Siðfræði lífs og dauða: changes in the book's content – and the philosopher's thinking?

^{Svava Sigurðardóttir}

Faculty of Philosophy, History and Archeology, University of Iceland, svs43@hi.is

Over the last four decades, Vilhjálmur Árnason¹ – currently professor emeritus in philosophy – has been at the forefront in the academic fields of moral and political philosophy, and medical- and bioethics in Iceland. His research and in-depth understanding of the ethical aspects of medicine and life sciences in Icelandic society are demonstrated by his extensive written work on these issues. The first edition of Vilhjálmur's book Siðfræði lífs og dauða (e. Ethics of life and death) was published in 1993 by Háskólaútgáfan at the University of Iceland. It is a comprehensive book on ethical issues related to healthcare, research, and public health. A second and improved edition was published in 2003, in addition to a German version in 2004. The third and latest edition was published in August 2023 and takes into account developments in the aforementioned fields in recent years, and as before, with a particular focus on Iceland.

 

The contents of this influential book will be discussed in this article, with special emphasis on comparing current subjects with previous editions. Moreover, the article considers if and how Vilhjálmur's thinking and perspective have changed over the years.

 

Keywords: respect for the human being, human dignity, relations, dialogue, consultation

 

Introduction

The first edition of Vilhjálmur Árnason's book Siðfræði lífs og dauða was published in 1993 by Háskólaútgáfan at the University of Iceland. It is a comprehensive book in Icelandic about ethical issues in medical practice, research in the healthcare sector, and health policy. The book was nominated for the Icelandic Literature Prize in 1993 and won the Special Award for academic work of outstanding quality, awarded annually by the Association of Icelandic Non-fiction Writers. The book consists of six chapters and as the title implies, it ranges from topics at the beginning of life, such as reproduction, to end-of-life issues, such as euthanasia and death. There are also more general reflections on moral reasoning, and in his approach Vilhjálmur succeeds in connecting theoretical and practical ethics through real-life situations from Icelandic healthcare and society (Vilhjálmur 1993).

 

Following a German translation of the book a decade later, Vilhjálmur made improvements to the Icelandic version, and a second edition was published by Háskólaútgáfan in 2003 (Vilhjálmur 2003). The refinements are mainly related to new topics, such as biobank and genetic research, that became prominent in moral debate after the publication of the first edition of the book. Additional issues discussed in more detail in this second edition include artificial insemination, in vitro fertilization, embryo research, and eugenics (Vilhjálmur 2003: 13).

 

A third extended and improved version was published in 2023 by Háskólaútgáfan and Siðfræðistofnun, thirty years after the printing of the first one. In this edition, Vilhjálmur uses the same theoretical foundation, criteria, and methodology to extend and improve the discussion on ethics and ethical decision-making. The content in the latest edition is updated at various points, reflecting developments that have taken place in areas such as technology and healthcare over the past twenty years (Vilhjálmur 2023).

 

The book has been used in teaching academic courses on ethics of healthcare and bioethics in Iceland, but it is also accessible to ordinary citizens. The book appeals to Icelanders since the author uses Iceland in his analyses, examining activities in the Icelandic healthcare sector, healthcare providers' code of conduct, and other ethical considerations related to healthcare in the Icelandic society.

 

This article will analyze and discuss the main content of the third edition of the book and compare it with previous editions. Firstly, the central idea and ideal, which appears in all versions of the book, will be presented. Secondly, the main subject and changes in the six chapters will be outlined. Finally, it will be addressed if and how Vilhjálmur's own thinking and perspective have changed over the years.

 

The central idea and ideal of Siðfræði lífs og dauða

The subtitles of the three publications of the book indicate possible changes over time. The subtitle of the first and second editions, which focus on issues related to medical practice and health policy, was changed from Difficult decisions in healthcare to Healthcare, research, public health in the third edition. This aligns with the growth in population health and the increased emphasis on healthcare research in recent decades, as well as the stronger connections between these fields. Vilhjálmur mentions himself in the third edition's preface that he adjusts arguments to changes in his thoughts, since he first wrote the book thirty years ago, indicating a change of his thinking (Vilhjálmur 2023: 14).

