Loneliness is a near-universal experience. It is particularly common for individuals with  psychopathological conditions or disorders. In this paper, we explore the experiential character of loneliness, with a specific emphasis on how social goods are experienced as absent in ways that involve a diminished sense of agency and recognition. We explore the role and experience of loneliness in three case studies: depression, anorexia nervosa, and autism. We demonstrate that even though experiences of loneliness might be common to many psychopathologies, these experiences nevertheless have distinctive profiles. Specifically, we suggest that: (i) loneliness is often a core characteristic of depressive experience; (ii) loneliness can drive, and even cement, disordered eating practices and anorectic identity in anorexia nervosa; iii) loneliness is neither a core characteristic of autism nor a driver but is rather commonly experienced as stemming from social worlds, environments, and norms that fail to accommodate autistic bodies and their distinctive forms of life. We aim to do justice to the pervasiveness of loneliness in many — if not all — psychopathologies, while also highlighting the need to attend to psychopathology-specific experiences of loneliness, agency, and (non-)recognition. Loneliness is widely discussed in literature, poetry, and religious texts, and is a focus of ongoing work in sociology, psychology, and neuroscience. In recent years, loneliness has also come to be regarded as an urgent public health concern. Given this wide interest in loneliness — and related themes like solitude, isolation, alienation, and togetherness — it is therefore surprising that philosophers have had little to say about it. When they do consider it, philosophers tend to frame loneliness in existential  or political  terms Seemann . These asocial goods — conversation, companionship, possibilities for self-development, evaluative and interpretive frameworks, and so forth — that accrue from close personal relationships. To be lonely is to experience an absence of the possibilities these goods afford and, accordingly, to feel one’s agency as a social being diminished.Recent philosophical work . While we have followed tradition in using this term, we have some hesitations.Before we start, a note on the word “psychopathology”. This word traditionally refers to the study of mental disorders involving “unusual” or “abnormal” thought, experience, and behavior. The three cases we discuss in this paper — depression, anorexia nervosa, and autism — are usually included as examples of psychopathological disorders  lonely — and thus denying the validity of an individual’s experience — will not be an effective remedial strategy. Moreover, reminding lonely people that “it’s only temporary” — as many well-intentioned intervention strategies do — brings little comfort or validation to those who are chronically lonely. The experience of loneliness is phenomenologically complex and diverse; loneliness comes in different forms and degrees of intensity and duration . We experience loneliness because we feel that we are somehow not recognized by others, somehow not seen. This failure to be seen, in turn, diminishes our sense of agency and felt possibilities insofar as we feel unable to appear in the world before others as a unique self. An agent, Lucas tells us, “exercises her agency when she gives an account of her discrete, particular judgment as part of a worldly conversation” . It has a self-directed aspect, too. Loneliness can disrupt our fundamental sense of being in the world in a deep and pervasive way, including our sense of spatial orientation, bodily movement, and possibilities for action, expression, and connection. In short, it can lead to a social, emotional, and relational aspects of mental disorders. These approaches see psychiatric disorders as involving not just symptoms or factors inside an individual’s brain or body, but also breakdowns of an individual’s wider relation to the people, things, and spaces around them ; it foregrounds both the pervasiveness of experiences of loneliness across various psychopathological conditions, while also highlighting differences in how and why loneliness is experienced in different disorders; and it has practical import insofar as it may impact diagnostic and remedial strategies.We think this is mistaken. In what follows, we defend this claim by considering loneliness in core feature of the disorder. Thomas Fuchs  is an eating disorder characterized by self-starvation. Loneliness is not generally considered a core diagnostic feature of AN. However, many anorectics report being lonely. They feel stigmatized, stereotyped, and cut off from communities who can understand and support them — a lack of access, in other words, to the kinds of social resources, relationships, and recognition that others take for granted. Accordingly, they often develop various ways to address this loneliness, where these strategies feed into and shape their disordered eating practices and anorexic identity. Examining how loneliness develops and is dealt with in these contexts can therefore be illustrative in that it helps provide a richer phenomenological picture of the drive for recognition and belonging that motivates many of these practices — beyond simplistic caricatures of AN as a “desire for thinness” — and the ways that anorectics negotiate and sustain them.The American Psychiatric Association classifies AN as involving self-starvation that leads to dramatic weight loss. According to current diagnostic criteria, someone can only be diagnosed with AN when their self-starvation leads to “significantly low body weight”. However, critics note that this approach is problematic for several reasons. One worry is that someone may already be a practicing anorectic before they meet a certain weight-loss threshold and therefore not satisfy current diagnostic criteria. This is particularly problematic since AN is typically characterized in relation to white aesthetics regarding body weight, shape, and size. These criteria may therefore exclude a significant portion of the population Kendall . Others relational and multidimensional approaches to AN and eating disorders more generally. These approaches move beyond individualistic perspectives — which focus on things like genetic or psychological predispositions, or disturbances of body-related perceptions and experiences — and instead adopt a more holistic view of how contextual and relational factors give rise to and support disordered eating   face manifestation of their condition:I wasn’t allowed to associate with other people.... I wasn’t allowed to play sports ... so there was nothing else in my life that I was good at.... My only other identity was grades and my body.... I was always known as the skinny one  from others  but also affective . One study found that messages of emotional support were the most frequent form of social support found on ProAna blogs .While ProAna communities can help combat loneliness, being part of a ProAna community often drives and sustains one’s commitment to disordered eating. Members often share expressions of support and encouragement for fasting, even enter into group fasts together. Indeed, it is common for ProAna communities to be closed groups, where entry can only be gained, and membership kept, if one is anorectic. Joining a ProAna community not only might alleviate feelings of loneliness but, in turn, help individuals sustain anorectic practices. Perhaps more than this, being a member can also work to solidify one’s In sum, the relationship between AN and loneliness is complex. Loneliness can prompt the start of, or the return to, disordered eating. AN can give rise to experiences of loneliness and isolation, and attempts to find community and support can encourage people to enter social spaces that both scaffold disordered eating practices and cement one’s identity as an anorectic person by providing recognition that is missing from other communities. In each of these ways, loneliness is not a constitutive feature of AN but nevertheless can drive and even exacerbate the disorder. In order to successfully — and respectfully — treat AN, therefore, it seems likely that we need to understand the key role loneliness plays in perpetuating it.loneliness in autism remains under-explored. We argue that attending to experiences of loneliness helps reveal how social difficulties experienced by autistic individuals do not merely arise out of some social deficit on the part of the autistic individual but are instead relational. In turn, looking at autism also broadens our previous analysis of loneliness in useful ways. It shows us that nonrecognition is not simply a psychological state or even an embodied evaluative attitude. It can be realized within material culture, encoded within the organizational character and structures of everyday built environments in ways that withhold possibilities for reciprocity and lead to an experience of diminished agency and loneliness.According to current diagnostic guidelines, autistic spectrum disorder (ASD) is a disturbance of an individual’s ability to engage with others and the social world . But this is not a value-neutral process. These decisions impact different bodies in different ways Hendren . Recent nonrecognition. For example, anti-homeless spikes and seat dividers remove possibilities for rest, comfort, and security; they make it clear that homeless bodies, who often have nowhere else to go, are not welcome to meet their basic needs within these spaces. Moreover, by removing homeless bodies from public spaces, these hostile designs render that population less visible to other members of the community, which further compounds problems of stigmatization and support (ibid. pp. 888–889). Again, there is much more to say about this topic. But this brief overview is sufficient for setting up some points we want to make about autistic bodies, nonrecognition, and the built environment.All these design decisions are meant to regulate bodies