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In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions re- garding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare re- sources. A large proportion of doctors in both countries supported including re- sponsibility for illness in prioritization decisions. This finding was more prominent in zero‐sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsi- bility (through patient contracts), and low support for integrating responsibility into co‐payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)—potentially because of the certainty of impact and direct link to ill health. In zero‐sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced—and clear—policy. Such policy should account for the distinctions we draw between responsibility‐sensitive and prog- nostic justifications for deprioritization.

Aims: The major causes of social inequalities in health are found outside of healthcare. However, healthcare can also play a role in maintaining, reducing, or reinforcing inequality. We present and discuss results from a panel study of doctors’ views on whether and how socioeconomic factors should play a role in clinical decision making. Methods: The panel comprised a representative sample of Norwegian doctors, established in 1994. For the current study, the doctors received postal questionnaires in 2008, 2012 and 2016. Data were analysed using descriptive statistics, correlation analysis, factor analysis and mixed models for repeated measurements. Results: The sample sizes were 1072 (65%), 1279 (71%) and 1605 (73%), respectively. The doctors were increasingly positive towards considering socioeconomic factors, and reported giving more time and advice and asking for less pay to compensate for unfavorable socioeconomic factors. General practitioners were more likely to consider socioeconomic factors and changed their practice accordingly compared to other clinicians. The percentage of doctors who agreed that different amounts of resources should be used to obtain similar health effects was high and increased over time. Conclusions: Increasingly more doctors are willing to consider patients’ socioeconomic factors in clinical care. This could be contrary to professional ethics, in which only medical need should count. However, it depends on how ‘need’ is interpreted. As treatment outcomes partly depend on non–medical factors, socioeconomic factors should be considered because they influence patients’ ability to benefit from medical care. Equality requires mitigating factors with negative impacts on health outcomes.

The commentary brings up two topics. The first concerns whether and how a patient’s socioeconomic status (SES) should count in clinical care. We provide a brief summary of Puschel and colleagues’ view and discuss it in relation to other accounts. We share their conclusion; considering SES in clinical care can be justified from a fairness perspective. Yet, we question the claim that this is a new perspective, and argue that the reason for the claim of novelty is an insufficient use of references. This leads to the second topic, which is a discussion of citation practices in philosophical/ethics papers. We describe common deviations from academic standards, and suggest how unfortunate practices can be reduced.

Aktiv dødshjelp er ulovlig i Norge, men et flertall av befolkningen støtter legalisering. Legers holdninger til aktiv dødshjelp ble sist undersøkt i 1993. Har legers holdninger endret seg?To spørreundersøkelser sendt til Legeforskningsinstituttets legepanel i henholdsvis 2014 og 2016 inneholdt spørsmål om aktiv dødshjelp. Svarene ble analysert med deskriptiv statistikk og logistisk regresjonsanalyse.Svarprosenten var henholdsvis 75,0 (2014) og 73,1 (2016). Majoriteten var motstandere av legalisering av aktiv dødshjelp. I 2016-undersøkelsen sa 9,1 % av respondentene seg «svært enig» og 21,5 % «litt enig» i at legeassistert selvmord bør tillates for personer som har «en dødelig sykdom med kort forventet levetid». Yngre og ikke-religiøse var oftere positive til legalisering. I 2014-undersøkelsen svarte 8,6 % at de ville ha vært villige til å utføre legeassistert selvmord hvis dette ble tillatt.Som i 1993 var et flertall av norske leger imot aktiv dødshjelp, men det synes å være flere enn før som støttet legalisering i visse tilfeller. De færreste var selv villige til å utføre aktiv dødshjelp hvis det ble tillatt.