 

The central idea of the books is that ‘both moral reasoning and moral communication are best explained in a dialogue between persons, about the issues being dealt with’ (Vilhjálmur 2023: 20), and the form of moral discourse is ‘a dialogue between people in specific situations’ (Vilhjálmur 2023: 20). Moreover, according to Vilhjálmur the dialogue is both a method (í. aðferð) for discussing and justifying difficult decisions, and a mode of interaction (í. samveruháttur), which he describes as ‘a precondition for good communication’ (Vilhjálmur 2023: 21). He refers to writings of Aristotle in The Politics who said, regarding human communication skills, that ‘it is a characteristic of man that he alone has any sense of good and evil, of just and unjust, and the like, and the association of living beings who have this sense make a family and a state’ (Aristotle, 1253a). Vilhjálmur further states that ‘[e]thics should not assume that the form of moral discourse is people's monologues with themselves and the code of conduct’ (Vilhjálmur 2023: 20) but it is rather a dialogue in specific situations. Here the author describes the dynamic form of moral discussion.

 

The main theme of moral reasoning in dialogue and communication runs like a thread throughout the book in all three editions, along with Vilhjálmur's ideal, which is respect for the human being. This implies that ‘human relations should be characterized by mutual respect’ (Vilhjálmur 2023: 28), and the respect for the human being is ‘a requirement of moral equality’ (Vilhjálmur 2023: 28). The author states that the main objective of the book is to consider how this ideal can be taken into account by healthcare providers in their professional work (Vilhjálmur 2023: 28). Vilhjálmur is influenced by Immanuel Kant in his arguments for the respect for the human being. That is, the principle never to treat oneself or anyone else ‘simply as a means, but always at the same time as an end’ (Vilhjálmur 2023: 29), and to respect the person's moral judgement and autonomy (Vilhjálmur 2023: 29). The author manages to deliver these important elements clearly and respectfully, in a meticulous and caring way throughout the books. He also highlights other moral interests of human beings, as his ideal involves more than respecting the person's autonomy. Therefore, he talks about respect for the human being (í. manneskjunni), which encompasses a broader concept than just the individual and goes beyond merely respecting their autonomy. This is then used in different contexts as respect for the patient, research participant or the citizen, but always with the same main moral requirements.

 

In explaining the factors included in the idea of moral respect, Vilhjálmur states that his understanding is partly affected by Kant's ideas as presented in Metaphysik der Sitten: mutual love and emotional connection, which requires closeness and care for welfare, and respect for the will of the person, which requires distance. This interplay of proximity and giving a person space is crucial in interpersonal relationships, and Vilhjálmur considers ‘the requirement to respect the person's welfare and her autonomy as two interwoven elements of showing people moral respect’ (Vilhjálmur 2023: 30). In the third edition the use of words is slightly changed from previous versions, and thus the meaning can be interpreted differently. In the first edition welfare and autonomy were mentioned as two sides of respecting the human being (Vilhjálmur 1993: 20), as two elements in the second (Vilhjálmur 2003: 25), and as two interwoven elements in the third edition. The adjustments refer more clearly to the connection of these elements than in the previous two versions, where it is conceivable to choose one side rather than the other.

 

In the first edition, Vilhjálmur describes the two sides as the moral interests of the human being, i.e. ‘to respect her autonomy and judgement [and] to care for her welfare’ (Vilhjálmur 1993: 20), but in the second and third editions, Vilhjálmur adds a third element to his explanation of the factors that together form the human being's moral interests, namely justice. Vilhjálmur's representation of the demand to show people moral respect is as follows (Vilhjálmur 2003: 25; Vilhjálmur 2023: 30):

• to respect a person's autonomy and judgement: the requirement of distance
• to care for a person's welfare: the requirement of closeness
• to treat a person justly: the requirement of impartiality

 

Vilhjálmur explains that these factors, such as respecting the individual‘s autonomy, caring for her welfare, and treating her with justice, are elements that are often in conflict in healthcare, mostly between the patient's autonomy and her welfare. In the second edition of the book the requirement for justice does not appear directly until the last chapter, in the discussion on health policy (Vilhjálmur 2003: 25). However, in the latest version Vilhjálmur specifically notes that justice is an important background factor of all the discussions in the book, even though it is not fully addressed until the last chapter about health policy and public health on a systemic level (Vilhjálmur 2023: 31).