and behavior. Some of them are intentional and involve the presence of discernible qualities or features ; others involve the intentional or unintentional absence of behavior-supporting resources . Whether intentional or unintentional, and involving presence or absence, these design decisions encode forms of loneliness within autism remains neglected . Still another reports how sounds, smells, tactile qualities, and visual aspects coalesce into an oppressive and inescapable atmosphere: “It is like a constant blanket of sound that just keeps coming at you until you are totally disoriented” , Cognitive Behavioral Therapy is often recommended to change these faulty beliefs and recalibrate behavior. And for some, these cognitive strategies may be effective. But they are also limited. They overlook the full picture given by first-person reports of how many anorectics live with and actively maintain AN as a shared project (Kuhle In the context of psychopathology, it may also help craft more nuanced intervention strategies. To take just one example, consider AN. Foregrounding how stigmatization and loneliness in everyday life drives many anorectics to seek out recognition in alternative communities, such as online ProAna communities, emphasizes the extent to which therapeutic interventions should be tailored to address individuals’ ct Kuhle , p. 120,ct Kuhle  — and mact Kuhle . Intervecommunity — an online space that meets different aspects of their basic needs for connection, affiliation, and sharing. And this is crucial because many with AN feel regularly misunderstood by families, friends, and doctors (Stinson Consequently, this relational approach — which, again, emphasizes the centrality of loneliness and desire for connection in driving AN — reminds us that when encouraging individuals to move away from ProAna sites as part of their recovery process, we are asking them to do more than just modify some core beliefs. We are asking them to leave a  Stinson . One ind Stinson , p. 2155For example, a gradual withdrawal from ProAna communities, instead of summarily cutting off all contact with them as a first step towards recovery, may be a more effective strategy (Osler and Krueger and material factors, and work to alleviate loneliness should be tailored accordingly.Finally, this focus on loneliness in psychopathology also highlights the importance of addressing issues of recognition and reciprocity when it comes to loneliness work more generally. When we are lonely, we feel that we are not seen — and often, powerless to do anything about it. Accordingly, whether in the context of psychopathology or elsewhere, we should be mindful that loneliness and nonrecognition is a problem involving broader social


Although one of the most prominent interventions against COVID-19, face masks seem poorly adopted by the general population. A growing body of literature has found that using face masks has social meaning. This qualitative study assessed the perceptions, representations and practices of mask wearing in the general population.A qualitative survey by short semi-structured walking interviews was carried out from April to December 2021 in 11 cities in France's Pays de la Loire region. Study locations were selected for their varied geographical, social, and economic characteristics, with urbanized and rural areas. Four domains linked to perceptions of masks and wearing them were explored: (i) evolution in mask wearing, (ii) decision-making methods for wearing and not wearing; (iii) incorporating the mask into way of life; (iv) projecting into the future.A total of 116 people were interviewed. Masks marked a shift from the ordinary world to the pandemic. Overall, interviewees considered masks an obstacle to breathing, communication, and social interactions, leading to establishing strategies circumventing the mask mandate. Poor attention was paid to their medical usefulness as an obligatory clothing accessory. Mask-wearing decisions were driven by social relations, common sense, and vulnerability. The greater the feeling of security , the less it was worn or worn properly, with decreased attention to others and their health. Most participants did not remember learning to wear a mask. Some were convinced that mask-wearing could not be learned . Institutions (school and work) played a central role by facilitating incorporation of masks into daily life.This study emphasizes the need to reinforce the individual medical values of face masks to prevent COVID-19. Ambitious education and training programmes should be planned to learn how and when to wear masks. Institutions (work and school) may be critical for this purpose. Face masks are one of the most prominent interventions against COVID-19 . AccordiBefore the COVID-19 pandemic, the French population was not used to wearing masks, even in winter during influenza season. Masks were limited to healthcare professionals, especially in a hospital setting, when caring for patients with transmissible diseases , 6. FollThe emergence of new variants or the occurrence of new epidemic waves have raised questions about protective measures against COVID-19 . The curIn this qualitative sociological study performed in the general population in diverse contexts in France, we investigated (i) the representations and perceptions of masks, (ii) the incorporation of masks into daily life, and (iii) how the usefulness of good compliance with mask-wearing rules with regard to controlling the pandemic is justified (or not).A qualitative study using walking interviews was carried out in outdoor public areas from April to December 2021 in 11 cities in the Pays de la Loire region in Western France, with a population of 3.8 million individuals . The stuThe interview guide was designed to approach, through experience, the representations and practices related to mask wearing . We sougData were analyzed using an inductive thematic approach to openly explore the perceptions, representations, and practices regarding mask wearing in the general population . Audio rNo ethics or Data Protection Committee Approval was required in France for this qualitative research as it did not come within the scope of application of the French Public Health Code.A total of 116 participants were interviewed. The saturation effect was reached halfway through the interview campaign. Of the participants, 70 (60%) were women, with a mean age of 51 years (min-max: 14–90), 47 (40%) were retired and 38 (32%) were living alone . The intDuring the interviews, masks were one of the main markers of the pandemic, referring to the health situation as a whole. In the narrative of the pandemic, wearing a mask was associated with the feeling of shifting from the ordinary world to the pandemic world , Q1-2.Well, it's a total change, I wasn't expecting it at all. It was in March last year, 14 months ago.”—Man, single, age 39, cleaner.“n = 53, 46%) situated “their first time” from summer 2020 to the start of the school year in September 2020. Memories were less precise and were marked by the notion of obligation.Participants were not aligned on the date or period which could in itself qualify the shift into the pandemic situation. Three phenomena seemed to play the role of memory activator for the first time masks were worn: the activity carried out while wearing the mask, the availability of masks and supply, and the feeling when wearing a mask , Q3–9. TFor me, I think it was for going to uni, before it was shut down. Just after the first lockdown… or no, it must have been during the summer season. Because unis were shut during the first lockdown and then there was the summer and masks were recommended, in the Port of Pornic for example. That was the first time I wore one”—Woman, single, age 22, sales assistant.“The second memory activators related to the difficulty in obtaining masks in spring 2021. Mutual aid within families and in neighborhoods was used to make cloth masks. Patterns or tutorials for making reusable masks with the least impact on the environment were all positive points mentioned.It was right at the start of the lockdown, cloth masks that we sewed ourselves, in a family workshop. We care about the environment and immediately got out our bits of material and sewed masks together”—Man, married with children, age 53, photographer.“The last memory activator was linked to the emotions felt when wearing the mask, mainly discomfort, the intensity of which varied from one person to another, going as far as feelings of suffocation.Heavens! Absolutely not, I really don't remember [the first time I wore a mask]! It's really not nice having something covering your mouth and nose…”—Woman, single, age 77, retired.“The medical reason for mask wearing was mentioned less than the feeling of constraint , Q10–24.It's not so bad in winter as it keeps you warm, but when it's hot, it's unpleasant to wear”—Woman, single, age 77, retired.“The mask was presented as an obstacle to breathing and communication, and a social barrier overall.It's really not nice when your mouth, nose, whatever are covered up”—Woman, single, age 77, retired.“The rhetoric of freedom was used to denounce mask-wearing. I call it a muzzle. There's a woman who said the next step would be a leash”—Woman, non-mask wearer, in a relationship, age 66, retired.“…The poor attention paid to the medical usefulness of masks was characterized by participants' practices. Some stated that they wear a single-use mask repeatedly for several days, others said they put their mask in their pocket once removed, most often simply rolled into a ball, or stored in their bag.I wear the same one several days in a row… because if I only use it for an hour or two, it can still be used the next day”—Woman, single, age 72, retired.“Drinking, eating or smoking were used as strategies for circumventing the mask mandate. These pretexts were sometimes sources of tension between those who practice them and others.If you want to take your mask off, you go and sit at the terrasse of a café”—Woman, mask-wearing, in a relationship, with children, age 41, homemaker.