Transplantation is a medically successful and cost-effective way to treat people whose organs have failed--but not enough organs are available to meet demand. T. M. Wilkinson explores the major ethical problems raised by policies for acquiring organs. Key topics include the rights of the dead, the role of the family, and the sale of organs.

It is generally wrong to manipulate. One leading reason is because manipulation interferes with autonomy, in particular the component of autonomy called ‘independence’, that is, freedom from intentional control by others. Manipulative health promotion would therefore seem wrong. However, manipulative techniques could be used to counter-manipulation, for example, playing on male fears of impotence to counter ‘smoking is sexy’ advertisements. What difference does it make to the ethics of manipulation when it is counter-manipulation? This article distinguishes two powerful defences of (...) counter-manipulative health promotion: that the counter-manipulation would prevent manipulation occurring, leaving people unmanipulated; and that the counter-manipulation would make people healthier without being any more manipulated than they would otherwise be. The article explains how counter-manipulation might work and the limits to its scope. The upshot is that counter-manipulative health promotion could respect the independence people are owed in virtue of their autonomy. However, autonomy is not the only consideration, and the article discusses further potential problems. Counter-manipulative health promotion might be misapplied, it might undermine trust, it might infringe on some norms for role behaviour and it might encourage a regrettable social practice. These objections are likely to be decisive against the counter-manipulation in some but not all cases. (shrink)

The current position on the deceased’s consent and the family’s consent to organ and tissue donation from the dead is a double veto—each has the power to withhold and override the other’s desire to donate. This paper raises, and to some extent answers, questions about the coherence of the double veto. It can be coherently defended in two ways: if it has the best effects and if the deceased has only negative rights of veto. Whether the double veto has better (...) effects than other policies requires empirical investigation, which is not undertaken here. As for rights, the paper shows that it is entirely possible that individuals have a negative right of veto but no positive right to compel acceptance of their offers. Thus if intensivists and transplant teams turn down the deceased’s offer, they do not thereby violate the deceased’s right. This leaves it open whether non-rights based reasons—such as avoiding bad publicity or distress —require intensivists and transplant teams to turn down or accept the deceased’s offer. This, however, is beyond the scope of this paper. The current position may or may not be wrong, but it is at least coherent. (shrink)

abstract This paper examines, from a philosophical point of view, the ethics of the role of the family and the deceased in decisions about organ retrieval. The paper asks: Who, out of the individual and the family, should have the ultimate power to donate or withhold organs? On the side of respecting the wishes of the deceased individual, the paper considers and rejects arguments by analogy with bequest and from posthumous bodily integrity. It develops an argument for posthumous autonomy based (...) on the liberal idea of self‐development and argues that this establishes a right of veto over donation. It claims, however, that whether the family's power to veto would conflict with posthumous autonomy rights depends on how it comes about. On the side of respecting the family's wishes, the paper first considers an argument from family distress. This supports a contingent, non‐rights‐based reason for the family's power that is trumped by the deceased's rights. It then outlines and criticises an argument based on family autonomy. The conclusion is that the individual has the right to veto the family's wish to donate and that, while the family has no right to veto the individual's wishes to donate, it can legitimately acquire this power and has done so in practice. (shrink)

Gametes, tissue, and organs can be taken from the dying or dead for reproduction, transplantation, and research. Whole bodies as well as parts can be used for teaching anatomy. While these uses are diverse, they have an ethical consideration in common: the claims of the people whose bodies are used. Is some use permissible only when people have consented to the use, actually wanted the use, would have wanted the use, not opposed the use, or what? The aim of this (...) article is to make progress in answering these questions. Initially I assume knowledge of people’s desires in order to test whether consent is directly required by their rights without worrying about mistaken uses against their wishes. I claim consent is not directly required by people’s rights. If we know people wanted or would want a use, their rights permit the use, but if we know they wanted or would want not to be used, their rights do not permit the use. The knowledge assumption is then dropped and the question becomes how to decide what to do when the wishes of rightholders are not known. I suggest working out what to do when wishes are known and then adjusting, on the basis of whatever evidence there is, for probability and strength of desire. There are other considerations too, for instance about default rules. The key general comment here is that, in setting rules, the costs to rightholders in not getting what they want needs to be taken into account. The final section tries to show that, in setting these rules, mistaken uses are not to be taken as worse than mistaken failure to use. (shrink)

People often have strong views about being the subjects of research after their deaths. Should these views be given any weight and, if so, how much? How could we find out what the views are and what should we do if we cannot? This paper defends the idea of posthumous interests and discusses the significance of those interests for research ethics. It argues that we can be guided by a symmetry between the interests of living and dead people and uses (...) posthumous privacy as an example. It also claims that the weight of those interests might not decline even over long periods of time. The arguments have important implications for the ethics of (amongst others) biomedical, archaeological, anthropological, historical, and sociological research. (shrink)