 

This is an example of how in the third edition Vilhjálmur puts more emphasis on justice at an interpersonal level. While considerations of justice were addressed in previous versions of the book, they are more prominently connected to all subjects in the latest edition, not just through the conditions for health policy formulation. Vilhjálmur, for instance, states that the requirement to respect the human being applies to an individual as a member of society rather than an isolated or atomic individual. This perspective demands ‘mutual [shared] responsibility, recognition and trust’ (Vilhjálmur 2023: 33), reflecting essential components of justice for any human.

 

Vilhjálmur thoroughly explores the concept of respecting the human being in each edition. In the context of the therapeutic relationship between a healthcare provider and a patient, he develops a theory of consultation (í. samráð) that incorporates all the requirements of moral respect. This approach is designed to promote mutual responsibility and serve as a middle ground between two extremes: paternalism and strong patient autonomy. Even in instances where certain factors, such as reduced autonomy or increased emphasis on welfare, become more prominent, the patient is still treated with moral respect. Thoughtful communication and consultation are intended to support patients, not least those who are ill or have cognitive impairment (Vilhjálmur 2023: 33).

 

In the first two editions, Vilhjálmur discusses how respect for the human being and the theory of consultation is relational and situational (Vilhjálmur 1993: 23; Vilhjálmur 2003: 28). However, in the latest edition, he provides the term relational autonomy to describe this concept, emphasizing the importance of giving special consideration to those who need assistance with decision-making (Vilhjálmur 2023: 34). This reflects a justice-oriented perspective that highlights solidarity and respect for human dignity – values and perspectives that underpin Vilhjálmur's entire discussion, especially noticeable in the new edition.

Making ethical decisions

In the first three chapters of all editions, Vilhjálmur establishes the foundation for ethical discussion and reasoning. He introduces the book's central idea and ideal, clearly explains key ethical concepts and principles, addresses the moral interests of the individual, explores in brief ethical theories, and outlines role-specific duties, responsibilities, and the requirement of moral respect. The discussion on human dignity and relational autonomy in the new edition further reinforces the core principles of this requirement.

 

The methodology and criteria that Vilhjálmur suggests for ethical evaluation, ethical reasoning, and decision-making in numerous examples and case studies are introduced in all editions. The examples are real-world moral dilemmas and most of them come from everyday situations in Icelandic healthcare. The number of examples in the third edition has increased (Vilhjálmur 2023: 24–26), but the criterion is essentially the same as the one presented thirty years ago (Vilhjálmur 2023: 23).

 

Guiding questions for critical ethical evaluation (Vilhjálmur 2023: 23):

1. What is the ethical problem in the example? Analysis of the situation
2. What moral interests are at stake? Analysis of ethical principles
3. Which code of conduct for health providers applies? Analysis of role-specific duties
4. What solutions can be formulated?
5. How do you justify your decision?

-        What arguments support your decision?

-        What are the arguments against it?

 

The first chapter of all editions lays the foundation for conceptual understanding and the possible application of ethics to ethical decision-making. The main elements (í. innviðir) of morality are presented, such as human dignity, autonomy and welfare, justice and love – moral goods or values necessary for an individual to grow and prosper as a moral being. In the third edition, the author has added that one learns these values through interaction (Vilhjálmur 2023: 48). Other important elements of morality presented in all editions are virtues, moral rules, role-specific duties and rights, conscience and sense of judgement (Vilhjálmur 1993: 39; Vilhjálmur 2003: 44; Vilhjálmur 2023: 48).