“Young participants used different techniques to maintain their social activities without wearing a face mask while still trying to protect themselves and others from the epidemic. They restricted their social circle, by meeting up in small groups formed only of students from the same school. In April and May 2021, SARS-CoV-2 testing was mentioned as a solution for withdrawing the mask during festive events. From June 2021, the vaccine replaced the test as a barrier to transmission. For large events, a quarantine was applied in previous days to prevent “last minute” contaminations.Now, when we see each other in our group of friends, we're all vaccinated or immunized”—Woman, single, age 73, retired.“n = 7, 6%). Most of the protest speeches targeted governmental measures and the confusion generated around the credit to be given to health measures.Some conspiratorial opinions were recorded, but remained an extremely small minority  in small towns and more generally when they had the feeling of being “in fresh air.”I don't wear one when I'm outside, but in the center, I do, when there are loads of people and we can't necessarily avoid them”—Man, in a relationship, with children, age 40.“In addition, fear of the police, who checked the mask mandate in large cities, was opposed to the complicity felt among small towns inhabitants, where participants felt they were in a familiar environment, protected because they are with their neighbors and family members. While people wear masks in public transport, this was not the case in their car regardless of the presence of passengers. At home, masks were mainly stored in their entrance halls, at the interface between the security of home and the more uncertain public space.Most participants declared they did not comply strictly with mask wearing in their private sphere when gathering for drinks or dinners. In return, most ensured that they applied “barrier precautions” and indicated they “kept their distance.” However, during probes, few were able to describe precisely which measures they applied to control transmission. This inability in most respondents to describe practical situations shows that in most cases, physical distancing is more a matter of discourse than a practice.When we go to friends' houses, we don't wear masks but at the same time, we don't get too close to each other and we don't hug”—Man, in a relationship, age 64, retired.“I don't wear one when I have visitors. We tend to believe that the risks are lower, plus we also know that we'll end up having drinks together and will have to take it off then anyway”—Woman, mask-wearer, single, age 23, doing civic service.“The decision-making for mask wearing relied on what the respondents themselves qualified as “common sense,” based on personal experiential knowledge. This “common sense” was also mentioned as the way of judging the real spread of the epidemic or the real dangerousness of the virus.I'm not a scientist, I trained as a pastry chef originally, but I've studied how bacteria proliferate and I think that wearing masks is more like a culture medium than a barrier. You just need to think a little bit logically to know that it's all crap. Maybe I'm wrong and maybe it is a really serious epidemic and everything… But I go out every day and I see the same people every day and, well, I'm sorry to say this, but no one has disappeared in a year”—Man, single, age 32, unemployed.“Frequenting people qualified as “vulnerable,” “at risk,” or “fragile” was the only argument that transformed practices. The most repeated public health message that came out in the interviews was: “protect yourself and protect others.” The “others” referred to vulnerable relatives, mainly regarding their age, such as parents or grandparents.We wore masks at Christmas with my whole family, it was really weird… sitting around the table at my grandparents' house. We'd never done it before, it was really strange, it felt clinical when we talked with each other. And it felt weird doing it with close family at a family dinner. But with grandparents and anyone a little bit vulnerable, obviously we tried to be careful… Otherwise, with friends, no, we didn't wear masks”—Woman, single, age 26, student.“Detailed analysis of practices highlighted a strong generational boundary. Young people presented themselves and were presented by their elders as those who were most likely to transmit the virus. The elders presented themselves and were presented by their juniors as those who were most likely to develop a severe form of the virus.In Lyon, we wanted to go and see our grandchildren, but my son said it would be better for us to be vaccinated before going, so we delayed our trip. We didn't even kiss our grandchildren (even though they'd been tested). We used protective measures”—Woman, in a relationship, age 65, retired.“People under the age of 30 mentioned masks as one of the elements in a toolbox to maintain socialization. Tests were the means often invoked to maintain a link with grandparents. Adults over the age of 60 visiting their own parents did not report this type of practice.For parties or birthdays, we got tested. For Juliette's 18th birthday, last time, the test was obligatory, PCR or antigen […] because it was when there were people from other high schools […]. We got tested 2 days before the party and took care to not see other people in between. And then, during the party, we didn't wear masks anymore. We also tried to not mix glasses and plates, we wrote our names on them”—Woman, living with her family, age 17, high school student.“Institutions (school and work) played a central role in incorporating appropriate practices regarding the uses and health dimension of masks , Q36–40.At work, we had rubbish bins for biological waste: masks and wipes. We had a protocol when we took a case or returned it”—Woman, single with children, age 41, salesperson.“The school also played a central role in disseminating good behavior, with teenagers declaring they were very respectful of the rules: regularly changing masks, respecting rules for wearing them.When we went back to school, they taught us how to wear our masks properly […] while before we wore them any old way. We had one for mornings and one for afternoons, and we had to change them at lunchtime”—Man, living with his family, age 15, high school student.“The practices and habits adopted at work influenced behaviors within the private sphere. Respondents not obliged to wear masks within institutions, did not perceive the need to learn how to wear a mask. Even more, they were convinced that wearing a mask was not something that needed to be learned.Learn how to wear them, no? But after that, I have no idea if I wore them correctly or not”—Woman, in a relationship, age 45, farmer.“Mimicry seemed to play an important role. In particular, we were able to observe the strength of this socialization with the mask. For example, because the people interviewed wore masks at work, they declared that they also wore masks when they left their home in the morning and all the journey home in the evening.Using walking interviews with residents from a French region, conducted between April and December 2021 in 11 different cities, this study captured social representations of face masks in the general population. As previously described, masks symbolized the pandemic and transformed daily life . DespiteThe current body of the literature shows that complex social dynamics can emerge from simple individual interactions, and sociocultural variables and local policies can interfere with mask adoption . A levelThe present study is original in that it involves interviews of individuals in the street to obtain their spontaneous expression of the representations and practices of mask-wearing in the specific context of a mask mandate. The use of masks partly revolved around social distancing with relatives. The more individuals belonged to the relative register, the less mask-wearing was felt to be legitimate and justified. The mask was presented by interviewees as a constraint that prevented social interaction. This finding has been described in previous studies, for example by preventing the interpretation of facial expressions , 22. PeoThe decision-making process on how and when to wear masks was based on personal experience and “common sense.” Most people interviewed had never been trained to wear a mask, and more generally had never been educated in preventing transmission. However, they did not feel the need to obtain instructions or advice on this matter. In previous studies, 70–75% of individuals in the public area or during mass gatherings wore their masks correctly , 23. ThiThe main limitation of this study was that it was carried out in a single French region, with reliance on self-reporting. There may be some factors specific to this setting that influence to what extent our findings can be generalized. No direct observations were performed on mask-wearing. The findings on practices derived from the participants' declarations. Moreover, an observational study was carried out from June to July 2020 to evaluate frequency and quality of facemask use in general populations in the same setting . The stuThis qualitative study emphasizes the need for reinforcement in the individual health and safety value of face masks in the prevention of COVID-19. Ambitious education and training programmes need to be implemented or planned to learn how and when to wear a mask. Institutions  may play a critical role in this aspect, providing better and sustainable incorporation of mask-wearing in the general population. From a long-term perspective, system changes should be considered to anticipate the emergence of new respiratory diseases requiring extended use of face masks.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.EB and FL participated in the data collection and analysis. GB participated in the data analysis. All authors contributed to the study design and writing. All authors contributed to the article and approved the submitted version.


