Self-harm within immigration detention centres has been a widely documented phenomenon, occurring at far higher rates than the wider community. Evidence suggests that factors such as the conditions of detention and uncertainty about refugee status are among the most prominent precipitators of self-harm. While important in explaining self-harm, this is not the entire story. In this paper, we argue for a more overtly political interpretation of detainee self-harm as resistance and assess the ethical implications of this view, drawing on interviews (...) with detainees from Australia’s offshore system. Self-harm by detainees is not only a medical ‘condition’ arising in response to oppression but a form of political action to lessen or contest it. We first establish how self-harm could be conceptualised as resistance. We then discuss its political purpose, noting it serves at least three functions: intrinsic, instrumental and disruptive or coercive. Viewing detainee self-harm as political resistance is a supplement to (rather than a substitute for) a medical approach. However, conceptualising self-harm this way has several advantages, namely, moving away from the idea that such behaviour is ‘maladaptive’, recognising detainees as political agents, combatting government claims of ‘manipulation’ and ‘blackmail’ and clarifying the duties of healthcare workers who work in detention. (shrink)

The global inequality in the distribution of vaccines is unjust. As countries scrambled to ensure enough vaccines, the world’s poorest were left to fend for themselves, and the generosity meant to mitigate this through COVAX was not sufficiently forthcoming. In light of this, I proposed a vaccine tax, which obligates those willing and able to pay to protect their own population to contribute to protecting those residing in the world’s low-income countries. Petrovic has offered an important critique of this proposal, (...) questioning both the fairness and the efficiency of the tax. However, when properly specified, the vaccine tax is not vulnerable to these critiques. (shrink)

This issue of the Journal of Medical Ethics focusses on the ethical implications of recent scientific and medical advances: for humans, for animals and for the boundary between the two. In this month’s ‘Current controversy’, Julian Savulescu and Tsutomu Sawai consider the implications of recent research to transplant human brain organoids into the brains of infant rats, arguing that such technology has the potential to enhance the cognitive capacities of animals in ways which invites questions over their moral status.1 This (...) debate will only increase in intensity as more sophisticated brain organoids begin to be introduced, in the future, even, perhaps, to primates. The ‘Feature Article’, written by Rodger et al,2 and its commentaries similarly consider the ethical duties owed to animals in the conduct of medical research and treatment, although in the context of xenotransplantation, where organs from animals (in particular, pigs) are transplanted into humans in a bid to tackle organ shortages. While Rodger et al proposes that in order to be ethically defensible, xenotransplantation should use genetic ‘disenhancement’ so as to eliminate or minimise the pain and suffering experienced by animals, the commentaries raise a number of issues with this proposal, questioning whether this requires the author to accept the morally permissibility of xenotransplantation in the first place, as well as whether disenhancement might inadvertently discourage the development of more ethical ways to tackle organ shortages. Taken together, these papers raise significant questions, not just about …. (shrink)

Rodger et al 1 argue that ‘ethically defensible xenotransplantation should entail the use of genetic disenhancement if it is demonstrated that’ the pain and suffering of donor pigs ‘cannot be eliminated by other means’. The phrase ‘genetic disenhancement’ refers to genetic manipulation that would produce an animal that is either less able or entirely unable to experience pain and suffering. (The phrase is euphemistic because, on one possible reading, it suggests the removal of an existing enhancement, rather than what it (...) actually is, namely a diminishment relative to the species norm.) The authors acknowledge that genetic ‘disenhancement’ is not a ‘morally ideal ‘solution’, but argue that ‘it is morally better to prevent unavoidable pain until a viable non-animal alternative becomes available’ (p. 1). In advancing this argument, they explicitly state that they make no assumption that xenotransplantation is, in principle, morally permissible. They take no stand on that issue, which is beyond the scope of their paper. They assume only that ‘ (1) xenotransplantation research will inevitably continue and (2) causing pain and suffering requires sufficient justification’ (p. 1). However, in the absence of an assumption that xenotransplantation is, in principle, morally permissible, the authors have not established their …. (shrink)

Advance directives for withholding life-saving treatment are controversial for dementia patients whose previously expressed wishes conflict with their currently expressed desires. To illustrate this ethical dilemma, McMahan conceives a hypothetical case in which an intellectually proud creative woman signs an advance directive stipulating her refusal to receive life-saving treatment if she contracts a fatal condition with dementia. However, when she develops dementia and forgets this advance directive, she contracts pneumonia and now expresses a desire to live. In response to such (...) dilemmas, scholars like Norman Cantor have defended the moral authority of advance directives by giving credence to one’s prior competent wishes over one’s current incompetent preferences. I argue that their arguments, which are rooted in the principle of respect for autonomy, operate under ableist assumptions about incompetent persons and exclude other important features of respect. I propose an ethics of care model as an alternative moral approach that reconceptualises respect as a matter of caring about people’s contemporaneous interests, even if they are not competently conceived. It fosters the virtues of care by encouraging healthcare providers to recognise dementia patients as legitimate narrative agents capable of authoring their own evolving life story. I argue that the ethics of care model not only provides an ethical defence of the creative woman’s current incompetent desire to live despite her advance directive, but also vindicates our moral intuitions about what it means to demonstrate respect to dementia patients. (shrink)

Rodger et al 1 present a thoughtful case for the ethical defensibility of genetic disenhancement targeting unnecessary harm and suffering of the pigs raised for xenotransplantation research. On the assumption that xenotransplantation research is unlikely to be halted (and by my lights, also that no other short-term palliative options can be identified or developed), their view appears to be largely reasonable and aligned with recent proposals by animal ethicists for targeting pain in factory-farmed animals. Yet, despite their thoughtful responses to (...) anticipated objections, the authors overlook an important class of recent harm-based objections grounded in the ethics of care. Drawing on recent work in animal ethics, I present a case for potential (a) care-based harms to pigs and (b) care-based harms to humans that are relevant to genetic disenhancement interventions of the sort these authors propose. I discuss each in turn below. The first concern over care-based harm draws on Mark Rowlands’2 notion that at least some non-human animals may be considered moral subjects, even if they are not considered moral agents. Rowlands’ view is based on the positive capacities that many animals possess for sympathy, compassion, kindness, patience and tolerance, as well as negative capacities including malice, anger and …. (shrink)

Jiren (畸人), literally translated as irregular (Ji) person (ren), is a critical concept in the classical Daoist text the Zhuangzi (5th–3rd century BC.).1 The concept refers to individuals with atypical body shapes. Some of them lack body parts of the standard human body, like a leg or toes. Some others have an atypical anatomy, like having a chin stuck down their navel; and some of them are, by social standards of the time, considered to be extremely ugly.1 These individuals are (...) described as incredibly virtuous. The description of Jiren individuals as virtuous does not simply aim to show there may be hidden virtues that social conventions blur. The point is not to show that we should also care for those with atypical bodies who have a hidden virtue. Rather, the point is to show that all human beings have an unconditional intrinsic value and moral worth. So, Jiren prescribes that an atypical body shape does not reflect inferiority. The variation of body anatomies should be understood as how the world is, not a value hierarchy. The concept of Jiren encourages, therefore, to consider one’s own and others’ value beyond their physical appearance. What’s more, Jiren encourages individuals to resist social pressures to fit a standard and to search inward for who they really are and accept it. This ethical groundwork set by the Jiren aims at freeing people from existing physical and mental boundaries to their well-being and helping them rethink …. (shrink)

Rodger et al argue for the disenhancement of animals intended for xenotransplantation; that is, the transference of tissues or organs from one species to another. The crux of their claim is that the conditions necessary to facilitate xenotransplantation will be hostile to those subjected to them. Thus, to minimise the suffering of living under such conditions, ‘ethically defensible xenotransplantation should entail the use of genetic disenhancement if it becomes possible to do so and if that pain and suffering cannot be (...) eliminated by other means.’1 In other words, if we can eliminate or meaningfully reduce the suffering of animals destined for xenotransplantation by obliterating their experiential capacity and lacking a less contentious method to achieve the same result, we should do so. When isolated, this argument is compelling. Suffering is terrible and should be avoided. Additionally, when we have the option to reduce another’s suffering—be that human, animal or otherwise—there are strong prima facie arguments that we should do so. This point is reinforced when we collectively are responsible for that suffering, as would be the case with xenotransplantation, and it is true regardless of how justified we are in causing that suffering. Thus, on the restrictive terms of Rodger et al ’s argument, I agree with them. We should eliminate, or if not possible, reduce, suffering wherever we can, and this applies to animals too. Having said that, when situated in the xenotransplantation context, issues with their proposal …. (shrink)

In ‘Parental Genetic Shaping and Parental Environmental Shaping’, Anca Gheaus argues there is a normative difference between parents using genetic means to influence the development of their child, and parents using environmental means to achieve the same ends. Genetic shaping but not environmental shaping, it is claimed, introduces a negative asymmetry in the child–caregiver relationship. In this paper, we argue that Gheaus’ argument fails as a critique of genetic shaping, and does not establish a moral difference between genetic and environmental (...) shaping. Contrary to Gheaus’ arguments in both ‘Parental Genetic Shaping and Parental Environmental Shaping’ and ‘Parental Enhancement and Symmetry of Power in the Parent–Child Relationship’, we also argue that even if genetic or prebirth shaping introduces further inequality in the parent–child relationship, this is not necessarily a bad thing, and it is not clear how a parent refraining from taking up the availability of such technology leaves the child better off. (shrink)

