Social Prescribing in National Health Service Primary Care: What Are the Ethical Considerations?

Policy Points Social prescribing is proposed as a way of improving patients' health and well-being by attending to their non-clinical needs. This is done by connecting patients with community assets (typically voluntary or charitable organizations) that provide social and personal support. In the United Kingdom, social prescribing is used to improve patient well-being and reduce use of National Health Service resources. Although social prescribing schemes hold promise, evidence of their effects and effectiveness is sparse. As more information on social prescribing is gathered, it will be important to consider the associated ethical issues for patients, clinicians, link workers, and community assets.

Deservingness put into practice: Constructing the (un)deservingness of migrants in four European countries.

The increased comparative research on perceptions of public welfare deservingness studies the extent to which different subgroups of citizens are deemed worthy or unworthy of receiving help from the welfare state. The concept of deservingness criteria plays a crucial role in this research, as it theorizes a universal heuristic that citizens apply to rank people in terms of their welfare deservingness. Due to the mainly quantitative nature of the research and despite the indisputable progress it has made, the subjective existence and actual application of these deservingness criteria remain a bit of a black box. What criteria of deservingness do citizens actually apply, and how do they apply them? This article opens the black box of welfare deservingness and sheds light on the nature and practice of deservingness criteria. Empirically, the paper explores how the deservingness of immigrants is discussed and established within 20 focus groups conducted in Slovenia, Denmark, UK, and Norway in 2016 with a total of 160 participants. All 20 focus groups discussed the welfare deservingness of immigrants based on similar vignette stimuli. Our analysis shows that (1) deservingness criteria are used both to construct images of target groups and as normative yardsticks; (2) deservingness criteria do not work independently of each other, but rather co-function in specific hybridized discourses; and (3) the moral logic of deservingness is supplemented by alternative moral logics, at least in the case of migrants.

Multi-dimensional approach to end-of-life care: The Welfare Model.

Appropriate and balanced decision-making is sentinel to goal setting and the provision of appropriate clinical care that are attuned to preserving the best interests of the patient. Current family-led decision-making in family-centric societies such as those in Singapore and other countries in East Asia are believed to compromise these objectives in favor of protecting familial interests. Redressing these skewed clinical practices employing autonomy-based patient-centric approaches however have been found wanting in their failure to contend with wider sociocultural considerations that impact care determinations. Evaluation of a number of alternative decision-making frameworks set out to address the shortcomings of prevailing atomistic and family-centric decision-making models within the confines of end-of-life care prove these alternative frameworks to be little better at protecting the best interests of vulnerable patients. As a result, we propose the Welfare Model that we believe is attentive to the relevant socio-culturally significant considerations of a particular case and better meets the needs of end-of-life care goals of preserving the welfare of patients. Employing a multi-professional team evaluation guided by regnant psychosocial, legal, and clinical standards and the prevailing practical and clinical realities of the particular patient's setting the Welfare Model provides a clinically relevant, culturally sensitive, transparent, and evidence-based approach to care determinations.

Stakeholder identities in Britain's neoliberal ethical community: Polish narratives of earned citizenship in the context of the UK's EU referendum.

This article examines the narrative strategies through which Polish migrants in the UK challenge the formal rights of political membership and attempt to redefine the boundaries of 'citizenship' along notions of deservedness. The analysed qualitative data originate from an online survey conducted in the months before the 2016 EU referendum, and the narratives emerge from the open-text answers to two survey questions concerning attitudes towards the referendum and the exclusion of resident EU nationals from the electoral process. The analysis identifies and describes three narrative strategies in reaction to the public discourses surrounding the EU referendum - namely discursive complicity, intergroup hostility and defensive assertiveness - which attempt to redefine the conditions of membership in Britain's 'ethical community' in respect to welfare practices. Examining these processes simultaneously 'from below' and 'from outside' the national political community, the paper argues, can reveal more of the transformation taking place in conceptions of citizenship at the sociological level, and the article aims to identify the contours of a 'neoliberal communitarian citizenship' as internalized by mobile EU citizens.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children.

BACKGROUND: Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents. OBJECTIVES: To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016. SELECTION CRITERIA: Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health. DATA COLLECTION AND ANALYSIS: One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3). MAIN RESULTS: Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems. AUTHORS' CONCLUSIONS: The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

The value of work: Addressing the future of work through the lens of solidarity.

