older person's physical needs while wishing to be able to deliver a 'deeper' level of care. The older people's dignity is presented in the main theme: Feeling trust - Showing respect. The staff members' dignity is presented in the main theme: Maintaining self-respect - Being shown respect. Threats to dignity are presented in the main theme: conflicts between the ideal and the reality. Conclusions. The results reveal that nursing home staff members deal with a moral conflict between what they are able to deliver and what they would like to provide in the care of older people. Relevance to clinical practice. To promote older people's dignity, there is a need to take account of staff members' work situation. Supervision and continuous education could be one way of achieving this.

Three nursing home residents speak about meaning at the end of life.

This article provides a deeper understanding of how meaning can be created in everyday life at a nursing home. It is based on a primary study concerning dignity involving 12 older people living in two nursing homes in Sweden. A secondary analysis was carried out on data obtained from three of the primary participants interviewed over a period of time (18-24 months), with a total of 12 interviews carried out using an inductive hermeneutic approach. The study reveals that sources of meaning were created by having a sense of: physical capability, cognitive capability, being needed, and belonging. Meaning was created through inner dialogue, communication and relationships with others. A second finding is that the experience of meaning can sometimes be hard to realize.

Ethical and methodological issues in interviewing persons with dementia.

People with dementia have previously not been active participants in research, with ethical difficulties often being cited as the reason for this. A wider inclusion of people with dementia in research raises several ethical and methodological challenges. This article adds to the emerging debate by reflecting on the ethical and methodological issues raised during an interview study involving people with dementia and their spouses. The study sought to explore the impact of living with dementia. We argue that there is support for the inclusion of people with dementia in research and that the benefits of participation usually far outweigh the risks, particularly when a ;safe context' has been created. The role of gatekeepers as potentially responsible for excluding people with dementia needs further consideration, with particular reference to the appropriateness of viewing consent as a primarily cognitive, universalistic and exclusionary event as opposed to a more particularistic, inclusive and context relevant process.

The concepts of health and illness revisited.

Contemporary philosophy of health has been quite focused on the problem of determining the nature of the concepts of health, illness and disease from a scientific point of view. Some theorists claim and argue that these concepts are value-free and descriptive in the same sense as the concepts of atom, metal and rain are value-free and descriptive. To say that a person has a certain disease or that he or she is unhealthy is thus to objectively describe this person. On the other hand it certainly does not preclude an additional evaluation of the state of affairs as undesirable or bad. The basic scientific description and the evaluation are, however, two independent matters, according to this kind of theory. Other philosophers claim that the concept of health, together with the other medical concepts, is essentially value-laden. To establish that a person is healthy does not just entail some objective inspection and measurement. It presupposes also an evaluation of the general state of the person. A statement that he or she is healthy does not merely imply certain scientific facts regarding the person's body or mind but implies also a (positive) evaluation of the person's bodily and mental state. My task in this paper will be, first, to present the two principal rival types of theories and present what I take to be the main kind of reasoning by which we could assess these theories, and second, to present a deeper characterization of the principal rival theories of health and illness.

On health, ability and activity: comments on some basic notions in the ICF.

PURPOSE: The purpose of this article is to highlight and at the same time criticize the holistic view of health expressed in the "International Classification of Functioning, Disability and Health (ICF)". Particular attention will be paid to the idea suggested in the ICF that not only the ability to perform a specified action but also its actual performance is included in the person's health. My argument intends to show that this is an untenable position. METHOD: The theoretical platform of this paper is philosophical action theory. My argument makes particular use of the distinctions between ability, opportunity, activity and will. My analysis also uses some insights from the contemporary philosophical discussion of health concepts. CONCLUSIONS: Ability (or capacity) and its opposite disability (or incapacity) are essential ingredients in the implicit philosophy of health of the ICF. However, the ICF also puts an emphasis on the actual performance of actions. This is entailed by the performance qualifier that is included in the ICF. I give some arguments for questioning the relevance of this qualifier if it is intended to have a place in the concept of health or have a general function for decisions in health care or rehabilitation. Instead I suggest the introduction of an opportunity qualifier, which could fulfill some of the purposes intended for the performance qualifier.

Views on dignity of elderly nursing home residents.

Discussion about a dignified death has almost exclusively been applied to palliative care and people dying of cancer. As populations are getting older in the western world and living with chronic illnesses affecting their everyday lives, it is relevant to broaden the definition of palliative care to include other groups of people. The aim of the study was to explore the views on dignity at the end of life of 12 elderly people living in two nursing homes in Sweden. A hermeneutic approach was used to interpret the material, which was gathered during semi-structured interviews. A total of 39 interviews were transcribed. The analysis revealed three themes: (1) the unrecognizable body; (2) fragility and dependency; and (3) inner strength and a sense of coherence.

The varieties of dignity.