Reproduction is broadly recognised as fundamental to human flourishing. The presumptive priority of reproductive freedom forms the predominant position in the literature, translating in the non-sexual reproductive realm as an almost inviolable right to access assisted reproductive technology (ART). This position largely condemns refusal or restriction of ART by clinicians or the state as discriminatory. In this paper, I critically analyse the moral rights individuals assert in reproductive pursuit to explore whether reproductive rights entitle hopeful parents to ART. I demonstrate (...) that none of the protected actions performed, or entitlements generated are sui generis ‘reproductive’ rights, leading to the claim that there is no such thing as a right to reproduce. Under scrutiny, the reproductive right is a far narrower and weaker rights assertion than is recognised in the literature. I argue that the predominant position is grounded in a fundamental misunderstanding of the scope and strength of reproductive claims.I also highlight a significant conceptual inconsistency in the literature. On one hand, there is broad consensus that reproductive rights are predominantly negative, yet access to fertility treatment is framed as a component of the right. This wrongly contorts the negative nature of reproductive rights into a positive claim-right to ART. I conclude that this mistakenly frames ART access as sitting within the scope of reproductive freedom. I offer a revised conceptual paradigm of reproductive rights that has important clinical and policy implications for the provision and regulation of ART. (shrink)

Parity of esteemdescribes an aspiration to see mental health valued as much as physical. Proponents point to poorer funding of mental health services, greater stigma and poorer physical health for those with mental illness. Stubborn persistence of such disparities suggests a need to do more than stipulate ethical and legal obligations toward justice or fairness. Here, I propose that we should rely more on our legal obligations toward informed consent. The latter requires clinicians to disclose information about risks in a (...) way that is sufficient to satisfy what a prudent patient would reasonably want to understand in their circumstances. I argue that inadequate disclosure of the mental health complications of common surgeries risks exposing the craft specialists performing them to clinical negligence claims. Patients could argue they were counselled about said risks, improperly or not at all: improperly, if advised by a craft specialist lacking sufficient expertise in mental health; not at all, if mental health complications were simply forgotten. From this, I argue that a prudent approach for craft specialists would be to support and fund ‘integrative’ specialists (from rehabilitation medicine, liaison psychiatry and health psychology), more often to work alongside them within a multidisciplinary team that is better placed to navigate consent (via a prehabilitation process, for example). Based on duties toward consent, the extension of this type of coworking is another way to improve the resource and understanding accorded to mental health—but by starting within the citadels of physical health. (shrink)

In a recent paper in JME, Shelton and Geppert use an approach by Menzel and Chandler-Cramer to sort out ethical dilemmas about the oral feeding of patients in advanced dementia, ultimately arguing that the usefulness of advance directives about such feeding is highly limited. They misunderstand central aspects of Menzel’s and Chandler-Cramer’s approach, and in making their larger claim that such directives are much less useful than typically presumed, they fail to account for five important elements in writing good directives (...) for dementia and implementing them properly: (1) Directives should be paired with appointment of trusted agents. (2) Appointed agents’ authority can be greatly weakened without advance directives to guide them. (3) Directives’ implementation does not require clinically precise assessment of dementia’s stage. (4) Palliative support is typically required for withholding of oral feeding to be compassionate. (5) The central purpose of stopping feeding is often not the avoidance of suffering but not prolonging unwanted life. (shrink)

Following the well-publicised case of Dr Sarah Benn, the former General Practioner (GP) who was suspended from the UK medical register earlier this year for breaching injunctions in order to peacefully protest climate change,1 uncertainty and wider discourse has persisted about the extent to which doctors can be involved in protests without risking regulatory action. In response to this uncertainty, in July the General Medical Council (GMC) published an explanation of how it manages concerns about doctors’ actions as part of (...) protests and activism. It includes the statement that they are bound by law to refer any conviction resulting in a custodial sentence directly to a Medical Practioners Tribunal Service (MPTS) hearing.2 They also state that the nature of the protest does not impact their consideration of whether there was a serious breach of professional standards or a risk to public protection.2 The move to clarify the GMC’s position has been cautiously welcomed by the UK Health Alliance on Climate Change but with criticisms that important questions remain unanswered, such as the GMC’s rationale for determining that public confidence in doctors is harmed by convictions arising from environmental activism.3 Interest in this issue shows little sign of fading, as regulatory action continues to be taken against climate activist doctors. Dr Diana Warner, a retired GP, was suspended from the medical register in August following a series of convictions for …. (shrink)

Savulescu and Cameron supported selectively locking down the elderly during the COVID-19 pandemic on two grounds: first, that preserving total lockdown would entail levelling down and, second, that levelling down is wrong. Their first assumption has been thoroughly addressed, but more can be said about their wider antiegalitarian point that levelling down is simply wrong. Egalitarians are not defenceless against the levelling-down objection. Even though some consider it the most serious challenge to supporters of equality, egalitarianism possesses sound reasons to (...) assert, not only that something valuable is preserved when we level down, but also that preserving it may be, in certain circumstances, preferable to pursuing other fundamental moral goals. Although troublesome from a well-being maximising standpoint, levelling down ensures that healthcare policy reflects a commitment with the idea that people are equal in moral worth. That commitment is important enough to trump certain improvements in individual well-being. In the case of pandemic lockdowns, not all the interests protected by free movement are as fundamental as to pursue them at the cost of equality. Savulescu and Cameron’s framework is so reliant on the view that levelling down is wrong that it fails to account for the valuable loss that having the elderly suffer alone represents. (shrink)

Rodger et al have interestingly argued that xenotransplantation should, if possible, entail the use of genetic pain disenhancement to prevent otherwise unavoidable pain in ‘donor’ animals.1 Their argument relies on the empirical assumption that xenotransplantation offers a realistic solution to organ shortage, and that, due to the recent clinical developments and the lack of human donors, it will thus continue for the foreseeable future. We argue below that other options should be prioritised over xenotransplantation, and that so-called ‘non-sentientist’ harms are (...) undervalued in discussions on disenhancement. We do not challenge the empirical claim made by the authors. That is, xenotransplantation research might continue for the foreseeable future since organ demand is increasing. However, we disagree with the priority given to xenotransplantation over other solutions that are more morally desirable. We argue that, if we comply with the 3R principles (Replacement, Reduction, and Refinement of the use of animals in research) and follow a minimal welfarist reasoning (to which the authors seem to adhere), then (1) the principle of replacement demands the use of non-animal alternatives if possible and (2) there are alternative solutions that lead to morally better consequences. Schematically, there are …. (shrink)

We read the four commentaries on our article with much interest.1 Each response provides stimulating discussion, and below we have attempted to respond to specific issues that they have raised. We regret that we are not able to respond point-by-point to each of them. However, before our responses, it may benefit the reader if we briefly summarise the claims in our article. First, we hold two presuppositions: (1) xenotransplantation research will inevitably continue for the foreseeable future, and (2) causing suffering (...) and pain requires sufficient justification and should be mitigated where possible. Second, based on these two presuppositions, we posit an argument for the further genetic modification of pigs for xenotransplantation that would eliminate certain experiences of pain and suffering should it become possible to do so. Gibson,2 in his commentary, is sceptical—for good reason—that ‘xenotransplantation-motivated disenhancement would be a temporary stopgap until the organ and tissue shortage problem is solved via less contentious means’. Gibson’s argument is grounded in the fact that the biotechnology industry—of which xenotransplantation is part of—is beholden to economic and market forces that would likely perpetuate constancy, thereby making it difficult to transition away from using disenhanced genetically engineered pigs for xenotransplantation. This point is well taken, …. (shrink)

One objection to xenotransplantation is that it will require the large-scale breeding, raising and killing of genetically modified pigs. The pigs will need to be raised in designated pathogen-free facilities and undergo a range of medical tests before having their organs removed and being euthanised. As a result, they will have significantly shortened life expectancies, will experience pain and suffering and be subject to a degree of social and environmental deprivation. To minimise the impact of these factors, we propose the (...) following option for consideration—ethically defensible xenotransplantation should entail the use of genetic disenhancementifit becomes possible to do so and if that pain and suffering cannot be eliminated by other means. Despite not being a morally ideal ‘solution’, itismorally better to prevent unavoidable pain until a viable non-animal alternative becomes available. (shrink)

Miller has recently argued that fetuses have the same inherent value as non-disabled adults. However, we do not need to postulate some property possessed equally by all humans, including fetuses, in order to explain the equality of non-disabled adults. It would suffice if there were some property possessed by all non-disabled adults, but not by fetuses.