Designing the future of work is crucial to the health and well-being of people and societies. Experts predict that developments such as the advancement of digital technologies, automation, and the movement of manufacturing jobs to low-wage countries will lead to major transformations in the labour market, and some foresee significant job losses. Due to the close relationship between employment and health, major job losses would have significant negative impacts on the health and well-being of individuals and societies. Job losses would also pose a major challenge to solidaristic support within societies because they would negatively affect the recognition of similarities among people, which is vital for solidaristic practice and institutions. To prevent these negative effects, a fundamental redesign of the relationship between work and income is necessary. And for this project to succeed, we need to reconsider of the value of work. Building on definitions of flourishing people and societies, we argue that the value of work should not be determined by the labour market, but according to its importance for society. Using a solidarity-based framework we argue that such a re-valuation of work will help to ensure social cohesion and increase reciprocity in our societies. It will serve as a foundation upon which we can reconfigure the relationship between work and income without risking the loss of social cohesion and solidarity.

Solidarity and care as relational practices.

Many working in bioethics today are engaging in forms of normative interpretation concerning the meaningful contexts of relational agency and institutional structures of power. Using the framework of relational bioethics, this article focuses on two significant social practices that are significant for health policy and public health: the practices of solidarity and the practices of care. The main argument is that the affirming recognition of, and caring attention paid to, persons as moral subjects can politically motivate a society in three respects. The recognition of solidarity and the attention of care can prompt progressive change toward a democratic willingness: (a) to provide for equal respect for rights and dignity; (b) to provide the social resources and services needed for just health and well-being; and (c) to focus its creativity and wealth on the actualization of potential flourishing of each and all. Solidarity is discussed as a morally developmental stance that moves from standing up for another, standing up with another, and standing up as another. Care is discussed as a morally developmental stance that moves from the attentive rehabilitation of another, attentive companionship with and for another, and attentive commitment to another.

Displacement and solidarity: An ethic of place-making.

Drawing on a conception of people as 'ecological subjects', creatures situated in specific social relations, locations, and material environments, I want to emphasize the importance of place and place-making for basing, demonstrating, and forging future solidarity. Solidarity, as I will define it here, involves reaching out through moral imagination and responsive action across social and/or geographic distance and asymmetry to assist other people who are vulnerable, and to advance justice. Contained in the practice of solidarity are two core 'enacted commitments', first, to engaging our moral imaginations and recognizing others in need and, second, to responsive action. Recognizing the suffering of displacement and responding through place-making should follow from even the most simplistic understanding of people as 'implaced'. Recognition, furthermore, that places are created and sustained, transformed, or neglected in ways that foster or perpetuate inequities, including health inequities, generates responsibilities concerning place-making. Place-based interventions, on either count, should be principal and, indeed, prioritized ways of showing solidarity for the vulnerable and promoting justice. Where solidaristic relations do not prevail, place-making can catalyze and nurture them, and over time advance justice. On the moral landscapes of bioethics, the terrain where care and health are or should be at the center of attention, an ethic of place and place-making for those who have been displaced - patients, the elderly, urban populations, and asylum-seekers, for instance - expresses and has rich potential for nurturing bonds of solidarity.

Union's inspiration: Universal health care and the essential partiality of solidarity.

Solidarity is commonly invoked in the justification of public health care. This is understandable, as calls for and appeals to solidarity are effective in the mobilization of unison action and the willingness to incur sacrifices for others. However, the reference to solidarity as a moral notion requires caution, as there is no agreement on the meaning of solidarity. The article argues that the reference to solidarity as a normative notion is relevant to health-related moral claims, but that it does not provide a convincing foundation of claims to universal health care. References to universal solidarity obliterate an important distinction between those moral demands that are founded on principles like justice, recognition, or humanity, and those demands that stem from partisan relations in communities. While there is no 'separate essence' of solidarity that could be referred to in order to argue for the conceptual necessity of solidarity's partiality, some features may reasonably be stipulated as being essential to solidarity with a view to its systematic function within moral philosophy. The normative and motivational force of the ties invoked by solidarity is particularly relevant when basic moral demands are not met, and societies are in need of significant forms of communal relatedness.

Solidarity and the problem of structural injustice in healthcare.

