Ethico-Political aspects of clinical judgment in opportunistic screening for cognitive impairment: Arendtian and aristotelian perspectives

To our knowledge, this is the only hospital in Sweden that has introduced such a program.

Screening for dementia is a controversial issue. On the one hand, there is widespread agreement about the benefits of detecting and diagnosing dementia early in the disease process – and screening can lead to early detection (see e.g. Ashford et al. 2006; Banerjee and Wittenberg 2009; Yokomizo et al. 2014). On the other hand, a majority of scholars and national screening committees argue that screening for dementia does not fulfil the generally accepted criteria for screening practices, criteria that were first formulated by Wilson and Jungner (1968) in 1968 and that since have been integrated in various forms into national law in many countries (see e.g. Boustani et al. 2003; Ranson et al. 2018). The three main concerns that are raised against screening for dementia are the lack of evidence of the effectiveness of current treatments, the uncertainty about the benefit-to-harm ratio of the available test instruments, and the lack of knowledge about how a positive test result and subsequent dementia diagnosis may affect the screened subject (see e.g. Burn et al. 2018:2; US Preventative Services Task Force 2020; The UK NSC recommendation on Screening for Dementia 2019). The ambition to improve early detection and diagnosis of dementia is, however, strong, and in the absence of any national population-based systematic screening programs – in which every member of a predefined population is offered testing – variations on this type of screening have emerged. One such example is “population-based opportunistic screening” (Gunnarson et al. 2021). Unlike systematic screening, opportunistic screening offers testing to a predefined population when the opportunity arises, most commonly when members of the population are admitted to hospital for other reasons than those that the screening concerns.

Temporary delirium is not uncommon among hospitalized patients and causes similar symptoms as cognitive impairment and dementia.

For a more thorough account of how the patients experienced and made sense of the testing practice, see Zeiler et al. 2021.

However, research on the practice of screening has uncovered other dimensions of this practice not covered by formal screening criteria such as the barriers to the implementation of screening (Minsky-Kelly et al. 2005) and “the bridging work” performed by profeesionals to facilitate implementation (Timmermans and Buchbinder 2012).

Virtues such as courage, temperance, liberty, magnificence, magnanimity, pride, patience, truthfulness, wittiness, friendliness, modesty, righteous indignation.

In the Aristotle-inspired literature on clinical judgment and professional judgment in general, lists of virtues of character are often constructed, at which the practitioners of a particular practice should aim (see e.g. Pellegrino and Thomasma 1993; Banks and Gallagher 2009). This is not our ambition in this article. Rather, we aim to gain a deeper understanding of why and how clinical judgment becomes such an integral part of the studied practice. For this, it suffices to remember that judgment and virtues of character are always mutually dependent. This does not mean, however, that the virtues of a particular professional practice are a set of professional skills that have no meaning outside that practice. On the contrary, precisely because they are virtues of character that are exercised and cultivated through action and experience, they cannot be fully separated from the acting person, nor from the sociopolitical context in which they are exercised. Thus, even though the virtues are professional, they always are and become part of a person’s whole life, including the societal and cultural contexts he or she inhabits (cf. MacIntyre 2011).

This is indeed a question of emphasis. For Aristotle, the ethical pursuit of eudaimonia is also political, since every individual person’s pursuit of the good life takes place in and is dependent on the city (polis), and may, as a consequence, result in the good city, which would be even “finer and more godlike”, as Aristotle puts it (Aristotle 2011, 1–3 [1094a-1094b], see also Broadie 2002, 10). For Arendt, too, the ethical and political dimensions of judgment are intimately intertwined. In fact, she understands judgment as that which connects the realm of the ethical – which “concerns the individual in his singularity” (Arendt 2003, 97) – and the political – which concerns “the viewpoint of the community or of the world we live in” (Arendt 2003, 79). In order to decide what is right or wrong to do in a particular situation, we need the discerning and deciding faculty of judgment, which is always political in nature, since it relies on the presence of others – the presence of a community – whose perspectives on the issue at hand we must take into account in order to make a judgment.

Arendt was never able to develop her theories on judgment fully. When she died of a heart attack in 1975, the title page of what was going to be the third and final part of her book Life of the Mind, which was intended to deal with the faculty of judgment, was found in her typewriter. Despite the absence of this final section, Arendt’s writings on judgment are quite extensive, and since her death many scholars have offered their interpretations of them. Today, there is an intense debate about whether one should understand them as constituting two distinct or one continuous theory about judgment. In the first camp, we find influential scholars such as Beiner (1992), Bernstein (1986), and Maurizio Passerin D’Entreves (2006), for whom Arendt went from understanding judgment as a form of political action, in her early writings, to understanding it as a form of retrospective thought exercised by the spectator, in her later writings. In the second camp, we find Linda M. G. Zerilli (2005) and Shmuel Lederman (2015), for example, in whose view Arendt never claimed that the actor exercises judgment; she ascribed this activity only to the spectator. In Zerilli’s and Lederman’s interpretation, however, the spectator and the actor are not two different persons, but two different ways of relating to the world, which are mutually dependent and deeply intertwined. In the present paper, we follow this second interpretation of Arendt’s writings on judgment.

The limited space of this article does not allow a thorough account of Arendt’s reading of Kant and the connections she makes between aesthetic and political judgment.

Unlike phronesis, where deliberation and action form part of one and the same, continuous movement, political judgment is separated from action. Arendt uses Kant’s metaphor of the spectator to illustrate this point. Whereas, as actors we are directly engaged and invested in what takes place, and therefore unable to sufficiently distance ourselves from it, as spectators, we are able to make judgments, since the subject matter of the judgments plays out before us. However, one should not think of the actor and the spectator as two different persons. The “spectator sits in every actor”, Arendt writes (Arendt 1992:63).

The patient sub-project has been approved by the Swedish Research Ethics Board (etikprövningsnämnden, approved, Ref. no. 2019–03034). The sub-study with health care personnel interviews was exempt from review, since it focused on these interviewees’ work and workplace in a way that did not address sensitive personal data (confirmed in a statement from the scientific secretary of the board, 31 October 2017).