We review recent research to introduce human brain organoids into the brains of infant rats. This research shows these organoids integrate and function to affect behaviour in rats. We argue that this raises issues of moral status that will imminently arise and must be addressed through functional studies of these new life forms. We situate this research in the broader context of the biological revolution, arguing we already have the technological power to create fully human embodied animals. This raises profound, (...) so far unaddressed ethical issues which call for urgent attention. (shrink)

Advance directives are critically important for capable individuals who wish to avoid the burdens of life-prolonging interventions in the advanced stages of dementia. However, this paper will argue that advance directives should have less application to questions about feeding patients during the clinical course of dementia than often has been presumed. The argument will be framed within the debate between Ronald Dworkin and Rebecca Dresser regarding the moral authority of precedent autonomy to determine an individual’s future end-of-life care plan. We (...) will use a brief analysis of the positions taken in two important papers that come out of the Dworkin/Dresser debate and a hypothetical patient, John, who will be followed from diagnosis of dementia to death, to show how advance directives should apply to key points in the progression of his disease, particularly in relation to food and nutrition. (shrink)

Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I (...) argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst’s argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully’s argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully’s is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD. (shrink)

‘Ethics first’ reform in China significantly changes the governance framework for the research of emerging technologies. The misapplication of human genome editing technology reflects the urgent need to reform the governance framework. Strengthening ethics governance in medical research has become a consensus in China, where legal and ethical reforms are proceeding in parallel. The protection of human dignity, the prevention of biosafety risks, as well as the regulation of technological crimes are at the core of the legal system, which has (...) been embodied in numerous fundamental legislations following the CRISPR-babies incident. Establishing a national ethics committee to coordinate ethics governance, and reinforcing ethics review and external oversight are significant steps in ethical reform. Essentially, ethics governance requires implementing the basic concept of ‘ethics first’, focusing on forward-looking and preventive governance rather than delayed intervention, while maintaining openness and collaboration. (shrink)

Some National Health Service healthcare boards in the UK will approve a request for female sterilisation only if the patient first accepts a trial period of 1 year with an intrauterine device (IUD), a form of long-acting reversible contraception. In this article, I argue that this requirement is not justified by appeal to any of (or any combination of) promotion of informed consent, paternalistic concerns regarding patient regret in later life and health service budgetary considerations. Informed consent and patient autonomy (...) may be promoted by a mandatory waiting period, but the concomitant imposition of an IUD trial during this period cannot be justified on these grounds. As long as elective vasectomy is offered by the healthcare system, elective female sterilisation should be accessible under reasonably similar—even if not identical—conditions. (shrink)

This month’s issue of _Journal of Medical Ethics_ features a symposium on ‘neuro rights’ and the ‘right to mental integrity’. Medical ethics and the law have long recognised bodily rights—motivating requirements that patients give informed consent before medical interventions are performed on them or before research is conducted on them. Rapid advancements in neuroscience and neurotechnology are raising new questions about the boundaries of bodily rights, whether they extend to the mind or the brain, or whether we need new concepts (...) and rights to apply to the mental sphere. As Farahany 1 writes in her recent (2023) book, ‘The Battle for Your Brain’, the global market for consumer neurotechnology is growing rapidly, expecting to reach US$21 billion by 2026. A growing number of people are using personal neurotechnology that allows them to visualise and track their emotions, levels of alertness and concentration, as well as their actual brain... (shrink)

The idea of a ‘right to mental integrity’, sometimes referred to as a ‘right against mental interference,’ is a relatively new concept in bioethics, making its way into debates about neurotechnological advances and the establishment of ‘neurorights.’ In this paper, we interrogate the idea of a right to mental integrity. First, we argue that some experts define the right to mental integrity so broadly that rights violations become ubiquitous, thereby trivialising some of the very harms the concept is meant to (...) address. Second, rights-based framing results in an overemphasis on the normative importance of consent, implying that neurointerventions are permissible in cases where people consent to have their mental states influenced or read off, a confidence in consent that we argue is misguided. Third, the concept often collapses the ethics of brain inputs and brain outputs, potentially resulting in a loss of important conceptual nuance. Finally, we argue that the concept of a right to mental integrity is superfluous—what is wrong with most violations of mental integrity can be explained by existing concepts such as autonomy, manipulation, privacy, bodily rights, surveillance, harm and exploitation of vulnerabilities. We conclude that bioethicists and policy-makers ought to either make use of these concepts rather than arguing for the existence of a new right, or they need to avoid making rights violations ubiquitous by settling on a narrower and more rigorous definition of the right. (shrink)

According to the expressivist objection, laws that only allow assisted dying for those suffering from certain medical conditions express the judgement that their lives are not worth living. I have recently argued that an autonomy-based approach that legally allows assisted suicide for all who make an autonomous request is a way to avoid the expressivist objection. In response to this, Thomas Donaldson has argued that rather than avoiding the expressivist objection, an autonomy-based approach extends this objection. According to Donaldson, this (...) is because helping a person achieve a goal requires endorsement of that goal. In this reply, I show that Donaldson misunderstands the target of the expressivist objection: it is not aimed at an individual’s attitude towards another person’s death but rather at a legal regulation. Moreover, helping someone end their life does not necessarily require endorsing this goal—instead, respect for a person’s autonomous choice can be another reason for providing assisted suicide. Donaldson also assumes that the autonomy-based approach requires doctors to accept autonomous requests for assisted dying. Yet, this approach merely makes it legal for individuals (not necessarily only doctors) to provide assisted suicide to autonomous persons but does not require anyone to do so. (shrink)

Tyler Paetkau, in his paper ‘Ladders and Stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions’, adds to the growing body of academic literature raising questions about the appropriateness and usefulness of the Nuffield Council on Bioethics (NCB)’s intervention ladder (2007) as a tool for policymakers.1 2 Paetkau is critical of the intervention ladder because he holds that it focuses on individual choice and personal responsibility and pays insufficient attention to ‘systemic interventions’. He suggests (...) substituting the new metaphor of an ‘intervention stairway’ for that of the intervention ladder. I argue that his diagnosis of the problems does not go far enough and that his suggested alternative metaphor is more confusing than helpful. Paetkau’s critical analysis of the intervention ladder makes some good points. It is true that this metaphor assumes a narrow range of policy options, with a focus on changing individual behaviour, and a consequent emphasis on personal responsibility. This is the flip-side of the NCB’s focus on liberty as always being a positive value and restriction seen as intrinsically wrong. Paetkau points out that this means that much routine public health action directed at changing the more structural features that impact on health is missing from the story. I set this …. (shrink)

In this paper, I examine the connections between bipolar disorder and consent. I defend the view that many (although far from all) individuals with bipolar disorder are competent to consent to a wide variety of things when they are in a manic state.

In a recent paper, Braun argued for an autonomy-based approach to assisted suicide as a way to avoid the expressivist objection to assisted dying laws. In this paper, I will argue that an autonomy-based approach actually extends the expressivist objection to assisted dying because it is not possible for one agent to assist another in pursuit of a goal without expressing that it would be good for that goal to come about. Braun argued that assisted dying should be viewed purely (...) as an individual’s autonomous action, but this requires the assistance of the medical professional to be understood as that of a non-moral automaton, such as a suicide booth. Instead, it will be argued that a beneficent motivation to promote human flourishing provides moral reasons for both non-interference in the actions, for example, suicide, of competent agents and for considering whether assisting another agent with their goal will promote their flourishing. (shrink)

In his feature article, Tyler Paetkau1 argues that the Nuffield Council on Bioethics’ (NCOB) infamous intervention ladder2 fails to acknowledge systemic influences towards poor health outcomes and instead places the blame on individuals. The ladder of interventions to change individual health behaviours runs from less intrusive to more intrusive and pays less attention to possible regulatory mechanisms for big businesses that would often avoid such intrusion on individuals and the punitive implications of that intrusion. Paetkau cites smoking bans and food (...) labelling as examples of various levels of public health measures intruding on individual freedoms. According to him, instead of preventing people from smoking in public spaces or trying to influence their food purchase decisions, we should instead address the social determinants of health through systemic interventions, by which he means ‘interventions that operate on the level of systems rather than individuals and do not target or require individual behaviour change’1 (p. 2). The argument, however, might be questioned. At points in the article, Paetkau proposes that his new, broadened ‘stairway’ set of public health interventions ‘highlights the intimate connection between systemic interventions and individual outcomes’1 (p. 5). However, in some places, …. (shrink)

In a recent article, Director makes the case that many individuals with bipolar disorder have the capacity to consent to many decisions while acutely manic, even when those decisions are out of character and cause harm. Referring to recent qualitative evidence, I argue that Director overlooks a key mechanism of manic incapacity, an inflexible experience of the future that impairs one’s ability to value. Without attention to the illness-specific experience of decision-making, capacity assessments risk false negatives in people with mania.