The concept of solidarity has recently come to prominence in the healthcare literature, addressing the motivation for taking seriously the shared vulnerabilities and medical needs of compatriots and for acting to help them meet these needs. In a recent book, Prainsack and Buyx take solidarity as a commitment to bear costs to assist others regarded as similar, with implications for governing health databases, personalized medicine, and organ donation. More broadly, solidarity has been understood normatively to call for 'standing with' or assisting fellow community members and possibly also distant others in regard to their needs, whether for its own sake or in order to realize the demands of justice. I argue here that the understanding of solidarity in the existing bioethics literature is unduly restricted by not sufficiently theorizing the notion of structural (or systemic) injustice and its import for understanding solidarity. Extending traditional conceptions of labor and social movement solidarity, I contrast unitary solidarity within a given group with 'networking solidarities' across groups. I analyze the meaning of structural injustice and its significance for solidarity, including countering institutionally entrenched inequalities and economic exploitation. I then apply this broadened conception to healthcare, discussing structural problems with the U.S. insurance system and the solidarity movements addressing its deficiencies. I analyze some natural disasters and global health challenges that were aggravated by structural injustices, along with the solidarity movements they engendered. Finally, I revisit the questions of governing health databases and of personalized medicine with the enlarged conception of solidarity in view.

Evaluating taboo trade-offs in ecosystems services and human well-being.

Managing ecosystems for multiple ecosystem services and balancing the well-being of diverse stakeholders involves different kinds of trade-offs. Often trade-offs involve noneconomic and difficult-to-evaluate values, such as cultural identity, employment, the well-being of poor people, or particular species or ecosystem structures. Although trade-offs need to be considered for successful environmental management, they are often overlooked in favor of win-wins. Management and policy decisions demand approaches that can explicitly acknowledge and evaluate diverse trade-offs. We identified a diversity of apparent trade-offs in a small-scale tropical fishery when ecological simulations were integrated with participatory assessments of social-ecological system structure and stakeholders' well-being. Despite an apparent win-win between conservation and profitability at the aggregate scale, food production, employment, and well-being of marginalized stakeholders were differentially influenced by management decisions leading to trade-offs. Some of these trade-offs were suggested to be "taboo" trade-offs between morally incommensurable values, such as between profits and the well-being of marginalized women. These were not previously recognized as management issues. Stakeholders explored and deliberated over trade-offs supported by an interactive "toy model" representing key system trade-offs, alongside qualitative narrative scenarios of the future. The concept of taboo trade-offs suggests that psychological bias and social sensitivity may exclude key issues from decision making, which can result in policies that are difficult to implement. Our participatory modeling and scenarios approach has the potential to increase awareness of such trade-offs, promote discussion of what is acceptable, and potentially identify and reduce obstacles to management compliance.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children.

BACKGROUND: Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents. OBJECTIVES: To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016. SELECTION CRITERIA: Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health. DATA COLLECTION AND ANALYSIS: One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3). MAIN RESULTS: Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems. AUTHORS' CONCLUSIONS: The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

Humanity and Social Responsibility, Solidarity, and Social Rights.

This article discusses the suggestion of having the notion of solidarity as the foundational value for welfare scheme reforms. Solidarity is an emerging concept in bioethical deliberations emphasizing the need for value-oriented discussion in revising healthcare structures, and the notion has been contrasted with liberal justice and rights. I suggest that this contrast is unnecessary, flawed, and potentially counterproductive. As necessary as the sense of solidarity is in a society, it is an insufficient concept to secure the goals related to social responsibility. The discussion on solidarity is also based on a questionable sense of nostalgia. Furthermore, solidarity and liberal justice share essential objectives concerning welfare schemes; therefore, the question arises whether the proper comparison should in the first place be within justice and solidarity.

The moral economy of austerity: analysing UK welfare reform.

This paper notes the contemporary emergence of 'morality' in both sociological argument and political rhetoric, and analyses its significance in relation to ongoing UK welfare reforms. It revisits the idea of 'moral economy' and identifies two strands in its contemporary application; that all economies depend on an internal moral schema, and that some external moral evaluation is desirable. UK welfare reform is analysed as an example of the former, with reference to three distinct orientations advanced in the work of Freeden (1996), Laclau (2014), and Lockwood (1996). In this light, the paper then considers challenges to the reform agenda, drawn from third sector and other public sources. It outlines the forms of argument present in these challenges, based respectively on rationality, legality, and morality, which together provide a basis for evaluation of the welfare reforms and for an alternative 'moral economy'.

Global justice, capabilities approach and commercial surrogacy in India.