Bakgrunn Aktiv dodshjelp er ulovlig i Norge, men et flertall av befolkningen stotter legalisering. Legers holdninger til aktiv dodshjelp ble sist undersokt i 1993. Har legers holdninger endret seg? Materiale og metode To sporreundersokelser sendt til Legeforskningsinstituttets legepanel i henholdsvis 2014 og 2016 inneholdt sporsmal om aktiv dodshjelp. Svarene ble analysert med deskriptiv statistikk og logistisk regresjonsanalyse. Resultater Svarprosenten var henholdsvis 75,0 (2014) og 73,1 (2016). Majoriteten var motstandere av legalisering av aktiv dodshjelp. I 2016-undersokelsen sa 9,1 % av respondentene seg «svaert enig» og 21,5 % «litt enig» i at legeassistert selvmord bor tillates for personer som har «en dodelig sykdom med kort forventet levetid». Yngre og ikke-religiose var oftere positive til legalisering. I 2014-undersokelsen svarte 8,6 % at de ville ha vaert villige til a utfore legeassistert selvmord hvis dette ble tillatt. Fortolkning Som i 1993 var et flertall av norske leger imot aktiv dodshjelp, men det synes a vaere flere enn for som stottet legalisering i visse tilfeller. De faerreste var selv villige til a utfore aktiv dodshjelp hvis det ble tillatt.

Different countries have adopted different strategies for tackling the challenge of allocating scarce health care resources fairly. Norway is one of the countries that has pioneered the effort to resolve priority setting by using a core set of priority-setting criteria. While the criteria themselves have been subject to extensive debate and numerous revisions, the question of how the criteria have been applied in practice has received less attention. In this paper, we examine how the criteria feature in the decisions and justifications of the Norwegian National Council for Priority Setting in Health Care, which has played an active role in deliberating about health care provision and coverage in Norway. We conducted a comprehensive document analysis, looking at the Council’s decisions about health care allocation as well as the reasons they had provided to justify their decisions. We found that although the Council often made use of the official priority-setting criteria, they did so in an unsystematic and inconsistent manner.

Research in neuroscience traditionally relies on rather small groups that deal with different questions on all levels of neuronal organization. Recent funding initiatives—notably the European “Human Brain Project” (HBP)—aim to promote Big Neuroscience for integrating research and unifying knowledge. This approach is characterized by two aspects: first, by many interacting researchers from various disciplines that deal with heterogeneous data and are accountable to a large public funding source; and second, by a decisive role of information and communication technology (ICT) as an instrument not only to perform but also to structure and guide scientific activities, for example, through simulations in the case of the HBP. We argue that Big Neuroscience comes along with specific ethical challenges. By examining the justification of Big Neuroscience and the role and effects of ICT on social interaction of researchers and knowledge production, we provide suggestions to address these challenges.

ObjectivesDoctors increasingly experience high levels of burnout and loss of engagement. To address this, there is a need to better understand doctors’ work situation. This study explores how doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care.DesignAn exploratory qualitative study design with semistructured individual interviews was chosen. Interviews were transcribed verbatim and analysed by a transdisciplinary research group.SettingThe study focused on a surgical department of a mid-sized hospital in Norway.ParticipantsSeven doctors were interviewed. A purposeful sampling was used with gender and seniority as selection criteria. Three senior doctors (two female, one male) and four in training (three male, one female) were interviewed.ResultsWe found that in order to provide quality care to the patients, individual doctors described ‘stretching themselves’, that is, handling the tensions between quantity and quality, to overcome organisational shortcomings. Experiencing a workplace emphasis on production numbers and budget concerns led to feelings of estrangement among the doctors. Participants reported a shift from serving as trustworthy, autonomous professionals to becoming production workers, where professional identity was threatened. They felt less aligned with workplace values, in addition to experiencing limited management recognition for quality of patient care. Management initiatives to include doctors in development of organisational policies, processes and systems were sparse.ConclusionThe interviewed doctors described their struggle to balance the inherent tension among professional fulfilment, organisational factors and quality of patient care in their everyday work. They communicated how ‘stretching themselves’, to overcome organisational shortcomings, is no longer a feasible strategy without compromising both professional fulfilment and quality of patient care. Managers need to ensure that doctors are involved when developing organisational policies, processes and systems. This is likely to be beneficial for both professional fulfilment and quality of patient care.