Neuropsychiatric disorders such as drug addiction, depression and schizophrenia are often centrally implicated in public health challenges. These conditions impact the individuals affected and have widespread implications, contributing to related crises such as opioid epidemic, rising suicide rates and homelessness. Despite their influence, public health interventions frequently emphasise individual responsibility, overlooking the complex interplay of neurobiological and systemic factors that underpin these disorders. Current public health frameworks, such as the Nuffield Council on Bioethics’ intervention ladder, prioritise efforts that encourage individual (...) behaviour change. Paetkau critiques this emphasis on individual responsibility, emphasising the need to consider more systemic factors, such as social determinants of health, as targets of necessary intervention.1 We aim to reinforce Paetkau’s critique of the intervention ladder by introducing three neuropsychiatric case studies, each highlighting the limitations of an individual-based framework in addressing psychopathology-involved public health issues. We argue that conditions like addiction, depression and serious mental illness undermine the emphasis on individual responsibility in public health and policy interventions. To this end, neuroscience demonstrates that effective public health interventions necessitate a shift from the long-standing emphasis on individual responsibility towards more comprehensive, systems-level interventions. Opioid overdose deaths in the USA have sextupled since 1999, with over 100,000 deaths in 2023 alone.2 The opioid crisis has since remained one of the most pressing public …. (shrink)

The Nuffield Council on Bioethics introduced an ‘intervention ladder’ to guide policymakers on public health interventions.1 The ladder’s vertical structure represents an ordering of interventions, from least to most intrusive. In his article, Paetkau acknowledges that this ladder is ‘a useful tool’ (p. 1) for evaluating public health interventions.2 However, he objects that its focus on individual behaviour is too narrow and obscures ‘interventions that operate on the level of systems rather than individuals’ (p. 2). To be sure, some of (...) the interventions on the original ladder do involve what might ordinarily be seen as ‘system’ or environmental changes. For instance, we might encourage active transport by building dedicated cycle lanes. However, these measures still have their intended effects through altering individual choices. What Paetkau means by a ‘systemic intervention’ is specifically one that improves public health without changing individual behaviour change (pp. 2–3). For example, reducing pollution or improving public health infrastructure. He suggests that, because the Nuffield ladder focuses on individual behaviour, it may lead policymakers to overlook these possibilities. Paetkau proposes broadening the ladder to include systemic interventions. This results in what he calls a ‘stairway’ (p. 3). It …. (shrink)

The Nuffield Council on Bioethics introduced an ‘intervention ladder’ to guide policymakers on public health interventions. 1 The ladder’s vertical structure represents an ordering of interventions, from least to most intrusive. In his article, Paetkau acknowledges that this ladder is ‘a useful tool’ (p. 1) for evaluating public health interventions. 2 However, he objects that its focus on individual behaviour is too narrow and obscures ‘interventions that operate on the level of systems rather than individuals’ (p. 2). To be sure, (...) some of the interventions on the original ladder do involve what might ordinarily be seen as ‘system’ or environmental changes. For instance, we might encourage active transport by building dedicated cycle lanes. However, these measures still have their intended effects through altering individual choices. What Paetkau means by a ‘systemic intervention’ is specifically one that improves public health _without_ changing individual behaviour change (pp. 2–3). For... (shrink)

The intervention stairway emerges from recognising the complexity inherent in public health issues. While the original intervention ladder is a valuable tool, it risks ignoring this complexity, narrowing our focus to individual-level interventions at the expense of systemic considerations. Some have interpreted this critique as claiming the ladder entirely precludes consideration of systemic factors.1 This is not the case. Instead, the claim is that the ladder obscures these factors, making them more challenging to recognise and incorporate into policy. This critique (...) has generated several responses. Smith and Gauthier argue that the ladder will not obscure systemic considerations as it is primarily a tool for policy evaluation, not policy creation.1 Moreover, they suggest that even if used for policy creation, the ladder will likely generate systemic interventions as these are often less intrusive. By contrast, Dawson has objected to the stairways’ focus on intrusiveness, supposedly at the expense of other values, saying, ‘the only justification for a tool such as the intervention ladder is if liberty is, implausibly, given some privileged status over other values’.2 These critiques warrant careful consideration but ultimately misunderstand the purpose of both the original ladder and the proposed stairway. Neither tool is meant to privilege liberty or be used in isolation. Rather, they are tools for weighing considerations of intrusiveness and proportionality designed to be applied within …. (shrink)

Introduced in 2007 by the Nuffield Council on Bioethics, the intervention ladder has become an influential tool in bioethics and public health policy for weighing the justification for interventions and for weighing considerations of intrusiveness and proportionality. However, while such considerations are critical, in its focus on these factors, the ladder overemphasises the role of personal responsibility and the importance of individual behaviour change in public health interventions. Through a study of vaccine hesitancy and vaccine mandates among healthcare workers, this (...) paper investigates how the ladder obscures systemic factors such as the social determinants of health. In overlooking these factors, potentially effective interventions are left off the table and the intervention ladder serves to divert attention away from key issues in public health. This paper, therefore, proposes a replacement for the intervention ladder—the intervention stairway. By broadening the intervention ladder to include systemic factors, the stairway ensures relevant interventions are not neglected merely due to the framing of the issue. Moreover, it more accurately captures factors influencing individual health as well as allocations of responsibility for improving these factors. (shrink)

The intervention ladder, developed by the Nuffield Council on Bioethics, is a framework intended to help evaluate the ethical acceptability and justification of public health interventions according to their intrusion on liberty.1 In their recent article, Paetkau2 argues ‘the ladder obscures potential interventions that operate on a systemic rather than individual level’ (p. 1) and that ‘it is crucial that systemic interventions not be left off the table when considering potential concrete interventions’ (p. 3), leading them to propose instead the (...) ‘intervention stairway’. Yet, in this commentary we argue the intervention ladder does not delimit the sorts of public health interventions that may be considered to address a public health issue, although it may speak to their putative justification. Hence, despite its other considerable shortcomings,3 4 there is no need, as Paetkau argues, to broaden the intervention ladder to include systemic factors. Contrary to Paetkau’s claim, the intervention ladder does not preclude policymakers from considering systemic factors’ impact on health outcomes or the public health interventions and strategies that could be implemented to address them. Paetkau adduces the example of measures to protect patients, healthcare workers and healthcare capacity from the threat of infectious diseases. They argue that certain …. (shrink)

The possibility of neurotechnological interference with our brain and mind raises questions about the moral rights that would protect against the (mis)use of these technologies. One such moral right that has received recent attention is the right to mental integrity. Though the metaphysical boundaries of the mind are a matter of live debate, most defences of this moral right seem to assume an internalist (brain-based) view of the mind. In this article, we will examine what an extended account of the (...) mind might imply for the right to mental integrity and the protection it provides against neurotechnologies. We argue that, on an extended account of the mind, the scope of the right to mental integrity would expand significantly, implying that neurotechnologies would no longer pose a uniquely serious threat to the right. In addition, some neurotechnologies may even be protected by the right to mental integrity, as the technologies would becomepart ofthe mind. We conclude that adopting an extended account of the mind has significant implications for the right to mental integrity in terms of its protective scope and capacity to protect against neurotechnologies, demonstrating that metaphysical assumptions about the mind play an important role in determining the moral protection provided by the right. (shrink)

Children dependent on life-prolonging medical technology are often subject to a constant background risk of sudden death or catastrophic complications. Such children can be cared for in hospital, in an intensive care environment with highly trained nurses and doctors able to deliver specialised, life-saving care immediately. However, remaining in hospital, when life expectancy is limited, can considered to be a harm in of itself. Discharge home offers the possibility for an improved quality of life for the child and their family (...) but comes with significant medical risks.When making decisions for children, two ethical models predominate, the promotion of the child’s best interests or the avoidance of harm. However, in some circumstances, particularly for children with life-limiting and/or life-threatening illness, all options may be associated with risk. There are no good options, only potentially harmful choices.In this paper, we explore decisions made by one family in such circumstances. We describe a model adopted from risk management programmes beyond medicine, which offers a potential framework for identifying risks to the child that are morally permissible. Some risks and harms to a child, not ordinarily permitted, may be acceptable when undertaken in the pursuit of a specified desired good, so long as they are as low as reasonably practicable. (shrink)

The current human rights framework can shield people from many of the risks associated with neurotechnological applications. However, it has been argued that we need either to articulate new rights or reconceptualise existing ones in order to prevent some of these risks. In this paper, we would like to address the recent discussion about whether current reconceptualisations of the right to mental integrity identify an ethical dimension that is not covered by existing moral and/or legal rights. The main challenge of (...) these proposals is that they make mental integrity indistinguishable from autonomy. They define mental integrity in terms of the control we can have over our mental states, which seems to be part of the authenticity condition for autonomous action. Based on a fairly comprehensive notion of mental health (ie, a notion that is not limited to the mere absence of illness), we propose an alternative view according to which mental integrity can be characterised both as a positive right to (medical and non-medical) interventions that restore and sustain mental and neural function, and promote its development and a negative right protecting people from interventions that threaten or undermine these functions or their development. We will argue that this notion is dissociated from cognitive control and therefore can be adequately distinguished from autonomy. (shrink)

Many technology ethicists hold that the time has come to articulate _neurorights_: our normative claims vis-à-vis our brains and minds. One such claim is the right to _mental integrity_ (‘MI’). I begin by considering some paradigmatic threats to MI (§1) and how the dominant autonomy-based conception (‘ABC’) of MI attempts to make sense of them (§2). I next consider the objection that the ABC is _overbroad_ in its understanding of what threatens MI and suggest a friendly revision to the ABC (...) that addresses the objection (§3). I then consider a second objection: that the ABC cannot make sense of the MI of the _non-autonomous_. This objection appears fatal even to the revised ABC (§4). On that basis, I develop an alternative conception on which MI is grounded in a plurality of simpler capacities, namely, those for _affect_, _cognition_, and _volition_. Each of these more basic capacities grounds a set of fundamental interests, and they are for that reason worthy of protection even when they do not rise to the level of complexity necessary for autonomy (§5). This yields a fully general theory of MI that accounts for its manifestations in both the autonomous and the non-autonomous. (shrink)

Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as ‘completely’ or ‘mostly’ unethical. Participants were also asked to rank-order the value of (...) five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as theleastvaluable (even less valuable than an anecdote) and 35.7.% viewing it as themostvaluable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects. (shrink)

Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different (...) from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1)prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2)prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies—while potentially resulting in care that deviates from usual standards–support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers. (shrink)