According to much modern social psychology, behavioural economics and common sense, people's actions and beliefs are frequently the result of rapid intuitive thought rather than careful deliberation. Richard Thaler and Cass Sunstein, in their influential book, Nudge, synthesised the literature and used it as the basis for numerous policy ideas.1 Not least, they gave the word ‘nudge’ as a handy term to apply to all sorts of ways of taking advantage of people's psychological quirks without coercing or bribing them. But (...) while Nudge was long on ideas and enthusiasm, it was short on conceptual clarity. The idea of a nudge was inconsistent with some of the policies Thaler and Sunstein endorsed and their account of nudging's relation to freedom and paternalism was flawed.In Salvaging the concept of nudge, Yashar Saghai acts as a friendly critic who thinks nudging has plenty to offer the policy world but sees that it needs both conceptual clarity and ethical defence.2 He wants to show how some of ways of taking advantage of people's psychology could leave them as free as before and he is especially concerned with what I would describe as a question of manipulation: …. (shrink)

ABSTRACT This paper considers what should be done about offers of organs for transplant that come with racist strings attached. Saving lives or improving their quality seem powerful reasons to accept the offer. Fairness, justice, and rejecting racism seem like powerful reasons against. This paper argues that conditional allocation should occur when it would provide access to organs for at least one person without costing others their access to organs. The bulk of the paper concentrates on defending this claim against (...) these objections: (i) that the good that might come about through conditional allocation does so through wrongful complicity in the racist's wrongdoing; (ii) that conditional allocation symbolizes support for racism; and (iii) that conditional allocation is unjust or unfair and is, for that reason, impermissible. The final section, on conditional allocation as a policy, considers the speculative possibility that conditional allocation would reduce access to organs for some, but it argues that, even then, conditional allocation could be justified. (shrink)

In a well known British case, the relatives of a dead man consented to the use of his organs for transplant on the condition that they were transplanted only into white people. The British government condemned the acceptance of racist offers and the panel they set up to report on the case condemned all conditional offers of donation. The panel appealed to a principle of altruism and meeting the greatest need. This paper criticises their reasoning. The panel’s argument does not (...) show that conditional donation is always wrong and anyway overlooks a crucial distinction between making an offer and accepting it. But even the most charitable reinterpretation of the panel’s argument does not reject selective acceptance of conditional offers. The panel’s reasoning has no merit. (shrink)

Paternalist policies in public health often aim to improve people’s well-being by reducing their options, regulating smoking offering a prime example. The well-being challenge is to show that people really are better off for having their options reduced. The distribution challenge is to show how the policies are justified since they produce losers as well as winners. If we start from these challenges, we can understand the importance of the empirical evidence that a very high proportion of smokers regret smoking. (...) In short, it is important that they regret it and important that the proportion is so high. This paper explains how, philosophically, regret can relate to well-being and it considers some of the strengths and weakness in the empirical research that the explanation brings out. The regret case for regulating smoking is indeed strong, although not as strong as the empirical researchers think. It is much weaker for paternalistic intervention in other public health problems, such as obesity and binge drinking. (shrink)

This paper gives a self-defence account of the scope and limits of the justified use of compulsion to control contagious disease. It applies an individualistic model of self-defence for state action and uses it to illuminate the constraints on public health compulsion of proportionality and using the least restrictive alternative. It next shows how a self-defence account should not be rejected on the basis of past abuses. The paper then considers two possible limits to a self-defence justification: compulsion of the (...) non-culpable and over-inclusive compulsion. The paper claims that objections to compelling the non-culpable do not greatly restrict the scope of the self-defence justification. The over-included are, however, innocent bystanders, and methods such as compulsory quarantine, vaccination, and screening are not justified in self-defence. (shrink)

Ronald Dworkin argues on the basis of a theory of well-being that critical paternalism is self-defeating. People must endorse their lives if they are to benefit. This is the endorsement constraint and this paper rejects it. For certain kinds of important mistakes that people can make in their lives, the endorsement constraint is either incredible or too narrow to rule out as much paternalism as Dworkin wants. The endorsement constraint cannot be interpreted to give sensible judgements when people change their (...) minds about the value of their lives. And the main argument for the endorsement constraint, which is based on the value of integrity, does not support Dworkin's anti-paternalism. (shrink)