 

Vilhjálmur does not use ethical theories in his analysis. However, in the first and second editions, he briefly introduces two categories of ethical theories: consequentialism, where justification of behavior is determined by its consequences, and non-consequentialist theories, where the moral rightness or wrongness of an action derives from its intrinsic properties (Vilhjálmur 1993: 40; Vilhjálmur 2003: 45). In the latest version, a third category is added based on communication, where justification of a behavior is determined in personal interaction. Examples are care ethics with an emphasis on relations, solidarity, and situational sensitivity, and discourse ethics (í. Samræðusiðfræði), which emphasizes willingness to communicate, communication skills, and the conditions for fair procedure in reasoning (Vilhjálmur 2023: 49).

 

Vilhjálmur highlights the main elements of morality that each theory emphasizes, showing how the theories can apply to different situations, which can matter when analyzing an ethical problem, and making an ethical decision. Individual ethical theories are not in the foreground of his ethical discussion, but he refers to them where appropriate, and most of them are to some extent involved in the analysis of the topics.

 

The centrality of context

Ethical decision-making is thoroughly presented by Vilhjálmur and he divides it into two categories, a ‘[d]ecision about how we want to live our life in general [and] a [d]ecision about how we should act in unique situations’ (Vilhjálmur 1993: 52; Vilhjálmur 2003: 56; Vilhjálmur 2023: 59). He briefly explains the first, which relates to the person herself, her character, maturity, and virtues, and bases the discussion primarily on virtue ethics. Vilhjálmur argues that a decision of this kind can be a precondition for a person to deal well with particular situations. Thus, he appeals to virtues and the character of the healthcare providers themselves, and in the latest edition, specific examples of professional virtues are presented. For the caring professionals he makes special note of the Icelandic virtue of nærgætni, being careful in the nearness of others (Vilhjálmur 2023: 48).

The second category of ethical decision-making involves thinking and reasoning about specific ethical issues in unique situations, to find out what should be done in special circumstances, and according to Vilhjálmur, ethical thinking mainly includes three interrelated factors, which he describes with a diagram (Vilhjálmur 2023: 62):

 

In Vilhjálmur's methodology, the first step is an assessment of the circumstances and the facts of the specific situation. Sometimes the facts are not clear and need to be clarified in order to highlight the ethical problem. This is because an understanding of the unique situation is crucial in the evaluation process, where moral interests and ethical principles related to the specific situations are assessed. A key question to answer is what would be appropriate to do in the particular circumstances evaluated, and in the critical analysis one's judgment and sense for the situation matter, along with the ability to know one's role and role-specific duties (Vilhjálmur 2023: 62). This reflects the aforementioned guiding questions for critical ethical evaluation.

 
In the new edition, a few additional questions are summarized, with reference to Øyvind Kvalnes discussion of elements of decision in his navigation wheel (Kvalnes 2019: 49–69): 1) Do we know all the facts relevant to the decision?; 2) Can I justify the decision based on ethical interests/values?; 3) Is the decision compatible with my role-specific duties and ethical principles/code of conduct? 4) Is the decision legal? 5) Is the decision compatible with the values of the institution? 5) Can we make the decision publicly or must it be kept secret? (Vilhjálmur 2023: 62).

In Vilhjálmur's criterion and methodology for ethical decision-making of specific situations, communication, dialogue, consultation and respect for the human being are the key factors. These criteria are not to be used as a rigid or technical tool: it requires sensitivity to unique situations, which sometimes leads to the inevitable need to make an exception from a generally accepted, i.e., prima facie moral rule or role-specific duty (Vilhjálmur 2023: 64–67). Vilhjálmur takes reasoning for such exceptions to be the main task of applied ethics. A situational sensitivity is a peculiarity in Vilhjálmur's entire moral discussion in all editions of the book, and in his contextualization he connects Kant's categorical obligations and Aristotle's situational factor of actions. In a nutshell: ‘Ethical principles without situational judgment are empty, but moral intuition without knowledge of general duties and values is blind’ (Vilhjálmur 2023: 51).