The antiabortion movement is increasingly using ostensibly scientific measurements such as ‘fetal heartbeat’ and ‘fetal pain’ to provide ‘objective’ evidence of the moral status of fetuses. However, there is little knowledge on how clinicians conceptualise and operationalise the moral status of fetuses. We interviewed obstetrician/gynaecologists and neonatologists on this topic since their practice regularly includes clinical management of entities of the same gestational age. Contrary to our expectations, there was consensus among clinicians about conceptions of moral status regardless of specialty. (...) First, clinicians tended to take a gradualist approach to moral status during pregnancy as they developed and viewed viability, the ability to live outside of the uterus, as morally significant. Second, in contrast to ‘fetal pain’ laws and philosophical discussions about the ethical salience of sentience, the clinicians in our study did not consider the ability to feel pain as a morally relevant factor in moral status determinations. Third, during previability and perviability, clinicians viewed moral status as a personal value decision, which should be made by pregnant people and parents of neonates. (shrink)

The antiabortion movement is increasingly using ostensibly scientific measurements such as ‘fetal heartbeat’ and ‘fetal pain’ to provide ‘objective’ evidence of the moral status of fetuses. However, there is little knowledge on how clinicians conceptualise and operationalise the moral status of fetuses. We interviewed obstetrician/gynaecologists and neonatologists on this topic since their practice regularly includes clinical management of entities of the same gestational age. Contrary to our expectations, there was consensus among clinicians about conceptions of moral status regardless of specialty. (...) First, clinicians tended to take a gradualist approach to moral status during pregnancy as they developed and viewed viability, the ability to live outside of the uterus, as morally significant. Second, in contrast to ‘fetal pain’ laws and philosophical discussions about the ethical salience of sentience, the clinicians in our study did not consider the ability to feel pain as a morally relevant factor in moral status determinations. Third, during previability and perviability, clinicians viewed moral status as a personal value decision, which should be made by pregnant people and parents of neonates. (shrink)

Large language models (LLMs) have now entered the realm of medical ethics. In a recent study, Balaset alexamined the performance of GPT-4, a commercially available LLM, assessing its performance in generating responses to diverse medical ethics cases. Their findings reveal that GPT-4 demonstrates an ability to identify and articulate complex medical ethical issues, although its proficiency in encoding the depth of real-world ethical dilemmas remains an avenue for improvement. Investigating the integration of LLMs into medical ethics decision-making appears to be (...) an interesting avenue of research. However, despite the promising trajectory of LLM technology in medicine, it is crucial to exercise caution and refrain from attributing their expertise to medical ethics. Our thesis follows an examination of the nature of expertise and the epistemic limitations that affect LLM technology. As a result, we propose two more fitting applications of LLMs in medical ethics: first, as tools for mining electronic health records or scientific literature, thereby supplementing evidence for resolving medical ethics cases, and second, as educational platforms to foster ethical reflection and critical thinking skills among students and residents. The integration of LLMs in medical ethics, while promising, requires careful consideration of their epistemic limitations. Consequently, a well-considered definition of their role in ethically sensitive decision-making is crucial. (shrink)

Seasonal influenza poses a significant public health risk in many countries worldwide. Lower immunity and less influenza virus circulating during the pandemic has resulted in a significant increase in cases since the lifting of COVID-19 restrictions in 2022. The seasonal influenza vaccine offers effective protection and is safe for use in large numbers of the population. This article asserts that a moral obligation to vaccinate against influenza can be understood as an Institutional Duty of Rescue. The traditional understanding of the (...) Duty of Rescue encounters issues with force and scope, making it difficult to apply to rescue cases in general, as well as being overdemanding for the individual agent. An Institutional view of the Duty of Rescue addresses these difficulties, looks at the wider context of rescue and leaves room for discussion on collective, preventative rescue measures. This makes the concept well suited to supporting a moral obligation to vaccinate against influenza as part of a collective effort on the part of institutional organisations. (shrink)

Nipah virus is a priority pathogen that is receiving increasing attention among scientists and in work on epidemic preparedness. Despite this trend, there has been almost no bioethical work examining ethical considerations surrounding the epidemiology, prevention, and treatment of Nipah virus or research that has already begun into animal and human vaccines. In this paper, we advance the case for further work on Nipah virus disease in public health ethics due to the distinct issues it raises concerning communication about the (...) modes of transmission, the burdens of public health surveillance, the recent use of stringent public health measures during epidemics, and social or religious norms intersecting with preventive measures. We also advance the case for further work on Nipah virus disease in research ethics, given ethical issues surrounding potential vaccine trials for a high-fatality disease with sporadic spillover events, the different local contexts where trials may occur, and the potential use of unproven therapeutics during outbreaks. Further bioethics work may help to ensure that research and public health interventions for Nipah virus disease are ethically acceptable and more likely to be effective. (shrink)

Ugar and Malele write that generic machine learning (ML) technologies for mental health diagnosis would be challenging to implement in sub-Saharan Africa due to cultural specificities in how those conditions are diagnosed. For example, they say that in South Africa, the appearance of ‘schizophrenia’ might be understood as a type of spiritual possession, rather than a mental disorder caused by a brain dysfunction. Hence, a generic ML system is likely to ‘misdiagnose’ persons whose symptomatology matches that of schizophrenia in the (...) South African context. The authors thus claim that ‘a generic or universal design cannot be effective given the heterogeneity of value judgements in defining what mental health disorders are in different contexts’.1 Should we take this to mean that ML systems ‘should not be designed with a generalised perception of mental disorders,’1 as the authors suggest? On the contrary, my view is that generic ML can be useful, with the caveat that issues of cultural sensitivity may engender translational challenges in various national and cultural contexts. Yet, if it can be demonstrated that a generic ML system can reliably and accurately pick up on shared symptomatologies across cultures despite what any individual or community might believe about their actual causes, this aspect is surely the function and value of diagnostic ML which we should take to matter. Cultural gaps in aetiological understandings of mental health conditions make it all the more important to advance generic ML as a calibrating diagnostic tool. In this commentary, therefore, I will endeavour to make a case for generic ML in mental healthcare. ### Aetiological (mis)understanding across cultures The fundamental complexity to which Ugar and Malele direct our attention is the fact that mental health conditions are attributed to variable causal explanations, rather than a …. (shrink)

The practice of medicine—and especially the patient-doctor relationship—has seen exceptional shifts in ethical standards of care over the past few years, which by and large originate in occidental countries and are then extrapolated worldwide. However, this phenomenon is blind to the fact that an ethical practice of medicine remains hugely dependent on prevailing cultural and societal expectations of the community in which it serves. One model aiming to conceptualise the dichotomous efforts for global standardisation of medical care against differing sociocultural (...) expectations is the individualism-collectivism model, with the ‘West’ being seen as individualistic and the ‘East’ being seen as collectivistic. This has been used by many academics to explain differences in approach towards ethical practice on key concepts such as informed consent and patient autonomy. However, I argue that this characterisation is incomplete and lacks nuance into the complexities surrounding cross-cultural ethics in practice, and I propose an alternative model based on the ethics of clinical care in Hong Kong, China. Core ethical principles need not be culture-bound—indeed, their very existence mandates for them to be universal and non-derogable—but instead cultural alignment occurs in the particular implementation of these principles, insofar as they respect the general spirit of contemporary ethical standards. (shrink)

Research involving recently deceased humans that are physiologically maintained following declaration of death by neurologic criteria—or ‘research involving the recently deceased’—can fill a translational research gap while reducing harm to animals and living human subjects. It also creates new challenges for honouring the donor’s legacy, respecting the rights of donor loved ones, resource allocation and public health. As this research model gains traction, new empirical ethics questions must be answered to preserve public trust in all forms of tissue donation and (...) in the practice of medicine while respecting the legacy of the deceased and the rights of donor loved ones. This article suggests several topics for immediate investigation to understand the attitudes and experiences of researchers, clinical collaborators, donor loved ones and the public to ensure research involving the recently deceased advances ethically. (shrink)

Introduction In their contribution, Ugar and Malele 1 shed light on an often overlooked but crucial aspect of the ethical development of machine learning (ML) systems to support the diagnosis of mental health disorders. The authors restrain their focus on pointing to the danger of misdiagnosing mental health pathologies that do not qualify as such within sub-Saharan African communities and argue for the need to include population-specific values in these technologies’ design. However, an analysis of the nature of the harm (...) caused to said populations once their values remain unrecognised is not offered. Building on Ugar and Malele’s considerations, we add a further perspective to their analysis by showing the need to design considering intended values to avoid the occurrence of epistemic injustices. 2 First, we argue that failing to acknowledge the hermeneutical offerings of the populations interacting with these systems can qualify as _contributory injustice_.shrink)

In their paper ‘Designing AI for mental health diagnosis: challenges from sub-Saharan African value-laden judgements on mental health disorders’, Ugar and Malele focused on the challenges and considerations surrounding the design and implementation of artificial intelligence (AI) and machine learning (ML) technologies for diagnosing mental health disorders in South Africa. Although the authors recognise the application of AI and ML in healthcare, they put forward the challenges, particularly in adopting Wakefield’s hybrid theory, where elements of naturalism and normativism are combined (...) in defining mental disorders. They argue that a generic or universally designed AI or ML would not be appropriate in countries with strong and varied local contexts. Hence, they believe that current and future AI developers should consider the cultural nuances, value systems and contextual factors in designing and implementing AI technologies for mental health diagnosis in Africa. When the authors argue that a universal definition of mental health may not be appropriate in Africa, we would like to offer something in contrast. If nomenclature like the Diagnostic and Statistical Manual of Mental Disorders (DSM) can be widely accepted, why does AI, which relies on these codes, encounter scepticism? Recognising the significant influence of culture on all aspects of patient care in psychiatry, the DSM-IV introduced the …. (shrink)

Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI) is an ethical framework developed by the WHO for using unproven interventions in public health emergencies outside the context of medical research. It is mainly intended for use when medical research would be impracticable, but there is still a need to systematically gather data about unproven interventions. As such, it is designed as something of a middle ground between clinical and research ethical frameworks. However, I argue that MEURI does not truly (...) lie at the intersection of clinical care and research. Due to its intent, structure and oversight requirements, it takes on most of the crucial features of research, to the point that it is best understood as a form of research. As a result, cases where MEURI could practicably be applied should instead make use of existing research frameworks. For those circumstances where research is truly impracticable, a more straightforward oversight system than MEURI is needed. While existing practices of compassionate use have some applicability, proposals to make use of clinical ethics committees to oversee unproven interventions may help achieve the right balance in acting in a patient’s best interests when the relevant evidence base is weak. (shrink)

Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI) is an ethical framework developed by the WHO for using unproven interventions in public health emergencies outside the context of medical research. It is mainly intended for use when medical research would be impracticable, but there is still a need to systematically gather data about unproven interventions. As such, it is designed as something of a middle ground between clinical and research ethical frameworks. However, I argue that MEURI does not truly (...) lie at the intersection of clinical care and research. Due to its intent, structure and oversight requirements, it takes on most of the crucial features of research, to the point that it is best understood as a form of research. As a result, cases where MEURI could practicably be applied should instead make use of existing research frameworks. For those circumstances where research is truly impracticable, a more straightforward oversight system than MEURI is needed. While existing practices of compassionate use have some applicability, proposals to make use of clinical ethics committees to oversee unproven interventions may help achieve the right balance in acting in a patient’s best interests when the relevant evidence base is weak. (shrink)

Earlier this year, the International Association of Bioethics (IAB) hosted the biennial World Congress of Bioethics (WCB) in Doha, Qatar. Understandably, controversy surrounded the decision to hold the conference there. Opponents thought Qatar’s human rights record rendered it incompatible with the IAB’s mission. 1 2 Proponents felt that the location was overall justified to advance equitable participation in the WCB. 3 4 The discussion about the Qatar venue was an important one. But unlike in real estate, where the mantra of (...) ‘location, location, location’ highlights the often singular importance of geophysical coordinates, the debate about equity in global bioethics scholarship and practice is broader than where the WCB takes place. As we entered the intercongress time frame, it is helpful to consider in what other ways the IAB—and leading journals such as the JME—can contribute to equity in bioethics outside of events such... (shrink)

Ugar and Malele 1 critique the use of ‘generic’ technologies like artificial intelligence (AI) and machine learning (ML) for mental health diagnoses, particularly in sub-Saharan African countries. They highlight how these AI medical tools often overlook traditional perspectives and local contexts. The article has the merit of working on ethical issues regarding the particularities and risks of using AI and ML for health diagnosis in the Global South, an urgent and neglected topic. According to the authors, the use of these (...) AI technologies leads to overgeneralisation in diagnosing mental disorders, which could be especially problematic in the mental health field because of value-laden judgements intrinsic to the definition of mental health disorders. This argument is theoretically grounded in the hybrid conceptualisation of mental disorders proposed by Wakefield. 2 This author’s perspective incorporates both factual and value components in defining mental disorders, framing them as context-dependent ‘harmful dysfunctions’... (shrink)

Hendricks set out to construct an antiabortion version of Jeff McMahan’s Embryo Rescue case in which you have two choices—(1) save a woman from an unwilling pregnancy or (2) save a fetus from being killed. In his Pregnancy Rescue case, he contends we ought to choose (2), which he thinks shows abortion is immoral. However, I argue the Pregnancy Rescue case is a false dilemma because you can save both. I propose an alternative, more elegant dilemma, the Ectogenesis Rescue case (...) with the same choices (1) and (2). Hendricks also believes his case can serve as an antiabortion version of Thomson’s Violinist case, showing that abortion is immoral even if a fetus is not a person. However, while Thomson’s Violinist substitutes the fetus with a person, Hendricks fails to substitute the fetus with something that is not a person. I propose an alternative, the Snakebite Rescue case, which does this. (shrink)

This manuscript reports on a landmark symposium on the ethical, legal and technical challenges of xenotransplantation in the UK. King’s College London, with endorsement from the British Transplantation Society (BTS), and the European Society of Organ Transplantation (ESOT), brought together a group of experts in xenotransplantation science, ethics and law to discuss the ethical, regulatory and technical challenges surrounding translating xenotransplantation into the clinical setting. The symposium was the first of its kind in the UK for 20 years. This paper (...) summarises the content of the expert lectures showcasing the progress which has been made in xenotransplantation including—the history of xenotransplantation, advances in gene edited animals and progress towards clinical xenotransplantation. We then set out the ethical and legal issues still to be resolved. Finally, we report the themes of the roundtable discussion highlighting areas of consensus and controversy. While the detail of the legal discussion was directed towards the UK, the principles and summary reported here are intended to be applicable to any jurisdiction seeking to implement clinical xenotransplantation. (shrink)

Recently clinicians have become more reliant on technologies such as artificial intelligence (AI) and machine learning (ML) for effective and accurate diagnosis and prognosis of diseases, especially mental health disorders. These remarks, however, apply primarily to Europe, the USA, China and other technologically developed nations. Africa is yet to leverage the potential applications of AI and ML within the medical space. Sub-Saharan African countries are currently disadvantaged economically and infrastructure-wise. Yet precisely, these circumstances create significant opportunities for the deployment of (...) medical AI, which has already been deployed in some places in the continent. However, while AI and ML have come with enormous promises in Africa, there are still challenges when it comes to successfully applying AI and ML designed elsewhere within the African context, especially in diagnosing mental health disorders. We argue, in this paper, that there ought not to be a homogeneous/generic design of AI and ML used in diagnosing mental health disorders. Our claim is grounded on the premise that mental health disorders cannot be diagnosed solely on ‘factual evidence’ but on both factual evidence and value-laden judgements of what constitutes mental health disorders in sub-Saharan Africa. For ML to play a successful role in diagnosing mental health disorders in sub-Saharan African medical spaces, with a precise focus on South Africa, we allude that it ought to understand what sub-Saharan Africans consider as mental health disorders, that is, the value-laden judgements of some conditions. (shrink)

This commentary aims to respond to some criticism against our paper entitled ‘Designing AI for Mental Health Diagnosis: Challenges from sub-Saharan value-laden Judgments on Mental Health Disorders’.1 While we are sympathetic to the invaluable critiques of some authors, we show that some misunderstanding arises in reading our conceptualisation of the condition we use as a central example of disease in our paper. We argue, in our paper, that there are obvious context-specific value judgments when it comes to mental health disorders, (...) which obscures an application of generic machine learning (ML) in the diagnosis of these conditions. To contextualise our contention, our understanding of mental health disorder is grounded in Jerome Wakefield’s2 hybrid theorisation of disease as that which encompasses aspects of the normativist and naturalist accounts of health. Wakefield theorises that facts are necessary but insufficient to make a condition a disease. Wakefield claims that a disorder requires harm that involves values. Thus, values and facts must go concomitantly for a condition to be considered a disorder. Here, a disorder is conceived as something that is a ‘harmful dysfunction’. On the one hand, harmful is value laden—characterised by how a society conceives the notion due to their set norms. On the contrary, dysfunction is a solely scientific term due to a failure to function in accordance with the reference class of an organism. …. (shrink)

Physicians frequently encounter situations in which their professional practice is intermingled with moral affordances stemming from other domains of the physician’s lifeworld, such as family and friends, or from general morality pertaining to all humans. This article offers a typology of moral conflicts ‘at the margins of professionalism’ as well as a new theoretical framework for dealing with them. We start out by arguing that established theories of professional ethics do not offer sufficient guidance in situations where professional ethics overlaps (...) with moral duties of other origins. Therefore, we introduce the moral theory developed by Christine M. Korsgaard, that centres around the concept of practical identity. We show how Korsgaard’s account offers a framework for interpreting different types of moral conflicts ‘at the margins of professionalism’ to provide either orientation for solving the conflict or an explanation for the emotional and moral burden involved in moral dilemmas. (shrink)

Physicians frequently encounter situations in which their professional practice is intermingled with moral affordances stemming from other domains of the physician’s lifeworld, such as family and friends, or from general morality pertaining to all humans. This article offers a typology of moral conflicts ‘at the margins of professionalism’ as well as a new theoretical framework for dealing with them. We start out by arguing that established theories of professional ethics do not offer sufficient guidance in situations where professional ethics overlaps (...) with moral duties of other origins. Therefore, we introduce the moral theory developed by Christine M. Korsgaard, that centres around the concept of practical identity. We show how Korsgaard’s account offers a framework for interpreting different types of moral conflicts ‘at the margins of professionalism’ to provide either orientation for solving the conflict or an explanation for the emotional and moral burden involved in moral dilemmas. (shrink)