In this chapter we discuss how external ethics advisors can contribute to securing fundamental ethical, legal, and social values in neuroscientific research. The context is the role of the work of advisors in the Human Brain Project (HBP), based on experiences from members of the (former) Ethics, Legal and Social Aspects Committee, and the current Ethics Advisory Board. Both committees were/are expected to advise the HBP Board of Directors on ethical, regulatory, social, and philosophical issues raised by research in the HBP. We discuss how size, organization, information, and expectations pose crucial challenges to this kind of research. Based on these considerations, we suggest three overarching normative principles (primum non nocere, weighing benefit and harm, and transparency) and a number of concrete measures. We conclude by underscoring the necessity of establishing structural systems to support these principles.

Background: Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines. Objectives: To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect. Method: Postal questionnaire to a panel of 1649 Norwegian medical doctors. Results: 1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on one’s own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence. Conclusion: It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.

Background Which role the health care system has and should have in reducing social inequality in health is unclear. The study objective is to gain knowledge about what Norwegian medical doctors believe their role should be. Material and method A questionnaire on how doctors take socioeconomic factors into account when treating patients was sent to a representative sample of 1,650 Norwegian doctors in 2008. Results 1,153 (70 %) doctors responded. 55 % believed doctors should contribute to reducing social inequality by offering patients with a low socioeconomic status extra help. However, the majority reported that they seldom/never take the patients' socioeconomic situation (such as bad private economy [81 %], little education [80 %], or unemployment [85 %]) into account in their clinical work. Some would consider lack of a social network (33 %), or heavy caring responsibilities (43 %) to be relevant. When responding to the question about how medical doctors take socioeconomic factors into account, 71 % said they give advice, 69 % spend more time, and 58 % offer an extra consultation. More regular GPs than other doctors reported they would take bad private economy (31 % vs. 15 %), unemployment (25 % vs. 12 %), or heavy caring responsibilities (54 % vs 39 %) into account. Interpretation To treat all patients equally is a fundamental value among doctors. Practical implications of equal treatment to all are not clear. Apparently inconsistent answers reveal a need for a professional and political clarification of which principles of equality that should guide doctors' practice.

BACKGROUND As outlined in the Norwegian Act relating to medical practitioners (of 1980), doctors practising in Norway loose their authorization automatically at age 75, but have the possibility of applying for a continued license. Such a regulation is rather unique from an international point of view. We have investigated doctors' attitude towards this regulation. MATERIAL AND METHOD The article is based on two postal questionnaire surveys; one sent to 1400 practising doctors in 2006 and one sent to 900 retired doctors in 2007. RESULTS 69% (969/1400) of the practising and 92 % (829/900) of the retired doctors responded. 80 % (772/969) of the practising and 34 % (284/829) of the retired doctors agreed with the requirement to apply for an extended licence at age 75. 25 % (97/389) of the respondents over 74 years had retained their license at the time of the investigation. INTERPRETATION Most doctors under age 70 accept automatic discontinuation of authorization at age 75, but support of the regulation decreases with increasing age.

Background We present and discuss the results of a Norwegian survey of medical doctors9 views on potential ethical dilemmas in professional practice. Methods The study was conducted in 2015 as a postal questionnaire to a representative sample of 1612 doctors, among which 1261 responded (78%). We provided a list of 41 potential ethical dilemmas and asked whether each was considered a dilemma, and whether the doctor would perform the task, if in a position to do so. Conceptually, dilemmas arise because of tensions between two or more of four doctor roles: the patient’s advocate, a steward of societal interests, a member of a profession and a private individual. Results 27 of the potential dilemmas were considered dilemmas by at least 50% of the respondents. For more than half of the dilemmas, the anticipated course of action varied substantially within the professional group, with at least 20% choosing a different course than their colleagues, indicating low consensus in the profession. Conclusions Doctors experience a large range of ethical dilemmas, of which many have been given little attention by academic medical ethics. The less-discussed dilemmas are characterised by a low degree of consensus in the profession about how to handle them. There is a need for medical ethicists, medical education, postgraduate courses and clinical ethics support to address common dilemmas in clinical practice. Viewing dilemmas as role conflicts can be a fruitful approach to these discussions.