Professional's role-specific duties

The second chapter of all editions covers in detail professional role-specific duties and responsibilities, patients' rights, the role of communication, and the relationship between patients and healthcare providers. Vilhjálmur explains the difference between positive and negative duties, and positive and negative rights, related to professional work, and the personal moral interests the duties protect, for instance as stated in code of conduct. The importance of the duty of confidentiality is thoroughly discussed, but also potential exceptions in well-defined and morally justified situations, such as when the public good, interests of innocent individuals, and even interests of the individual himself are at stake. In this analysis he employs, among other things, John Stuart Mill's principle of liberty and arguments for its limitations (Vilhjálmur 2023: 69–122).

 

Vilhjálmur emphasizes that the person's autonomy is always tied to certain situations. The claim for patient autonomy in the therapeutic relationship is increasingly influenced by relational ideas in the latest edition and it is now first specifically stated as relational autonomy. Moreover, according to Vilhjálmur, the requirement of respecting autonomy should be primarily understood negatively in the therapeutic relationship, which means that the professional should not decide for the person without her knowledge and will and has a duty to inform about alternatives (Vilhjálmur 2023: 114). As stated by the author, that kind of relationship is characterized by mutual trust, shared responsibility, consultation and dialogue, and part of the person's autonomy consists in developing reasoned valuation, which can take place in a dialogue between a healthcare provider and a patient (Vilhjálmur 2023: 117). The author is critical of consumerist ideas of patient autonomy and in the new edition there is more emphasis than before on professional resistance to wishes of patients that are contrary to what professional can responsibly defend.

Important factors for decision-making

Chapter Three discusses decisions regarding treatment and research, including informed and uncoerced consent. It outlines the prerequisites for understanding and autonomy of the consenting individual, which are consistent across all editions: i) providing sufficient information for decision-making; ii) ensuring the individual understands the information and can make a decision; iii) ensuring the consent is uncoerced and voluntary; iv) confirming the individual is competent to give consent (Vilhjálmur 2003: 132; Vilhjálmur 2023: 124).

 

The last item, competence, is discussed in detail, including the conditions for assessing a person's competence and how to respect the moral interests of those who cannot make their own decisions. In those situations, Vilhjálmur refers, among other things, to relational autonomy and shared responsibility. In the latest edition, he has added ‘and with others’ (Vilhjálmur 2023: 136) to the subtitle of ‘[d]esicions for others’ (Vilhjálmur 2023: 136), which reflects relational ideas. In this context in the new edition he talks about sensitive situations, such as in relation to treatment of people with dementia, patients in compulsory detention, and various decisions regarding children.

 

Vilhjálmur has revised the discussion about informed consent and ‘a one-sided emphasis on the importance of informing patients and research participants in detail, has given way for the claim to protect them from deception, hype, and coercion’ (Vilhjálmur 2023: 15). The earlier mentioned prerequisites for informed consent are the same, but he distinguishes between a strong and a weak duty to inform. By a strong duty he means that healthcare providers must inform the person in detail for her to understand the issues at stake and make an informed decision. He argues that in this sense the duty to inform is ‘situational because it is a matter of judgment when it is useful in healthcare’ (Vilhjálmur 2023: 130). Weak understanding refers, on the other hand, to avoiding deception, hype and coercion, and ‘in that sense the duty to inform is absolute, because it includes the moral requirement for respecting the person’ (Vilhjálmur 2023: 130).

 

Vilhjálmur discusses this in a clinical context, but this understanding is no less important in scientific research, with the aim of showing respect for the participants and not to deceive. Issues in research ethics are particularly considered in the second and third editions of the book. These editions present criteria that set limits on the pursuit of scientific knowledge, based on the moral interests of research participants. These are classified into several main provisions: i) that protect autonomy and concern the consent of research participants; ii) that concern the welfare of the participants, connected to the risk of participating; iii) concerning justice requirements to protect those who are vulnerable (this provision is new and has been added to the third edition); iv) about professional responsibility of those who conduct the research; v) about confidentiality and privacy, as a premise for trust and confidence (Vilhjálmur 2003: 167; Vilhjálmur 2023: 166).