In health professions, ethics is considered a fundamental competence. The increase in clinical autonomy in the field of physiotherapy is associated with an increase in ethical situations in their clinical practice.To explore the ethics of the clinical relationship between physiotherapists and patients, the ethics training received by physiotherapists, and if in the clinical context, physiotherapists identify the necessary attitudes and apply the ethical recommendations of the profession for the ethical situations they experience.A qualitative exploratory and descriptive study was performed with physiotherapists. Data were collected through semi-structured interviews. The data were analyzed using content analysis, as proposed by Krippendorf. The study protocol was approved by the University of Valencia Ethics Committee of Human Research.This study included 15 physiotherapists , which was sufficient to reach data saturation. We identified four categories: (i) Ethics of the clinical relationship , (ii) Ethics training received , (iii) Necessary attitudes for professional ethical practice ; (iv) Experiences from professional practice .The ethics of the clinical relationship between physiotherapists and patients is determined by the attitudes of the practitioner, which are the result of his or her values and previous experiences; and are very centered on ethics of indication . It is necessary to improve the ethical training received by physiotherapists, which is poorly focused on professional attitudes. Physiotherapists in their professional practice, as autonomous agents, face complex ethical situations , such asThe difficulty in making decisions is that they involve situations in which analysis of the facts, questions, and decisions must be based on professional ethical principles. Faced with such questions, physiotherapists must abandon their instinctive or intuitive responses and submit them to an ethical analysis within a clear theoretical framework, without losing sight of the fact that there is not always a single solution to a conflict of these characteristics. These are situations that require deliberation on how to respond and how to integrate ethical principles and professional guidelines. To become a professional, one must learn not only to think in certain ways but also to perform skills, and to practice or act consistently about the norms, values, and conventions of the profession .The increasing diversity and complexity of ethical issues and dilemmas which physiotherapists encounter have been reflected in the recent years on formal codifications and guidelines for professional morality: in Spain Professional Ethics in physiotherapy is based on the Code of Ethics principles elaborated by the World Physiotherapy , of whicThe interest in physiotherapy Professional Ethics has also been reflected in the increased number of articles on the subject. However, Professional Ethics cannot be relegated solely to compliance with deontological codes, but also deals with reflecting on what is the legitimate good of the profession and how to resolve ethical conflicts that arise in practice , 12, 13.Research shows that despite the noticeably increased interest in Professional Ethics in physiotherapy, knowledge about this area is still limited and physiotherapists rarely use ethical knowledge and skills to analyze ethical issues raised in their daily clinical practice , 17–19. The main purpose of this study was to explore the ethics of the clinical relationship between physiotherapists and patients, as well as the ethics training received by physiotherapists. Secondly, we aimed at evaluating if physiotherapists identified in the clinical context the necessary attitudes and experiences related to Professional Ethics.The methodological approach was qualitative and exploratory. The study was performed in 2019 at the University of Valencia (Spain).Given the qualitative and exploratory nature and the objective of the study, a convenience sampling was carried out, and in addition, the participants were asked to nominate colleagues who met the same inclusion criteria  , who werA homogeneity and heterogeneity analysis  were carFor recruitment, two members of the research team screened potential participants based on the study inclusion criteria, and contacted them by email, phone, or in person.In this interview, the characteristics of the study were widely reported, obtaining their verbal acceptance. Subsequently, they were emailed information sheets for study participation and acceptance for recording the interview. Both written informed consents were completed and signed at the time of the in-person interview.The data were collected via semi-structured interviews conducted by two of the team’s researchers, between March and October 2019. The semi-structured interviews were carried out in a private, quiet, and isolated environment, and through focused individual, in-depth interviews with a flexible script based on the research questions. All the interviews were conducted in Spanish. The content of the interview was developed by two university professors who were experts in Professional Ethics and Physiotherapy. The questions were designed solely for this study and were based on both their experience of working as a physiotherapist and teaching Professional Ethics. The proposed questions were further discussed with two nursing university professors and experts in qualitative analysis. For data collection, in addition to video recording (informed consent was previously obtained), a data collection notebook was designed to record the appropriate notes by the interviewer (22).Each interview lasted around 90 min and was videotaped for later analysis of its content. The number of semi-structured interviews was determined by data saturation  . InitialAfter collecting baseline data to frame the sociodemographic and professional profile of the participants, the interview began with certain questions formulated sequentially. Sample questions are shown in As the interviews unfolded, these initial broad questions were outlined until the categories or theoretical concepts that explained the discourses emerged. The categories developed facilitated the understanding of the different scenarios and experiences , 24. TheDigital recordings from all semi-structured interviews were transcribed verbatim. Data were analyzed using content analysis, as proposed by Krippendorf . A narraThrough careful review and continuous comparison of the data, categories and subcategories were obtained mainly from inductive reasoning, by observing both the manifest and the latent contents . The manFrom the beginning of the investigation, the interviews were coded by the study’s principal researcher (MIML) and by another researcher who assumed the role of assistant (VGC), to ensure the reliability and consistency of the results, and to provide an assessment of the reliability between researchers.More than 90% of the obtained codes were consistent between both researchers. The results of each interview were discussed among members of the research team and content revisions were conducted when necessary. Following content reviews, the codes were stable. The principal investigator was also involved in the entire process, to ensure consistency and adequacy of the process. Finally, as a quality criterion, the COREQ 32-item Checklist was followed to guarantee reliability . SeveralInformed consent was obtained in July 2018 by the Ethics and Research Committee of the University of Valencia (H1531842325974). Informed consent documents were designed for study participation and the treatment of the image and sound of the study participants after recording, as well as a study-specific confidentiality commitment. The interviews were stored on digital equipment with a secure password and respecting European regulations and protection data regulations in Spain  15/1999, December 13). An effective anonymization system was established that did not allow the subsequent identification of the study subjects.All participants were informed of the objectives of the project and voluntarily signed their consent to participate in it, being able to revoke it if they chose. To guarantee compliance with Organic Law 1/1982, of May 5, on civil protection of the right to honor, personal and family privacy, and one’s image, the express consent of the participants was asked concerning the use of the images of their voice recordings.The interviewees felt satisfied and grateful that someone was interested in their experience and the ethical aspects of their profession.Fifteen physiotherapists participated in the study . The homogeneity analysis highlighted that all participants had extensive healthcare practice (5 or more years), performed undergraduate university teaching at the time of data collection, and regularly attended scientific events. 60% of the participants (nine) were working in the private healthcare sector, 40% carried out management activities, 33.3% published research studies, and 26.6% implemented postgraduate teaching .From the inductive analysis of the data, four main categories emerged, Ethics of the clinical relationship (A), Ethics training received (B), Necessary attitudes for professional ethical practice (C), and Experiences from professional practice (D) . Each caDescribed below through passages from the interviews:This category explored the ethics that underlie the clinical relationship, differentiating the ethical principles (A1) and the type of clinical relationship (A2).All participants highlighted the importance of carrying out ethics based on values, from which respect for the rights and dignity of the patient is considered a free and autonomous subject. Other principles that must be present in the clinical relationship are professional responsibility, equity, justice, humanization, commitment, self-determination, confidentiality, privacy, and information to the patient. Some participants observed:P1. “… patients have to be treated with good manners and respect.”P5. “… self-determination, respect, autonomy,” “…it is the patient’s freedom.”P6. “… respect, dignity of the patient,” “…confidentiality,” “…autonomy.”P13. “… autonomy, respect and humanized attention.”Some interviewees stated that in the clinical relationship, a climate of trust should be established to create empathy, personalization, and a helping relationship. The factors that have been highlighted to intervene in the clinical relationship are the cultural level and attitude of patients and physiotherapists. Other factors such as high healthcare pressure, little time for patient care, technology, or bureaucratization of care, sometimes make it difficult to establish a correct professional relationship and therefore depersonalize the relationship. Several participants talked about such relationships:P4. “…you have to empathize but keep your distance at the same time, some patients step over their role,” “…too many patients are treated at the same time.”P9. “…the type of relationship that is established is a helping relationship.”P10. “…the system itself creates problems in the clinical relationship … many patients, standardization of the time for treatment, dehumanization of care ….”P13. “…establishing a climate of trust and a helping relationship is very important.”In this category, the ethical training that the interviewees received (B1) and the training that physiotherapy students currently receive (B2) were compared.All participants stated that they had not received ethical training during the physiotherapy studies. This was given in a transversal way and