BACKGROUND By law, Norwegian physicians are required to evaluate costs and benefits of various medical interventions before patients are subjected to them. A prerequisite for filling this "gate-keeping" role adequately is to be informed about medical benefits and costs. This article examines physicians' knowledge of costs related to an MR (magnetic resonance) examination of a knee. MATERIAL AND METHODS In 2006, the Research Institute of the Norwegian Medical Association sent a questionnaire to a representative sample of 1 400 Norwegian physicians. The following question was included: "What do you think is the total cost for a standard MR-examination of a knee (the sum of that paid by patients and the standard reclaimable fee [from health authorities] for this type of examination)". An unpaired t-test was used to compare answers from subgroups of doctors, and Pearson's correlation coefficient was used to establish relationships between cost estimates and other variables. RESULTS Physicians' estimates for the costs of an MR examination showed great variation. 57 % of respondents over or underestimated the costs by 50 % or more than the actual price of 1250 NOK. The most common mistake was overestimation; 47 % estimated the cost to be above NOK 1875, while 10 % thought it was below NOK 625. INTERPRETATION The results indicate that doctors should know more about costs, they cannot fulfil their role as gate-keepers without such knowledge.

BACKGROUND To assess whether development of health services in Norway has been well balanced in terms of satisfaction; time series variation has been compared for population satisfaction with health services and physician job satisfaction. MATERIAL AND METHODS Data were retrieved from the following sources and years: the reference panel of The Research Institute of the Norwegian Medical Association on physician job satisfaction in the years 1994, 2000, 2002 and 2006; the municipal surveys of TNS Gallup on population satisfaction with health care (primary) in the years 1995 - 2000, 2003 and 2005 and in 1999, 2000 and 2003 for satisfaction with hospitals, and from the Norwegian part of the International Social Survey Program (ISSP) on population willingness to allocate resources to public health care (in 1990 and 2006). Time series of physician satisfaction were computed from changes in satisfaction between consecutive surveys. Time series of population satisfaction were computed from annual regression-adjusted means that control for the association between satisfaction and observable personal characteristics. RESULTS On a scale from 10 to 70, hospital doctors' job satisfaction increased from 50.2 in 1994 to 52.3 in 2006. General practitioners' job satisfaction increased from 52.3 to 55.5 in the same period. From 1995 to 2005, consumer satisfaction with primary care increased from 4.43 to 4.54 and with hospital services from 4.23 to 4.47 (on a scale from 1 to 6). The proportion of the population who believes more public resources should be spent on health care increased from 82.7 % in 1990 to 85.2 % in 2006. INTERPRETATION The development in the health care sector seems to be balanced in the sense that views of the population and health personnel have followed parallel trajectories. A large and increasing share of the population is willing to allocate more resources to health care.

The objectives of this study are to measure physicians’ knowledge of the prices of pharmaceuticals, and investigate whether there are differences in knowledge of prices between groups of physicians. This article reports on a survey study of physicians’ knowledge of the prices of pharmaceuticals conducted on a representative sample of Norwegian physicians in the autumn of 2010. The importance of physicians’ knowledge of costs derives from their influence on total spending and allocation of limited health-care resources. Physicians are important drivers in the effort to contain costs in health care, but only if they have the knowledge needed to choose the most cost-effective treatment options. A survey was sent to 1 543 Norwegian physicians, asking them for price estimates and their opinions on the importance of considering the cost of treatment to society as a decision factor when treating their patients. This article deals with a subsection in which the physicians were asked to estimate the price of five pharmaceuticals: simvastatin, alendronate (Fosamax), infliximab (Remicade), natalizumab (Tysabri) and escitalopram (Cipralex). The response rate was 65%. For all the five pharmaceuticals, more than 50% and as many as 83% gave responses that differed more than 50% from the actual drug price. The price of more expensive pharmaceuticals was underestimated, while the opposite was the case for less expensive medicines. The data show that physicians in general have poor knowledge of the prices of the pharmaceuticals they offer their patients. However, the physicians who frequently deal with a drug have better knowledge of its price than those who do not handle a medication as often. The data also suggest that those physicians who agree that cost of care to society is an important decision factor have better knowledge of drug prices.