As a part of a research project on Dignity and Older Europeans (Fifth Framework (Quality of Life) Programme3) I explore in this paper a set of notions of human dignity. The general concept of dignity is introduced and characterized as a position on a value scale and it is further specified through its relations to the notions of right, respect and self-respect. I present four kinds of dignity and spell out their differences: the dignity of merit, the dignity of moral or existential stature, the dignity of identity and the universal human dignity (Menschenwürde). Menschenwürde pertains to all human beings to the same extent and cannot be lost as long as the persons exist. The dignity of merit depends on social rank and position. There are many species of this kind of dignity and it is very unevenly distributed among human beings. The dignity of merit exists in degrees and it can come and go. The dignity of moral stature is the result of the moral deeds of the subject; likewise it can be reduced or lost through his or her immoral deeds. This kind of dignity is tied to the idea of a dignified character and of dignity as a virtue. The dignity of moral stature is a dignity of degree and it is also unevenly distributed. The dignity of identity is tied to the integrity of the subject's body and mind, and in many instances, although not always, also dependent on the subject's self-image. This dignity can come and go as a result of the deeds of fellow human beings and also as a result of changes in the subject's body and mind.

The international classification of functioning, disability and health and action theory

In this study a conceptual framework, which is central to philosophical action theory was introduced. The purpose was to show that this framework is useful for the analysis of crucial concepts in the area of disabilities and handicaps. The recently introduced International Classification of Functioning, Disability and Health (ICF), published by the World Health Organization (WHO) was used as a case of illustration. By the analysis of this classification according to the philosophical action theory, an important complication was derived from the way we communicate about disabilities. We often say simply that a person is unable to do this or that without considering the external factors or of the existence or non-existence of an opportunity. If these factors and the opportunities were considered, in most cases one surely would produce an opportunity that could compensate all these people. About the notion of disability and participation introduced by ICF, two distinct ontological categories have been formed. However, in the final version of the ICF these categories were in a sense amalgamated into one ontological category covering the same domain. To resolve this basic confusion of ICF and in order to uniform category activity/participation the action category was proposed to replace category activity/participation and to introduce the category opportunity as a supplementary qualifier...

Este estudo tratou da introdução de um modelo conceitual, central na teoria filosófica da ação, a fim de mostrar que este modelo é usável para a análise de conceitos cruciais na área de incapacidade e desvantagem. A título de ilustração foi usada a Classificação Internacional de Funcionamento, Incapacidade e Saúde, publicada recentemente pela Organização Mundial da Saúde (OMS). Analisando esta classificação a luz da Teoria Filosófica da Ação, surgiu uma importante complicação relacionada ao modo como as incapacidades são comunicadas. Neste sentido, nós simplesmente dizemos que uma pessoa é incapaz de fazer isto ou aquilo, desconsiderando os fatores externos ou existência ou não de oportunidades. Se estes fatores e as oportunidades fossem considerados certamente, na maioria dos casos, haveria uma compensação para estas pessoas. Sobre a noção de atividade e participação introduzida na Classificação, mesmo sendo concebidas como duas categorias ontológicas distintas, elas foram, de certa forma, amalgamadas em uma categoria ontológica cobrindo um mesmo domínio. Para resolver a confusão básica dessa Classificação e para uniformizar a categoria atividade/participação foi proposta a categoria ação para substituí-las e introduzida a categoria oportunidade como um qualificador suplementar...

Se trata de un estudio sobre la introducción de un modelo conceptual, fundamentado en la Teoría Filosófica de la Acción, con el fin de mostrar que este modelo es válido para elanálisis de conceptos cruciales en el área de incapacidad y desventajas. A título de ilustración fue usada la Clasificación Internacional de Funcionamiento, Incapacidad y Salud, publicada recientemente por la Organización Mundial de la Salud (OMS). Analisando esta clasificación según la Teoría Filosófica de la Acción, surgió una importante complicación relacionada al modo como las incapacidades son comunicadas. En este sentido, nosotros decimos simplemente que una persona es incapáz de hacer esto o aquello, desconsiderando los factores externos y la existencia o no de oportunidades. Si estos factores y las oportunidades ciertamente fuesen considerados, en la mayoría de los casos, habría una compensación para estas personas. Sobre la noción de la actividad y la participación introducida en la Clasificación, aún siendo consideradas todavía como dos categorias ontológicas distintas, ellas fueron, de cierta forma, ligadas a una categoría ontológica cubriendo un mismo dominio. Para resolver la confusión básica de esa Clasificación y para uniformizar la categoría actividad/participación fue propuesta la categoría acción para substituirlas e introducir la categoría de oportunidad como un calificador suplementar...

Action theory, disability and ICF.

PURPOSE: The purpose of this paper is to make a critical analysis of the conceptual platform of the recently introduced International Classification of Functioning, Disability and Health (ICF). Special attention is paid to the suggested definitions of the concepts of activity and participation. My argument intends to show that these definitions are not coherent. METHOD: The theoretical platform of this paper is philosophical action theory. My argument makes particular use of the distinction between capacity and opportunity and shows that both concepts are applicable to all actions. Capacity and opportunity are distinguished from the actual performance of actions. The latter presupposes the existence of a will. On this conceptual basis follows an analysis of the distinction between activity and participation as conceived by the WHO in ICF. CONCLUSIONS: The main conclusion of my reasoning is that the notions of activity and participation in ICF partly rest on confusion between capacity for action and the actual performance of an action. If my conclusion is sound this has far-reaching consequences for the application of the ICF in the practice of rehabilitation. My diagnosis therefore is that the conceptual framework of ICF is in great need of a strict action--theoretic reconstruction.