Narrow and broad views of research

A new angle in the discussion on scientific research appears in the latest edition of the book, when Vilhjálmur points to a possible narrow view of the relationship between justice and research in research ethics. He refers to Alex J. London's book For the Common Good: Philosophical Foundations of Research Ethics (2022) in his reflections on the social role of research and maintains that ‘research has yielded great social benefits that have enabled individuals to better plan their lives’ (Vilhjálmur 2023: 174). However, Vilhjálmur adds a precaution to his thoughts, and the assumptions are that research should provide information ‘that enables the institutions in the society to protect basic interests of citizens [and] in this way, research connects to the aim of a just society’ (Vilhjálmur 2023: 174). He further notes that ‘this vision of a social role of research is increasingly important in a changing research environment where entire nations have become research subjects [but] it is essential from the perspective of justice that the research is for the common good, and that includes respecting the fundamental interests of every individual’ (Vilhjálmur 2023: 175). In this broad view of research for the common good, reciprocity is emphasized, integrating both collective and individual interests.

 

Chapter Three also covers topics related to biobanks, genomic research, and data-driven research. These topics have changed considerably between editions parallel to developments in genomics and post-genomics, following the completion of the Human Genome Project. New issues are addressed, such as return of biobank results, personalized medicine and counseling, translational medicine, and genetic engineering and, where relevant, connected to Icelandic circumstances (Vilhjálmur 2023: 175–192). Vilhjálmur highlights the requirement for respecting the human being as before to ‘protect her autonomy and welfare and ensure the interest of those who are vulnerable’ (Vilhjálmur 2023: 175), reflecting the perspective of justice. In the latest edition, he uses the wording protect her autonomy in this context, instead of respecting her autonomy and judgement. This may refer to the fact that the moral interest of autonomy is not always taken into consideration in the scientific and technological changes that take place in the aforementioned fields, and some individuals are particularly vulnerable in such situations, for example those who are unable to take care of their interests.

Beginning and end of life

In the following three chapters, the discussion is related to special subjects connected to healthcare. Chapter Four deals with issues concerning the beginning of life, such as reproductive freedom, assisted reproduction, embryo research, the moral status of a fetus, and recent legislation in Iceland about the termination of pregnancy. In the new edition, there is an improved discussion about fetal screening and fetal diagnosis, reflecting advances in science and technology, and there is an increased awareness about the status of disabled people and eugenics (Vilhjálmur 2023: 193–254). Vilhjálmur outlines three different views on the topic – liberal, conservative, and moderate – and presents the precautionary principle as a responsible premise when dealing with fundamental elements of life, such as in embryo research (Vilhjálmur 2023: 202–203), thus showing a moderate attitude.

 

End of life issues are discussed in Chapter Five, for example the topics of brain death, organ transplantation, the right to refuse treatment, palliative care, and euthanasia. Recent changes in Icelandic legislation on organ removal for organ transplantation are introduced in the latest edition and the main ones are presumed consent of a deceased person unless the person, or a close relative, has expressed her opposition (Vilhjálmur 2023: 260–261). The discussion on euthanasia is more detailed and improved in the new version, based on the experiences of countries that have legalized euthanasia, and Vilhjálmur's view appears as moderate and between two extremes, as indicated by the following quote: ‘the problem is to navigate the narrow path that lies between taking unjustified actions that prevent the patient from dying and taking unjustified actions that have the direct aim of killing the patient’ (Vilhjálmur 2023: 286).

Public health ethics and health policy

The main change in Chapter Six in the third edition is a discussion about public health ethics reflecting the growth of the field in recent years, and new challenges, such as infection prevention following the Covid-19 pandemic that lately swept across the globe. The concept of health is defined and Vilhjálmur distinguishes between health (í. heilbrigði) and being healthy (í. heilsa). The former refers ‘to normal bodily functions of the species that can be objectively described’ (Vilhjálmur 2023: 306) thus a narrow view of health, and the latter ‘more to individual's own experience of being healthy or having a disease’ (Vilhjálmur 2023: 306), which refers to a phenomenological and existential context.