The infected blood inquiry, chaired by Sir Brian Langstaff, has now concluded.1 It is the largest public inquiry ever carried out in the UK, investigating what has been described as the ‘worst treatment disaster in the history of the NHS’.1 2 It was established to examine the circumstances in which more than 30 000 people in the UK were infected with HIV and hepatitis C after being given contaminated blood and blood products during the 1970s and 1980s, which had been (...) imported to meet the demand for a new blood-clotting treatment known as ‘factor VIII’. This treatment was created by pooling the plasma from thousands of donors, increasing the risk of infection. The risk was further heightened by the inclusion of donor plasma from the USA, where people with a high risk of infection, including prisoners, were paid to provide blood, whereas the UK system has always relied on altruistic donation.3 The inquiry gathered extensive evidence and was informed by the involvement of over 2000 infected individuals. It considered questions of informed consent, openness and transparency, including disclosure of risks. In his report, Sir Langstaff concluded that the scandal "could largely, though not entirely, have been avoided" and resulted from "systemic, collective and individual failures to deal ethically, appropriately and quickly, with the risk of infections being transmitted in blood, with the infections when the risk materialised and with the consequences for thousands of families". He highlighted six themes arising from the inquiry. (shrink)

‘ The Journal of Medical Ethics reflects the whole field of medical ethics and aims to encourage a high academic standard for this ever-developing subject, and the enhancement of professional and public discussion’. A single issue of this Journal can reflect only some aspects of this ‘whole field’ and only some of the ways in which they are studied and discussed. The contributions to this issue however illustrate a rich variety, both of those aspects of contemporary healthcare with which medical (...) ethics is currently concerned and also of the disciplined imaginative ways in which these may be ethically analysed with an eye to enhancing both public discussion and professional practice. The aspects of healthcare examined in this issue include some that are notably contemporary: genomics, mobile health, environmental sustainability and artificial intelligence, but also others more familiar to earlier generations: mixed wards in hospitals, coercion in psychiatry, patient and public involvement in research, abortion, palliative medicine and intensive care. These various aspects of healthcare practice are analysed in terms of a variety of ethical principles, philosophies, values and virtues. Most familiar perhaps are the four principles of beneficence, non-maleficence, respect for autonomy and justice or fairness, together with those of individual human rights, for example to personal security and dignity; but in addition the rights, derived from the philosophy of Afro-communitarianism, of populations and of their researchers. The Aristotelian value of human flourishing moreover informs some of these analyses as does reflection on the virtues of kindness and curiosity. This issue’s contributions on contemporary aspects of healthcare include two concerned with the ethics of …. (shrink)

In his paper ‘Ethical problems with kindness in healthcare’, Jesudason sets out an interesting examination of the concept of kindness, arguing that it poses significant ethical challenges due to its discretionary nature. I suggest that kindness, a concept difficult to define, may still have a role to play in healthcare. Different treatments of kindness show us that it need not be discretionary, and that kind care can be provided to all. Finally, curiosity may also have a role to play in (...) medicine to help promote inclusiveness. (shrink)

Aristotle’s ethical system was guided by his vision of human flourishing (also, but potentially misleadingly, translated as happiness). For Aristotle, human flourishing was a rich holistic concept about a life lived well until its ending. Both living a long life and dying well were integral to the Aristotelian ideal of human flourishing. Using Aristotle’s concept of human flourishing to inform the goals of medicine has the potential to provide guidance to clinical decision-makers regarding the provision of burdensome treatments, such as (...) intensive care treatment, where pursuing a chance of survival must be balanced against the risk of exposing patients to a negative dying experience. By conceptually uniting potentially competing goals of medicine, such as prolonging life and the promotion of peaceful deaths, Aristotle’s understanding of human flourishing creates an argument for the integration of palliative care considerations into intensive care decision-making and for advanced care planning with healthy patients. (shrink)

The article argues the thesis that institutions have aprima facieobligation to fund the feedback of individual findings in genomic research conducted on the African continent by drawing arguments from an underexplored Afro-communitarian view of distributive justice and rights of researchers to be aided. Whilst some studies have explored how institutions have a duty to support return as a form of ancillary care or additional foreseeable service in research by mostly appealing to dominant principles and theories in the Global North, this (...) mostlynormative studyexplores this question by appealing to underexplored African philosophy. This is a new way of thinking about institutional responsibility to fund feedback and responds to the call to decolonise health research in Africa. Further studies are required to study how thisprima facieobligation will interact with social contexts and an institution’s extant relationships to find an actual duty. The research community should also work out procedures, policies and governance structures to facilitate feedback. In our opinion, though the impacts of feeding back can inform how institutions think about their actual duty, these do not obliterate the binding duty to fund feedback. (shrink)

Rapid advancements in artificial intelligence and machine learning (AI/ML) in healthcare raise pressing questions about how much users should trust AI/ML systems, particularly for high stakes clinical decision-making. Ensuring that user trust is properly calibrated to a tool’s computational capacities and limitations has both practical and ethical implications, given that overtrust or undertrust can influence over-reliance or under-reliance on algorithmic tools, with significant implications for patient safety and health outcomes. It is, thus, important to better understand how variability in trust (...) criteria across stakeholders, settings, tools and use cases may influence approaches to using AI/ML tools in real settings. As part of a 5-year, multi-institutional Agency for Health Care Research and Quality-funded study, we identify trust criteria for a survival prediction algorithm intended to support clinical decision-making for left ventricular assist device therapy, using semistructured interviews (n=40) with patients and physicians, analysed via thematic analysis. Findings suggest that physicians and patients share similar empirical considerations for trust, which were primarilyepistemicin nature, focused on accuracy and validity of AI/ML estimates. Trust evaluations considered the nature, integrity and relevance of training data rather than the computational nature of algorithms themselves, suggesting a need to distinguish ‘source’ from ‘functional’ explainability. To a lesser extent, trust criteria were also relational (endorsement from others) and sometimes based on personal beliefs and experience. We discuss implications for promoting appropriate and responsible trust calibration for clinical decision-making use AI/ML. (shrink)

In a recent article, I argued that all humans are morally equal, and that this generates an argument against abortion. Here, I defend my argument against two objections from Räsänen: that it is possible to ground equal human value in the ability to flourish in a particular kind of way, and that being human is not, in fact, a binary property in the way needed for the argument to work. I show that this proposed criterion for grounding human value falls (...) prey to my original argument, and that Räsänen’s attempt to conceive of subhuman entities fails. (shrink)

ObjectivePatient involvement is used to describe the inclusion of patients as active participants in healthcare decision-making and research. This study aimed to investigate incoming year 1 medical (MBChB) students’ attitudes and opinions regarding patient involvement in this context.MethodsWe established a staff–student partnership to formulate the design of an online research survey, which included Likert scale questions and three short vignette scenarios designed to probe student attitudes towards patient involvement linked to existing legal precedent. Incoming year 1 medical students (n=333) were (...) invited to participate in the survey before formal teaching commenced.ResultsSurvey data (49 participants) indicate that students were broadly familiar with, and supportive of, patient involvement in medical treatment. There was least support for patient involvement in conducting (23.9%), contributing to (37.0%) or communicating research (32.6%), whereas there was unanimous support for patients choosing treatment from a selection of options (100%).ConclusionIncoming members of the medical profession demonstrate awareness of the need to actively involve patients in healthcare decision-making but are unfamiliar with the utility and value of such involvement in research. Further empirical studies are required to examine attitudes to patient involvement in healthcare. (shrink)

BackgroundInformal mHealth is widely used by community health nurses in Ghana to extend healthcare delivery services to clients who otherwise might have been excluded from formal health systems or would experience significant barriers in their quest to access formal health services. The nurses use their private mobile phones or devices to make calls to their clients, health volunteers, colleagues or superiors. These phone calls are also reciprocal in nature. Besides, the parties exchange or share other health data and information through (...) text messages, pictures, videos or voice clips. There are some ethical dimensions that are inherent in these practices that ought to be critically scrutinised by bioethicists.ObjectiveThe author has argued in this paper that informal mHealth at large scale adoption in Ghana is associated with some bioethical challenges.MethodsThis essay was largely based on an analysis of an empirical study published by Hampshireet alin 2021 on the use of informal mHealth methods in Ghana.ResultsWidespread adoption of Informal mHealth in Ghana is associated with privacy invasion of both the nurses and their clients, breaches confidentiality of the parties, discredits the validity of informed consent processes and may predispose the nurses to some other significant aggregated harms.ConclusionThe author affirms his partial support for a formalised adoption process of informal mHealth in Ghana but has reiterated that the current ethical challenges associated with informal mHealth in Ghana cannot escape all the debilitating bioethical challenges, even if it is formalised. (shrink)

In their article, Sahan and colleagues have presented ethical dilemmas faced by clinical scientists working in genomics.1 This is a welcome development since thus far little has been published on the ethical issues faced by clinical scientists in general. In their article, the authors present the three themes which emerged from discussions with clinical scientists in respect to three case studies: ‘(1) the redistribution of labour and responsibilities resulting from the practice of genomic medicine; (2) the interpretation and certainty of (...) results and (3) the proposal that better standardisation and consistency of ethical approaches (for example, more guidelines and policy) could resolve some of the challenges arising’.1 One theme which appeared not to emerge is that of ethics education received by clinical scientists during their training, and this is the theme on which this commentary will focus. As noted elsewhere, ‘Clinical Scientists receive some lectures on clinical and research ethics as part of their training, but it amounts to only to a couple of hours of lectures (references omitted)’.2 The usual route to becoming a clinical scientist involves undertaking the 3-year postgraduate Scientist Training Programme (STP), though the ‘equivalence’ route is quite commonly taken by clinical scientists working in …. (shrink)