the competence was acquired through the attitude of the teachers and the professionals who supervised the practices. Several participants reported the following information:P1. “… there was something related to law, but I do not remember a specific ethics subject,” “… the situations and possible ethical dilemmas that might appear were solved in the practices.”P3. “… I have learned through clinical practice with unexpected situations that I have encountered.”P4. “… I received the knowledge of legislation but not of ethics.”P6. “… I did not receive specific training in my career, I learned from teachers and professionals.”All the participants agreed that there is currently more training in ethics than in the past, but it is not sufficient because basic individual education is also lacking. Current training includes important aspects that were not included in previous curricula, such as, for example, continuity of care, the relationship of trust, the development of the human dimension, or evidence-based clinical practice…P3. “… before we treated pathologies, how we treat people,” “…most of the students are vocational and establish a good relationship with the patient.”P4. “…now the contents are more consistent with the profession … ethics is being applied, and students are better trained.”P6. “…it is difficult for them to see the importance of ethics, and this is shown in some situations in which private conversations are held in front of patients, other patients are discussed, or the use of mobile phones in practices.”In this category, the attitudes that participants considered necessary for professional practice were identified, differentiating between personal attitudes (C1) from professional attitudes (C2).All participants highlighted the importance of beliefs and values in personal attitudes. The basic attitudes that participants identified in the physiotherapists were to be communicative, helpful, close, empathetic, respectful, sensitive, responsible, assertive, committed, and humanized. Several examples are reported as follows:P1. “… communicative attitude is very important … empathy and assertiveness.”P4. “… the affective component is very important, offering closeness and the attitude of helping others.”P9. “… commitment and responsibility are necessary ….”P14. “… you have to show empathy and sensitivity.”Most of the interviewees stated that the necessary professional attitudes for ethical behavior are: having autonomy in professional practice based on knowledge and experience, informing the patient through signing the informed consent, guaranteeing the autonomy of the patient, considering the opinion of the patient, achieving a climate of trust and respect based on active communication, favoring a safe environment with privacy and confidentiality, minimizing pain and establishing a therapeutic attitude of help. All of them are attitudes necessary for the humanization and personalization of the physiotherapist’s care. Participants described examples of professional attitudes such as:P2. “…act as best as possible using the best techniques for the patient’s recovery,” “…the patient has to be informed.”P3. “…do what I have to do, respecting the patient, without judging,” “… patient’s safety is a priority at all times,” “… we must minimize pain but make them understand that pain is not a whim.”P6. “…a behavior that is within what is correct, respecting not to produce pain,” “… inform and facilitate the informed consent “, “… good therapeutic attitude toward the patient.”P8. “…apply what the patient needs and not according to the physiotherapist,” “… we must have the patient’s opinion and establish a therapeutic relationship … informed consent is necessary but is rarely written.”This category showed some situations experienced by the participants in their professional practice and ethical situations in which healthcare ethics were compromised or could be compromised. This category was classified into two subcategories: general experiences (D1) and experiences depending on working in the public and/or private healthcare environment (D2).Most of the interviewees stated that they had not experienced any discriminatory experience regarding patients about race, culture, or immigration. 6 participants highlighted that ethics decreased due to unnecessary harm, 5 pointed out the attention to the patients who simulated symptoms or problems compared to the rest of the patients, 4 the possible favor in treatment to certain patients, 2 the violation of privacy and intimacy, 2 declared having suffered reverse discrimination of the patients due to the fact of being a woman, 1 reported the application of rigid treatment protocols that depersonalized care and 1 stated that they had witnessed unethical situations due to political ideology. Some participants commented on their experiences:P3. “…sometimes a favor in treatment can be thought of if it is justified but never undermining the rights of other patients,” “… the privacy and intimacy of the patient must be guaranteed.”P7. “…I have seen colleagues causing unnecessary harm but I avoid conflicts, I do not dare to say anything,” “… I have not seen discrimination based on immigration, but health tourism does not seem right to me … I have suffered positive discrimination for being a woman from some of my colleagues.”P8. “…an unethical situation is the one that occurs when the protocol does not allow administering a treatment to a patient although knowing that it would have good results in that patient … our decisions are not ethical for reasons beyond our control … sometimes there are very strict treatment protocols that leave little room for personalized treatment.”P10. “…quantifying unnecessary harm is complicated, how can it be done?,” “… care for the simulator patient is legally complicated, it should be treated like any other patient,” “… when favor in treatment is done, a dichotomy arises, doing more or less it is very complicated,” “… there continues to be paternalism and gender issues.”Half of the interviewees expressed there are differences in care in the public and private sectors, such as care for the patient who simulated symptoms or problems, the types of treatment applied highlighting manual therapy, economic criteria, favorable treatment to certain patients, and the type and time of application of treatment. Many participants commented on the differences, by giving examples such as:P5. “… different treatments are depending on whether it is in a public or private center,” “in the public sector, the patient is not touched and the patient wants to be touched,” “… sometimes the principle of autonomy is not respected,” “… there are inappropriate treatments, insufficient and even excessive for different reasons such as when they come from insurance companies,” “… sometimes the patient is forgotten and only what needs to be done is done,” “… the rehabilitation doctor does not count on the physiotherapist.”P8. “…in the private sector there are sometimes conflicts of payment with the treatments, what you can charge and what you cannot,” “… the least ethical situations that arise are those derived from private insurance companies due to economic issues.”P11. “…in the public sphere there are more unethical situations due to the short time of treatment…informed consent is never requested.”P14. “…the treatments are the same in public and private sectors, what varies is the duration of the sessions for example, and the type of treatment.”Information units of the categories and subcategories A, B, C, and D are summarized and shown in This study revealed some aspects regarding the clinical relationship, in terms of the ethical principles and type of relationship, underlining also the necessary personal and professional attitudes of the physiotherapist. Regarding the ethical training and professional attitudes received by physiotherapy students, there is low homogeneity in the curricula, and, in general, teachers are not sufficiently qualified; and students do not perceive it as important within the curriculum. As a strength, this is the first study that has explored the ethical behavior of physiotherapists in their professional practice, and the insights gained from this study will contribute to the body of knowledge on Professional Ethics in Physiotherapy.According to previous research, physiotherapists do not usually refer to ethical principles or guidelines in ethical decision-making , 31. TheEthical principles should help in addressing ethical issues by helping to identify an ethical issue and justifying why a certain action ought to be preferred over another. According to Meine and Dunn , codes tThe results highlighted the type of clinical relationship, in terms of empathy, personalization, and a helping relation, while constraining issues were short time for patient care, and employers putting pressure on the physiotherapists. Ethical problems in a situation when the patient does not receive the amount of physiotherapy that is needed, for whatever reason, often due to resource issues  and the As this study pointed out, there is currently more ethics education available than before. Still, ethics education during healthcare professionals’ studies seems to be poorly integrated into the respective curricula, and after graduating, physiotherapists rarely take part in further ethics education . Ethics The results of the study, concerning the general experience of the ethical situations in their professional practice are mostly in line with a previous study stating, that most of the ethical issues encountered in physiotherapy practice concern providing high-quality care and allocation of resources , equality, self-determination and relationships with patients and other healthcare professionals . This stPrevious research has identified a gap in knowledge concerning the impact of the setting on encountering ethical problems. There are studies focused on ethical problems in the public sector  as well The study was carried out in one center in Spain, thus any generalizations should be cautioned. Future research is warranted to explore the ethical behavior of physiotherapists in other countries and contexts. Additionally, the behavior of physiotherapy students in their clinical practices might be also studied, and therefore results could be compared, although comparing qualitative data may pose a challenge. Quantitative research about the behavior of physiotherapists in their professional practice could be implemented. Future studies could use mixed methods, comparing results for quantitative and qualitative content.The ethics of the clinical relationship between the physiotherapist and the patient is very much determined by the attitudes of the practitioner, which are the result of his or her values and previous experiences. Physiotherapists identified in the clinical context the necessary attitudes, but currently many physiotherapists focus strictly on ethics of indication, founded mainly on the principles of Beneficence and Non-Maleficence. An attitudinal change is therefore essential in terms of ethics, focusing on a model of shared responsibility where the principles of patient autonomy, freedom, judgment must be involved, generating an interaction in which the physiotherapist influences the clarification and determination of the best treatment for the patient while respecting the dignity of the individual. To this end, it is necessary to improve the ethical training received by physiotherapists, which is poorly focused on professional attitudes.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics and Research Committee of the University of Valencia (H1531842325974). The patients/participants provided their written informed consent to participate in this study.MM-L and EM-S: conceptualization and writing—original draft preparation. KN: methodology. AA-G, ÁD, and SC-A: formal analysis and writing—review and editing. EM-S, SC-A, and AA-G: investigation. RJ-V: resources. VG: data curation. RJ-V and VG: supervision. ÁD: project administration and funding acquisition. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