Governments can try to counter obesity through preventive regulations such as sugar taxes, which appear to raise costs or reduce options for consumers. Would the regulations improve the welfare of adult consumers? The regulations might improve choice sets through a mechanism such as reformulation, but the scope for such improvement is limited. Otherwise, a paternalistic argument must be made that preventive regulations would improve welfare despite reducing choice. This paper connects arguments about obesity, health, and choice to a philosophically plausible (...) view of welfare. On the negative side, two errors to avoid are failing to see the limited value of health and thinking that findings of irrationality would alone settle arguments about welfare. On the positive side, preventive regulations could make people better-off if welfare is the satisfaction of preferences and if preventive regulations could better satisfy preferences by overcoming certain forms of irrationality. The leading evidence is from widespread attempts to lose weight. However, at least for the United States, most adults are not trying to lose weight, and that casts doubt on whether they would benefit from preventive regulations. If they would not, that seems a strong albeit not decisive reason against these regulations. (shrink)

Kidneys for transplantation are scarce, and many countries give priority to children in allocating them. This paper explains and criticizes the paediatric priority. We set out the relevant ethical principles of allocation, such as utility and severity, and the relevant facts to do with such matters as sensitization and child development. We argue that the facts and principles do not support and sometimes conflict with the priority given to children. We next consider various views on how age or the status (...) of children should affect allocation. Again, these views do not support priority to children in its current form. Since distinctions based on age ought to be positively justified, the failure of all these attempts at justification implies that the priority to children is ethically mistaken. Finally, the paper points to evidence that the paediatric priority reduces the overall supply of kidneys, at least in the United States. Paediatric priority is a real-world policy that seems discriminatory, in some places probably reduces the supply of organs, has no robust official defence, and is unsupported by mainstream ethical principles. Consequently, it should be ended. (shrink)

: It has recently become known that, in Liverpool and elsewhere, parts of children's bodies were taken postmortem and used for research without the parents being told. But should parental consent be sought before using children's corpses for medical purposes? This paper presents the view that parental consent is overrated. Arguments are rejected for consent from dead children's interests, property rights, family autonomy, and religious freedom. The only direct reason to get parental consent is to avoid distressing the parents, which (...) carries implications for the consent process, secret harvesting of body parts, and the weight to be given to parental feelings. (shrink)

This paper develops a normative evaluation of the minimum wage in the light of recent evidence and theory about its effects. It argues that the minimum wage should be evaluated using a consequentialist criterion that gives priority to the jobs and incomes of the worst off. This criterion would be accepted by many different types of consequentialism, especially given the two major views about what the minimum wage does. One is that the minimum wage harms the jobs and incomes of (...) the worst off and the other is that it does neither much harm nor much good. The paper then argues at length that there are no important considerations besides jobs and incomes relevant to the assessment of the minimum wage. It criticizes exploitation arguments for the minimum wage. It is not clear that the minimum wage would reduce exploitation and the paper doubts that, if it did, it would do so in a morally significant way. The paper then criticizes freedom arguments against the minimum wage by rejecting appeals to self-ownership and freedom of contract and by arguing that no freedom of significance is lost by the minimum wage that is not already taken account of in the main consequentialist criterion. The conclusion is that, at worst, the minimum wage is a mistake and, at best, something to be half-hearted about. Footnotes1 My thanks to Paul Brown and Jerry Cohen for their written and verbal help, Andrew Williams for long discussions of this paper, two anonymous referees and the editors, and audiences at the Universities of Auckland, Newcastle, and Reading. (shrink)

If ‘community’ is the answer, what is the problem? While questions undoubtedly arise in allocating resources to public health, such as ‘how much?’ and ‘to whom?’, we already have answers based on (i) the observation that disease and illness are bad, (ii) views of justice and fairness and (iii) an appreciation of market failure. What does the concept of community add to the existing answers? Not nothing, I shall argue, but not much either. In some cases, health providers should take (...) advantage of ties of community to deliver services more effectively. The desire to preserve communities may have some minor implications for devolved health care funding. The value of community may set some limits to inequalities in access to health care. That’s about it. I do consider some other claims of behalf of the concept, e.g. that people would not support justice in health care without a sense of community; but I don’t find these claims very plausible. Finally, I point out some ways in which communities can be damaged by the promotion of public health understood as population health. (shrink)

Mill's On Liberty is centrally concerned with avoiding social tyranny. But Mill's Principle of Liberty defines interfering, in the context of social pressure, as intentionally punishing and it seems to allow speech and actions that critics have thought would conflict with liberty in self-regarding matters. To critics, Mill draws distinctions among social influences where no genuine difference is to be found and he permits more social pressure than can be accepted by someone who values liberty highly. In this article, I (...) explain where and why Mill draws the line he does between permitted and forbidden influences and show the line is coherent and tracks a genuine difference. I also show that although the Principle leaves residual social pressure, Mill has resources besides the Principle that can prevent social influences that threaten individuality while retaining beneficial social influences. (shrink)