 

Health policy and the social and political project to formulate a just health policy is discussed, and Vilhjálmur sets forth criteria, both substantive ethical criteria (í. efnisleg viðmið) and procedural criteria (í. málsmeðferð) for fair decisions about health policy and prioritization (Vilhjálmur 2023: 310–314). In Vilhjálmur's conceptualization of a just health policy, he draws upon Norman Daniels's account inspired by John Rawls's theory of justice, and the veil of ignorance related to equal respect for people, moral reciprocity, fairness, and shared responsibility (Vilhjálmur 2023: 325). He also builds on the discourse theory of democracy of Jürgen Habermas, e.g. regarding the contextualization of the connection of the individual's and society's interests, to claim that ‘it is not possible to protect the rights of the individual without also protecting the welfare of the society to which he belongs’ (Vilhjálmur 2023: 328). This relates to prioritization in a welfare system. In this context, the ideal of moral respect is fleshed out through demands for the democratic inclusion of citizens in the formation of health policy and the democratic accountability of the authorities.

Changed thinking and perspective?

The question of whether Vilhjálmur's thinking and perspective have changed over the years can be answered with yes and no, based on the content and discussion in the three editions of Siðfræði lífs og dauða. Vilhjálmur's main idea of the book has not changed, but he explains some issues more clearly in the third edition, such as situational sensitivity, unique situations, and the reasoning for unavoidable exceptions from prima facie rules. An example of this is Vilhjálmur's emphasis on the interwoven moral interests of human beings that are always tied to particular situations. Even though a person's autonomy is reduced in a certain situation or her welfare is increased based on the interests at stake, the person is still morally respected, and a justified exception from a prima facie rule does not entail that the moral principle loses its value.

 

Vilhjálmur's perspective of the moral interest of justice has changed in the third edition. Justice considerations were mainly covered through the discussion about health policy at the systemic level in the first and second editions, but in the latest one the perspective of justice is underlying all discussions. It is more obvious at the interpersonal level, and there it relates to ideas of relational autonomy, solidarity, and human dignity.

 

Apart from the obvious changes in the third edition such as the introduction of new topics, there has been a change of emphasis in Vilhjálmur's thinking about informed and uncoerced consent. Instead of the main aim of informing the person to increase her autonomy, the focus is more on avoiding deception, hype, and coercion, out of respect for the patient or research participant. A new perspective appears in the discussion on the social role of research for the common good, but despite focusing on the social benefits in that context, Vilhjálmur continues to emphasize the respect for the moral interests of the human being.

 

Respect for the human being, dialogue, communication, and consultation are still the key elements running through the book, in the third edition just as in the former versions. However, what is new to Vilhjálmur's perspective is a more precise relational and situational contextualization, like relational autonomy and interwoven elements in the respect for the human being, fleshed out in different relational contexts. Discourse ethics is still one of Vilhjálmur's characteristics in his writings, but he is increasingly under the influence of care ethics and virtue ethics in his discussions. This is more prominently contextualized in relational and situational terms in the third edition, along with an appeal to the virtues and moral judgment of professionals. Additionally, the cautious perspective and moderate stance between extremes evident in earlier versions are maintained.

 

Vilhjálmur's book Siðfræði lífs og dauða is an important contribution to Icelandic society, and the third edition provides a good basis for ethical reasoning and ethical decision-making for solving future challenges in the healthcare sector, in a dialogue in specific situations characterized by mutual respect, based on the central idea and ideal of this comprehensive book.

Notes

¹ In Iceland, the surname – Árnason – is a patronymic and a description rather than a name. Icelanders use and are known by their given name. This practice is followed throughout this article and Vilhjálmur Árnason will be referred to as Vilhjálmur when citing his works.

References