It can be assumed that value judgements, which are needed to judge what is ‘good’ or ‘better’ and what is ‘bad’ or ‘worse’, are involved in every decision-making process. The theoretical understanding and analysis of value judgements is, therefore, important in the context of bioethics, for example, to be able to ethically assess real decision-making processes in biomedical practice and make recommendations for improvements. However, real decision-making processes and the value judgements inherent in them must first be investigated empirically . For this to succeed, what exactly a ‘value judgement’ is and of what components it might consist must initially be theoretically clarified. A corresponding conceptual model can then support or even enable empirical data collection and analysis and, above all, subsequent ethical analysis and evaluation. This paper, therefore, presents a value judgement model with its theoretical derivation. It also illustrates its application in an interview study of decision-making between animal experimentation and alternative methods in the context of biomedical research. Though the model itself can be theoretically deepened and extended, the application of the model works in general and helps to uncover what value judgements can enter into decision-making. However, the empirical methods, for example, qualitative interviews, can also be better oriented towards eliciting value judgements (as understood according to the model). Further applications of the model to other topics or by means of other empirical methods are conceivable. However, by leaving these judgments implicit, they may cloak important value issues and controversies and, as such, frame or ‘bias’ the decision-making process. , p. 583.A  researcher thus obviously does not need to be (directly) aware of the reasoning structure of one of her/his value judgements. This poses a particular problem if one wants to empirically investigate decision-making processes in order to make an ethical assessment of these processes and the value judgements involved—as is often the case in so-called empirical bioethics.1However, even when one theoretically acknowledges the importance of value judgements in research contexts, the common problem in praxis is that, as Hofmann et al. put it:beliefs that “are directed to objectivity” definition and conceptual model of value judgments in the context of decision making are already needed to empirically identify such judgments .In short, a clear What is a plausible definition of ‘value judgement’ that allows for the development of an empirically applicable model for identifying and analyzing value judgements in decision-making processes?How can value judgements, according to this definition, be depicted theoretically in an empirically fruitful manner ?These research questions have arisen in the context of a specific project in the field of animal research ethics that used interview techniques. However, the resulting ‘value judgement model’ can be relevant to all areas of bioethics where decisions and thus value judgments are investigated with socio-empirical studies. The model is therefore mainly a contribution to the methods of empirical bioethics and their practical operationalization. Nevertheless, it also contributes to the philosophical sharpening of the term ‘value judgment.’However, in philosophy and ethics, literature concentrating on a more detailed analysis of the ‘nature’ of a value judgement is rather scarce,In the following, firstly, the ‘value judgement model’ itself, along with the explicit definition of the term ‘value judgment’ will be presented. This will be followed by explanations of the model and the  rationale for the definition. After that, the model will be applied to examples from the project about alternative methods for animal experiments. This article will end with a discussion of the strength and weaknesses the conceptual model and its application, with a word regarding its further use as part of the methods of empirical bioethics.An explicit or (mostly) implicit evaluative conclusion (using ‘thin’ or ‘thick’ concepts) in relation to a general or concrete state of affairs (esp. action/decision) which is based on at least one evaluative and one descriptive premise and which is intended to, and can language-pragmatically fulfil, an evaluative function. .As a consequence, value judgements can be premises of a practical syllogism and, thus, part of the justification of an action/decision. Therefore, it is important that not only the actual components of a value judgment  are represented in the model, but also some other elements or causal factors of decision-making in this context. So, for example, emotions, interests, or epistemic processes that sometimes can be difficult to delineate from a value judgment or one of its components should also be represented.The conceptual model presented in the following is intended to reflect a  representation of the logical or even  causal relationships of components of a value judgment in a decision-making process. The model is based on our explicit definition of ‘value judgement:’all factors or elements of a decision-making process. It is limited to those that have been considered particularly important, especially regarding the empirical application planned . Furthermore, the model does not presuppose that one value judgement alone has to be sufficient to justify a particular decision/action. Different value judgements can play a role in concrete decision-making situations and may stand in opposition to each other. Thus, further arguments or complex argumentations, in which value judgements are only making up a part, might be necessary. Such argumentations might also contain trade-offs between different value judgements  value judgements). Basically, this implies that there will be another value judgement on a meta-level, referring to the value judgements about an actual action or decision situation; however, this goes beyond the model proposed here. For the model, it is only important to recognize which value judgements were (probably) involved in a decision-making process, not to determine how ‘powerful’ a particular judgement was for the final action or decision.However, the model finally developedThe elements of the model see Fig.  are descValue judgement(s), descriptive premise(s), evaluative premise(s), logical connection, object to be judgedred elements in the figure are components of a value judgement as established when analyzing the concept ‘value judgement’ and developing the explicit definition . Descriptive and evaluative premises are regarded as central to every value judgement, and because of the justificatory/argumentative structure, some logical connection(s) between descriptive and evaluative premises is unavoidable. The ‘object to be judged’ by a value judgement can be an action or a decision; it is the object to which the value judgement is referring and to where its evaluative function aims. This object is necessarily represented in the descriptive premise(s).All the Value(s)Values  are crucial for building evaluative premises. They may also influence or constitute emotions and interests/needs, which, in turn, may also influence the building or acceptance of evaluative premises (see below).Emotion(s)beliefs is often rejected, because even if emotions may have some cognitive content, they are not only judgements, but characterized by their affective features [The relationship between emotions and values is difficult: are values constitutive of (certain) emotions, or are (certain) emotions instead constitutive of values? This depends on how emotions are characterized. In addition to understanding emotions as mere affective phenomena, there are also views that regard emotions themselves as a kind of “judgement of value” —even thofeatures . This isfeatures , p. 8. TInterest(s)/need(s)/want(s)Interest is the partaking of a person in another person, living being, thing, or an event; stemming from original, vital, or psychic drives or needs. They not only produce pleasure in something but also initiate actions and desires and are, therefore, generalized behavioral tendencies. There are interests that persist over time and, in turn, interests that change erratically. Needs are what a living being strives for to maintain, improve, and increase its life. Wants are often the motivational component which, together with beliefs and plans, play a central role in explaining actions and intentions [Like emotions, it is assumed that interests, needs, and wants influence evaluative premises or can be a further basis for them. tentions . They, itentions .Epistemic processesEpistemic processes have to do with how knowledge is gained and justified, especially in the context of scientific research and methodology. In this context, they are important for the generation (and further justification) of descriptive premises.Further factorsThis element of the model is deliberately broad and contains other factors necessary for the formation—or justification—of descriptive premises. In the context of research, these can include institutional or systemic preconditions of science, existing traditions of scientific working methods, or the infrastructure available . In other applications of the value judgement model, of course, the factors may differ.a fortiori, the model proposed. The initial conceptual analysis of the basic terms ‘value’ and ‘judgement’—as separate components of the complex term ‘value judgement’ —is —is a formoral value.There are different characterizations of the meaning of ‘value’ in the context given. Value, in the broadest sense, is taken as something that goes hand in hand with the notion of “goodness” or “badness” . It has Regardless of whether it is a moral value or not, a value is the “reason or the result of an evaluation, i.e., the preference of one action over another or, in general, of one object or fact over another” , which i Z, Z is a value iff (if-and-only-if):Z is an intentional object for an individual A ;Z refers to a state of affairs X;it is the case a) that X has certain qualities such that it is a good, and b) X counts for A as a goodCondition (ii) of the analysis establishes an objective reference to a state of affairs, while conditions (i) and (iii) establish a subjective reference. However, it must be presupposed for condition (ii) that facts can be determined sufficiently intersubjectively or that the existence of a fact can be interpreted in a sufficiently consistent manner.For allintentional object for an individual A, because she/he can consciously refer to it. ‘Clean water’ refers to a state of affairs in the empirical world, for example, whether the water available for individual A  is not contaminated or similar. Since ‘clean water’ is important for a human being for health reasons, inter alia, it is a good for individual A, and individual A would count it as a good even if it was not available . Therefore, ‘clean water’ is a value, which can be expressed as a desirable idea (‘It is desirable that there is clean water everywhere’), but also as an action-oriented directive (‘Clean water everywhere is a fact that should be worked towards’).The ‘availability of clean water’  can be used as a simple example of a value. ‘Clean water’ is an Values can be represented in a hierarchy, from more concrete values to more general, superordinate values, which, in most cases, also represent intrinsic values  and not extrinsic values . The example of ‘clean water’ is a relatively concrete and probably also extrinsic value.in relation to a general or concrete state of affairs (esp. action/decision) …” from our above definition of ‘value judgment’ becomes understandable.From these considerations, the element “… The term ‘judgement’ can be interpreted in philosophy in various ways: (i) psychological: ‘judgement’ as the result of a thought process; (ii) linguistically: ‘judgement’ as a (declarative) sentence; (iii) logical: ‘judgement’ as a conclusion; and (iv) ontologically: ‘judgement’ as a proposition or a fact (cf. ).practical syllogism can serve as a classic example of a judgement in the sense used.In the following, ‘judgement’ shall be used particularly in its logical meaning, i.e., as a result of a logical-argumentative context of interlinked statements. The prescriptive or evaluative knowledge/belief component), (ii) a minor premise designating a certain concrete characteristic (descriptive knowledge/belief component), and (iii) a conclusion containing an action or possibly a request for action. In more modern accounts  is also considered. For example:All humans should exercise.I am a human(I want to do what other humans should do).