Inequalities, ineffective governance, unclear surrogacy regulations and unethical practices make India an ideal environment for global injustice in the process of commercial surrogacy. This article aims to apply the 'capabilities approach' to find possibilities of global justice through human fellowship in the context of commercial surrogacy. I draw primarily on my research findings supplemented by other relevant empirical research and documentary films on surrogacy. The paper reveals inequalities and inadequate basic entitlements among surrogate mothers as a consequence of which they are engaged in unjust contracts. Their limited entitlements also limit their opportunities to engage in enriching goals. It is the role of the state to provide all its citizens with basic entitlements and protect their basic human rights. Individuals in India evading their basic duty also contribute to the existing inequalities. Individual responsibilities of the medical practitioners and the intended parents are in question here as they are more inclined towards self-interest rather than commitment towards human fellowship. At the global level, the injustice in transnational commercial surrogacy practices in developing countries calls for an international declaration of women and child rights in third party reproduction with a normative vision of mutual fellowship and human dignity.

Keep your sunny side: a street-level look at homelessness.

This opinion piece considers my personal experiences of poverty, homelessness, loss, and physical disability in relation to recent discussions of social defeat and resistance among permanent supported housing tenants with physical and mental illnesses. By drawing attention to the onslaught of deprivation and humiliation that generally comes with the territory of poverty and homelessness in the United States, I hope to influence the ways in which clinicians, social service providers, and scholars think about specific instances of social defeat and resistance. My basic point is that any specific experience of resistance or defeat cannot be adequately understood in isolation. Rather, such experiences must be understood in relation to individual life histories of defeat and resistance, and to the symbolic and material sources of success and failure available to citizens who occupy a particular section of social space in a given society.

Distributive justice and cognitive enhancement in lower, normal intelligence.

There exists a significant disparity within society between individuals in terms of intelligence. While intelligence varies naturally throughout society, the extent to which this impacts on the life opportunities it affords to each individual is greatly undervalued. Intelligence appears to have a prominent effect over a broad range of social and economic life outcomes. Many key determinants of well-being correlate highly with the results of IQ tests, and other measures of intelligence, and an IQ of 75 is generally accepted as the most important threshold in modern life. The ability to enhance our cognitive capacities offers an exciting opportunity to correct disabling natural variation and inequality in intelligence. Pharmaceutical cognitive enhancers, such as modafinil and methylphenidate, have been shown to have the capacity to enhance cognition in normal, healthy individuals. Perhaps of most relevance is the presence of an 'inverted U effect' for most pharmaceutical cognitive enhancers, whereby the degree of enhancement increases as intelligence levels deviate further below the mean. Although enhancement, including cognitive enhancement, has been much debated recently, we argue that there are egalitarian reasons to enhance individuals with low but normal intelligence. Under egalitarianism, cognitive enhancement has the potential to reduce opportunity inequality and contribute to relative income and welfare equality in the lower, normal intelligence subgroup. Cognitive enhancement use is justifiable under prioritarianism through various means of distribution; selective access to the lower, normal intelligence subgroup, universal access, or paradoxically through access primarily to the average and above average intelligence subgroups. Similarly, an aggregate increase in social well-being is achieved through similar means of distribution under utilitarianism. In addition, the use of cognitive enhancement within the lower, normal intelligence subgroup negates, or at the very least minimises, several common objections to cognitive enhancement. Subsequently, this paper demonstrates that there is a compelling case for cognitive enhancement use in individuals with lower, normal intelligence.

Public goods and procreation.

Procreation is the ultimate public goods problem. Each new child affects the welfare of many other people, and some (but not all) children produce uncompensated value that future people will enjoy. This essay addresses challenges that arise if we think of procreation and parenting as public goods. These include whether individual choices are likely to lead to a socially desirable outcome, and whether changes in laws, social norms, or access to genetic engineering and embryo selection might improve the aggregate outcome of our reproductive choices.

Ethical challenges with welfare technology: a review of the literature.

Demographical changes in high income counties will increase the need of health care services but reduce the number of people to provide them. Welfare technology is launched as an important measure to meet this challenge. As with all types of technologies we must explore its ethical challenges. A literature review reveals that welfare technology is a generic term for a heterogeneous group of technologies and there are few studies documenting their efficacy, effectiveness and efficiency. Many kinds of welfare technology break with the traditional organization of health care. It introduces technology in new areas, such as in private homes, and it provides new functions, e.g. offering social stimuli and entertainment. At the same time welfare technology is developed for groups that traditionally have not been extensive technology users. This raises a series of ethical questions with regard to the development and use of welfare technologies, which are presented in this review. The main challenges identified are: (1) Alienation when advanced technology is used at home, (2) conflicting goals, as welfare technologies have many stakeholders with several ends, (3) respecting confidentiality and privacy when third-party actors are involved, (4) guaranteeing equal access and just distribution, and (5) handling conflicts between instrumental rationality and care in terms of respecting dignity and vulnerability. Addressing these issues is important for developing and implementing welfare technologies in a morally acceptable manner.