∴ I exercise.When applied to moral justification, the practical syllogism contains a general moral premise , as a major premise, a concrete case in the minor premise, and the  action or possible call to action (imperative) in the conclusion. For example:It is wrong to kill a human being.Paul is a human being.(I don’t want to do anything wrong).∴ I will not kill Paul / Do not kill Paul!The conclusion of such an argument is called a  action judgement, which, however, can be used to clarify  what a  value judgement is.According to the Aristotelian original, a practical syllogism consists of (i) a major premise containing a general principle, law, or maxim , an addwhich is based on at least one evaluative and one descriptive premise …” in our proposed definition of 'value judgment' follows.As a result of these considerations, the element “… too simply put, as a value judgement could also be a judgement about what is bad (not good). Value judgements are (conscious) evaluations and must be separated from mere valuings. Valuing refers here to the (immediate) liking, appreciation, or disliking of things, without much awareness that one (and why one) is valuing a specific thing  . The diY”) (cf. ). Value how it is good or bad in a certain way. Then, other (more) ‘thin’ concepts are legitimate evaluative terms, such as ‘right’ and ‘wrong,’ ‘just’ and ‘unjust,’ or ‘beautiful’ and ‘ugly.’ Additionally, the wide range of ‘thick’  concepts, such as ‘tactful,’ ‘charitable,’ ‘cruel,’ ‘paternalistic,’ ‘altruistic,’ or even ‘valid’ when assessing the quality of an empirical study, may then be legitimate terms.7‘Good’ and ‘bad’ in a value judgement can be given a more precise meaning in a given context, i.e., when it is said It is wrong to kill a human being.Paul is a human being.∴ It is wrong to kill Paul.In comparison to the action judgement, the value judgement is missing the volitive or conative component.evaluative propositional operators. For example, generally ‘it is  good that p’ or ‘it is  bad that p.’When looking closer at the logical structure, a  value judgement does not follow from a practical syllogism but is a judgement of a theoretical syllogism.If a prescriptive premise is used (= reference to a norm), this refers implicitly to the evaluative premise on which it is based. Evaluative premises can refer directly to a  value ,An explicit or (mostly) implicit evaluative conclusion (using ‘thin’ or ‘thick’ concepts) …” in our definition of ‘value judgment’.These first considerations explain the element “exclusively ‘related to values’ or similar .see also , p. 21),crypto-normative [in abstracto, in reality, many statements are—or at least seem to be—descriptive and evaluative simultaneously, probably also due to the ‘thick’  concepts that are used.It is aggravating that descriptive statements can be ‘disguised’ value judgements; such sentences are often also referred to as being ormative , 44. FurDescriptive statements (premises) are substantiated by reference to everyday experience, scientific findings, or accepted law; evaluative statements (premises) are substantiated by reference to general valuation assumptions . The boundary between the two types of statements is flexible and determined both by the beliefs about the scientific or unscientific character of certain opinions or theories and the scope of the given value system  linguistic pragmatic function for differentiation is sometimes decisive. Consider what the utterance of the judgement is supposed to achieve in the respective discursive context: should it just convey information (descriptive function) or should it  convey an evaluation ? To count as a value judgement, the conclusion of the argument must not only be able to fulfil an evaluative function. Rather, the evaluative function must be intended.Therefore, in the end, the … which is intended to, and can language-pragmatically fulfil, an evaluative function.”These second considerations make it clear why the definition of 'value judgment' contains the closing element of our above definition: “In the following, we discuss how the model can be applied in empirical ethical research using a practical example based on data from our R2N-E1 project mentioned at the beginning , which Value judgements inevitably play a role in deciding whether to use an animal model or an (possible) alternative. Various aspects of scientific validity  are often weighed, on the one hand, and the possibility of reducing the suffering or distress of animals, on the other. However, the fact that such decisions are also based on value judgements, which are partly ethical, partly methodological (and partly even pragmatic), is not always made sufficiently evident in the biomedical sciences . This castructure of value judgements in the decision-making about alternatives to animal experimentation was conducted. In the end, 13 bioscientists in basic and translational research who either (a) perform animal experiments themselves, (b) use alternative methods, or (c) at best both, were interviewed in 2020 in the form of a semi-structured interview. The interviews, which were conducted in German, were structured to invite narration of relevant decision-making situations . The interviews were transcribed and processed for empirical and ethical analysis with methods of qualitative content analysis.10As an essential part of the R2N-E1 project, an interview study investigating the reconstructed. This reconstruction was oriented mainly towards the idea of a ‘rational reconstruction.’ That is, it was about reconstructing the argumentation  in a rationally plausible and consistent way. Such a process always involves interpretation, and, depending on the specific narration of the interviewee, the interpretation was either relatively ‘close to the text’ or quite speculative . The latter occurred mainly where it concerned the elements that have been called ‘Context factors influencing components of value judgement(s)’  the premises; in others, the narrations only mentioned reasons, i.e., premises, but not the value judgement itself. Therefore, some of the elements according to the model often had to be descriptive and evaluative backings. Backings are, thus, mainly (further) justification of the premises, but also entail factors influencing the content of the premises . Logically, these are other premises in an extended argumentation, but they are often implicitly thought about and, are rarely made more explicit than the value judgements themselves and their (immediate) descriptive and evaluative premises.Personal values and interests were rarely communicated by the interviewees. Because of this, we have chosen to use a simplified tabular form for the actual evaluation of the interviews in which the value judgement is supported by its descriptive and evaluative premises  backings in Table first example: Alternative method A has the consequences Z / has not the consequences Z  when the experiments fail. The evaluative premise is often connected to the content of the descriptive premise and evaluates, for example, the outcomes described in ethical terms.In the examples depicted in Table second example supported her or his descriptive premise with statements such as “we used to do an animal experiment for this kind of research” but “we can replace the animal experiment equivalently in terms of knowledge gain.” The evaluative premise is based on the scientists’ judgement that “the animal experiments (in this kind of research) are cruel.” In contrast to the rather clear premises, the backings are more speculative and constructed such that values like animal welfare, avoidance of cruelty, truth, common good, professional success informs, etc. justify value judgements and their premises, respectively.The interviewee from the third example is interesting because the value judgement itself was not as clear to identify as in the former examples but had to be reconstructed from a variety of evaluative and descriptive premises. The descriptive premise is based on the scientist’s claim that “there was no option to do a cell culture experiment for the specific research question at hand.” It was added that “someone would do the experiment anyway.” The scientist made a distinction in the evaluative premise between his or her own respectful behavior towards animals and the potentially disrespectful behavior of other scientists. The chance to share this respectful experience of animal experimentation was also seen as a chance to educate students about the morally responsible handling of animals in laboratories. These elements build our reconstructed value judgement. Backings, in this case, are the available funding options that influenced the research possibilities and the scientist’s wishes to improve the handling of animals.The cost, which will be discussed as an additional fourth example. One interviewee said that alternatives such as cell culture experiments are just cheaper, which is an obvious reason to choose them. This can be paraphrased as value judgment: ‘Alternative method A is cheaper .’ An evident evaluative premise might be ‘A method that is cheaper is favorable (to other methods that are more expensive).’ This evaluative premise is likely to be shared even by those who disagree with the value judgment in a specific case .The model can also be useful when analyzing different value judgments that relate to the same issue, such as organoids,In fact, another interviewee did not, at first sight, agree with the value judgment, essentially saying: ‘Alternative method A is not necessarily cheaper .’ The difference is not explained by the evaluative premise, but mainly at the level of the descriptive premises; the interviewee talked about so-called However, the first mentioned interviewee made clear that the choice nevertheless depends quite clearly on whether the research question can be answered at all with the alternative; otherwise, irrespective to the costs, the animal model must be chosen. The descriptive premise would probably reflect that. For example, ‘Alternative A allows investigating the same research question as animal experiment B.’13advantage over animal experiments in order to be chosen. This could include, as an example,  costs.At the level of backings, statements about the cost of a specific alternative are thus likely to be related to the type of alternative method, funding structures, and (existing) infrastructure . Statements might also have to do with the interests and values of the researchers, whether they consider something to be ‘cheap’ or ‘expensive’ . This became clear in an interview in which the interviewee referred to her/his own values or professional values as a scientist . In her/his opinion, it is not the goal of the scientist to avoid or replace animal experiments (but rather to do ‘good science’). Therefore, alternative methods must offer an From the example, one can see that both differences in value judgments on the topic of ‘cost’ and differences in the justification of a comparable value judgment will depend less on evaluative premises than on descriptive premises. Nevertheless, the evaluative premise(s), interests, values, and the professional self-image of researchers can be significant as backings; and must, therefore, also be taken into account in order to be able to classify and evaluate the value judgment with regard to costs.The conceptual model highlights the fact that the value judgment is only the tip of the iceberg and that the various components of the value judgment must also be taken into account for an ethical evaluation.describe or explain real decisions or processes of decision-making. This means that some aspects always remain excluded, which could perhaps also play a role in actual decision-making in reality.The model inevitably has certain theoretical limitations. Individual components, for example, of a value judgement, such as ‘interests,’ ‘emotions,’ and especially ‘epistemic processes,’ are not (yet) sufficiently tied back to more extensive philosophical or, where plausible, psychological theories. Furthermore, the model cannot completely instrument, especially as an analytical and/or interpretative tool within the framework of empirical-ethical research.value judgements from an argumentative point of view. This, however, is precisely a point of view that is particularly significant in an ethical approach—in contrast to an approach, for example, from axiology or psychology. Therefore, the strength of the model must be seen less in its—extendable—theoretical pervasiveness and more in how well it is ultimately able to support the analysis of ethical decision-making and evaluation. In this regard, it must be acknowledged that our value judgment model is not the only way to make implicit value judgments (more) explicit. However, on the one hand, it is a plausible way to do this, and on the other hand, it also allows us to uncover the argumentative structure and to put the individual components and factors of a decision-making process into a systematic nexus. Moreover, the model also contributes to a further general theoretical understanding of value judgements—notwithstanding its applicability as an analytical or interpretative framework for empirical interview data.These limitations are pragmatic and exist in order for the model to remain applicable as an The concrete object of knowledge  in empirical-ethical projects is not always sufficiently identified nor theoretically determined in more detail. Our model presented here was one of the rather few attempts to provide such a theoretical basis even before the empirical data collection and analysis was carried out.To be clearer about what the object of knowledge is (how it is understood) is not only a theoretical-reflexive concern. It also determines which empirical methods are used and how exactly, for example, interviews should be conducted and how the interview questions should be designed. The latter, of course, should be done in a way that evokes relevant statements from the interview partners about the object of knowledge. However, this presupposes that one has a sufficiently clear understanding of the object of knowledge . In this way, interview questions can be targeted from the outset so that their answers are more likely to contain something relevant about value judgements or their components. Additionally, a model like our value judgement model presented here is also significant when it comes to classifying, evaluating, and—argumentatively—interpreting the interview data . While the value of the former (formulation of questions) cannot be discussed further here, the value of the latter  can, at least, be exemplified  identified with the model in the R2N-E1 example are ethical , while others are not. The latter does not mean that they are automatically un-ethical. They may simply refer to extrinsic values that indirectly promote intrinsic values. But they may invite particularly critical scrutiny that might be important for improving research practice(s) regarding animal experimentation and alternatives in basic and translational biomedical research. However, ‘ethical reasons’ are not necessarily convincing. They are, after all, usually the subject of an ethical debate.This, in turn, is relevant for an Overall, the value of our model is, above all, to make the reasons and their argumentative connections transparent against an ethical background; thereby allowing a (better) critical examination of the respective decision-making process.The value judgement model presented is a first attempt not only to describe value judgements and some of their components merely theoretically, but, above all, to be able to identify, analyze, and interpret them more precisely in empirical-ethical studies. As a first attempt, it is fraught with ‘teething troubles.’ Still, its successful application to the R2N-E1 project demonstrates its inherent potential to improve empirical-ethical research theoretically and methodologically. Our model does this by orienting both the empirical data collection (which object of knowledge is to be investigated exactly?) and the (subsequent) empirical analysis  more clearly. Last but not least, the model and its application supports (or even enables) the normative or evaluative analysis and interpretative work .In the future, further theoretical refinements and philosophical or psychological deepening of individual components would be conceivable. Depending on the purpose, the focus could be on individual components of the model or additional components to be incorporated. The application of the model to other topics than presented here  is, of course, possible (and encouraged!). Furthermore, the model could also be applied in the context of other empirical methods, such as document analyzes instead of interview studies.Regardless of which direction may be taken in the further use of the value judgement model, it has become clear that the possibilities and limits of a theoretical model—as an analysis and interpretation tool—such as the one presented, can only be determined in actual practical use, i.e., in the context of empirical-ethical research, not exclusively through philosophical reflection.


Simulated reality encompasses virtual, augmented, and mixed realities—each characterized by different degrees of truthfulness in the visual perception: “all false,” “coexistence of true and false,” and “difficult distinction between true and false,” respectively. In all these technologies, however, the temperature rendering of virtual objects is still an unsolved problem. Undoubtedly, the lack of thermal tactile functions substantially reduces the quality of the user’s real-experience perception. To address this challenge, we propose theoretically and realize experimentally a technological platform for the in situ simulation of thermal reality. To this purpose, we design a thermal metadevice consisting of a reconfigurable array of radiating units, capable of generating the thermal image of any virtual object, and thus rendering it in situ together with its thermal signature. This is a substantial technological advance, which opens up new possibilities for simulated reality and its applications to human activities. Simulated reality –5, also Ideally, simulated reality technology should recreate all perceptive functions of the users. Indeed, the expected success of simulated reality lies in its ability to offer comprehensive and real-time experiences, which necessarily include, besides interactive images and sounds –22, alsoTo address this challenge, here we develop an advanced technological platform that allows in situ thermal rendering of virtual objects within simulated reality environments. The proposed setting recreates thermal sensing and can be incorporated in thermal infrared vision. To illustrate this concept, we first present thermal infrared renderings of virtual, augmented, and mixed reality scenes through an example Fig. . To achiFigure The proposed approach to the in situ simulation of thermal realities consists of 3 steps. In the first step, a radiating metadevice is developed, based on the “thermotics” technology –48, capaThe experimental setup, sketched in Fig. For a 3D scenario, we selected a cup as a model and generated the front, side, and vertical views of its infrared patterns shown in Fig. −1 K −1), used as substrate for the metadevice. Of course, the temperature of the metadevice can be varied at will.To begin with, the generated thermal infrared signals must be transmitted to a virtual reality setup. Our metadevice is the device used to generate the real thermal infrared signals of virtual objects. The generated signals are recorded by a thermal infrared camera. The effective temperature distributions of the metadevice infrared patterns  are then transmitted to a microcomputer system via a wire or a local-area network for further processing, namely, the 3D rendering of the virtual object. It is worth noting that the transmission of thermal signals from the infrared camera to a microcomputer, like a Raspberry Pi, has been successfully tested in a recent work . In Fig.An example of image processing algorithm is illustrated in Fig. To enable tactile thermal sensing of the generated virtual objects, one option presently under testing is to attach thermoelectric heat/cold sources ,63 to a The in situ simulation of thermal reality is a noncontact human–computer interaction technology that provides a novel way of interaction by simulating real thermal perception. In our system, the user’s hand can hover over virtual objects in virtual reality, and the thermal perception of the virtual objects is realized by sensing their thermal radiation. This mode of interaction not only aligns with human lifestyle habits but also provides a more realistic perception experience in augmented reality environments, thereby greatly enhancing the user’s sense of immersion.Compared with eyes and ears, skin is often overlooked as a sensory interface in the context of simulated reality. As the largest organ of the human body, the skin contains many thermal receptors responsible for our temperature sensing and thus plays a key role, when one tries to extend the simulated reality experience beyond visual, auditory, and mechanical perception. Our setup for in situ simulation of thermal realities represents a substantial step forward in this direction. This will offer users a more immersive experience and pave the way for industrial innovations in this field of technology, further expanding its applications and impact.In Supplementary Materials See concrete experimental details in Supplementary Materials