The carbon emissions of global healthcare activities make up 4%–5% of total world emissions, with the majority coming from industrialised countries. The solution to healthcare carbon reduction in these countries, ostensibly, would be preventive healthcare, which is less resource intensive than corrective healthcare in itself and, as a double benefit, reduces carbon by preventing diseases which may require higher healthcare carbon to treat. This leads to a paradox: preventive healthcare is designed to give humans longer, healthier lives. But, by extending (...) life spans, the carbon emissions of a person increase both over a lifetime and in the medical industry overall. At the same time, the need for higher carbon end-of-life care does not disappear, particularly in resource intensive countries. This article will first identify sources of healthcare carbon, focusing on the industrialised world, and explain various efforts towards healthcare carbon reduction, which include preventive healthcare. Second, it will develop the ‘paradox of prevention’—that preventive healthcare may save healthcare carbon by proximally reducing the need for medical treatments, but also, paradoxically, result in more healthcare carbon both in an individual’s life and in the medical industry. The third section will offer ethical principles for approaching the paradox of prevention. The conclusion will emphasise the need for institutional approaches to healthcare carbon reduction in the industrialised world, which will relieve some of the tensions of healthcare industry decarbonisation and individual healthcare carbon use. (shrink)

We read with great interest the commentaries submitted in response to our paper about clinical scientists and the role of ethical preparedness1. The responses raised some important themes that intersect with those discussed in our paper, and we are grateful for the opportunity to expand on them. Pruski2 highlights the importance of ethics education for clinical scientists, noting insufficient provision of such teaching within the clinical science profession. This gap means that scientists completing higher specialist training, who now encounter more (...) complex ethical challenges, are not benefitting from equivalent ethics education standards enjoyed by their counterparts in medical professions. We agree that clinical scientists deserve access to quality education in ethics in order to develop their skills in this area. Alongside a formal element to education, we see ethical preparedness (EP) as advocating for more informal education opportunities. This can be facilitated through the encouragement and creation of space (both physical and metaphorical) to discuss ethical issues as they arise in practice and explore potential scenarios in a supportive and judgement-free environment. Cultivating such an environment plays is crucial to develop professional skills in navigating ethical challenges, promoting a greater sense of collective responsibility and capability to do justice to ethical issues encountered. Van Steijvoort et al 3 draw …. (shrink)

Much has been published about the ethical issues encountered by clinicians in genetics/genomics, but those experienced by clinical laboratory scientists are less well described. Clinical laboratory scientists now frequently face navigating ethical problems in their work, but how they should be best supported to do this is underexplored. This lack of attention is also reflected in the ethics tools available to clinical laboratory scientists such as guidance and deliberative ethics forums, developed primarily to manage issues arising within the clinic.We explore (...) what ethical issues are being experienced by clinical scientists, how they think such issues could be best analysed and managed, and whether their practice might be enhanced by more situated approaches to ethics deliberation and practice such as ethical preparedness. From thematic analysis of cases presented by clinical scientists at a specially convened meeting of the UK Genethics Forum, we derived three main ethical themes: (1) the redistribution of labour and responsibilities resulting from the practice of genomic medicine; (2) the interpretation and certainty of results and (3) the proposal that better standardisation and consistency of ethical approaches (for example, more guidelines and policy) could resolve some of the challenges arising.We argue that although standardisation is important for promoting shared understandings of good (including ethical) practice, supplementary approaches to enhance and sustain ethical preparedness will be important to help clinical scientists and others in the recently expanded genetic/genomic medicine environment foster quality ethical thinking. (shrink)

Owing to technological advances, genomic medicine is moving from specific to broader genetic analyses and from specialised to mainstream services. Sahan et al 1 point to complex ethical cases encountered by clinical laboratory scientists in the context of genomic medicine’s expansion. The authors discuss debates on interpreting and reporting genetic results, offering extended genetic testing and differences in the perceived responsibility of clinical laboratory scientists in different settings. As demonstrated by the case examples in the article, while genomic medicine holds (...) the promise of providing clinical answers, its mainstreaming can introduce a new type of ‘odyssey’ for patients and/or relatives, such as when there are uncertain findings. The integration of genomics in healthcare at large can also impact communication decisions and perceptions of responsibility for clinical laboratory scientists. Clinical laboratory scientists might report less to non-specialists than to genetic/genomic specialists, as they feel responsible for minimising the potential of non-specialists misunderstanding, misinterpreting or miscommunicating the genetic findings to patients.1 In this way, the perceived responsibility affects patients and the type and amount of genetic information they receive. We agree with the authors that current limitations in knowledge and capabilities among non-specialist clinicians necessitate identifying effective ways to communicate outcomes and …. (shrink)

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the use (...) of coercion in patients lacking mental capacity. The committee’s recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols. (shrink)

The concept of ethical preparedness (EP), defined as a set of practices in genomic medicine aimed not only at efficiently managing sensitive issues in the laboratory but also at ensuring adherence to ethical principles,1 has potential benefits for clinical laboratory scientists, contingent on three key conditions. First, fostering cooperation and mutual support between commercial and non-commercial laboratories in cases involving moral dilemmas or the uncertain nature of variants identified in the laboratory is crucial for establishing the best practices in genomic (...) medicine. Medical codes emphasise regulations aimed at maintaining the authority of colleagues and avoiding patient and family misunderstandings, as well as promoting a culture of mutual trust and support within the medical profession.2 Such practices among laboratories would benefit both patients/clients and scientists. The important thing is to recognise that while laboratory results may possess prospective value for future generations, genomic medicine addresses the clinical needs …. (shrink)

The practice of placing men and women in the same hospital room (mixed gender rooms) has been prohibited in the UK National Health Service for over a decade. However, recent research demonstrates that the practice is common and increasing in a major New Zealand public hospital. Reports and complaints show that the practice also occurs in Australia. We argue that mixed gender rooms violate the fundamental human rights of personal security and dignity. The high rates of cognitive impairment, sensory impairment (...) and frailty in hospital wards exacerbates the risk for these violations and subsequent harm. We argue for the adoption of specific national policies prohibiting mixed gender rooms and public reporting of breaches. Importantly, these guidelines can be adopted without compromising the rights of gender minorities. In the long term, hospitals should be built with single occupancy rooms. (shrink)

Sahan et al draw much needed attention to the ethical complexity encountered by clinical laboratory scientists. They point out that, on the one hand, clinical laboratories are increasingly required to analyse ‘much broader swathes’ of genomic information than had previously been the case and to consider how best to report—or not report—the results that arise. On the other hand, they also note how clinical laboratory services are supporting genomic testing that is transitioning from specialist to mainstream services, such that questions (...) of whether and how to report genomic information must ‘accommodate the considerations of an expanded multidisciplinary team (MDT)’.1 These two factors, among others, increase both the ‘range and complexity’ of ethical dilemmas faced by clinical laboratory scientists. This trajectory will continue in line with trends towards further mainstreaming of genomic medicine, and the use of genomic sequencing (generating ‘much broader swathes’ of information) over more targeted approaches. In this challenging environment, Sahan et al contend that the notion of ‘ethical preparedness’ (EP) has a crucial role to play. Here ‘EP’ is understood as a state of both systems and individuals that is characterised by the ‘capability, opportunity and motivation to respond to the ethical issues arising in a particular clinical situation, as well as being able to anticipate ethical concerns in advance in areas where practice is rapidly evolving’.1 Notably, cultivating the …. (shrink)

In Sahan et al ’s article,1 they present the ethical challenges faced by clinical laboratory scientists in genetic medicine, including labour allocation and responsibility, interpretation and accuracy of results with new technologies, and the need for better standardisation and ethical consistency. At the same time, they also propose a potential solution to the aforementioned challenges: ethical preparedness(EP). Along with their vivid case discussions and insightful analysis, I would like to propose two more points that are worth further examination and discussion (...) to aid stakeholders in better comprehending the ethical issues that clinical laboratory scientists face in the practice of genetic medicine. The case 1 reported by Sahan et al raises concerns about who should be responsible for tracking families or individuals with genetic results, particularly in the absence of mainstream services to track future risks. However, this should not be a factor influencing the decision to inform gene carriers. If there is a clear division of responsibilities in current practice, clinical laboratory scientists can report detected gene carriers without psychological burden. However, the decision to report gene carriers should be based on who is being served when clinical laboratory scientists face genetic problems in clinical practice and who is being considered when …. (shrink)

All contemporary frameworks of mental capacity stipulate that we must begin from the presumption that an adult has capacity. This presumption is crucial, as it manifests respect for autonomy and guards against prejudice and paternalism on the part of the evaluator. Given its ubiquity, we might presume that we all understand the presumption’s meaning and application in the same way. Evidence demonstrates that this is not the case and that this has led to harm in vulnerable persons. There is thus (...) strong reason to question our presumptions about the presumption of capacity. We distinguish between two main ways of understanding and applying the presumption of capacity, and advocate for the one that we argue mitigates risk of harm. Our proposed interpretation offers many advantages in that it is consonant with actual practice of capacity evaluations, precludes confused and abusive avoidance of needed evaluations, and preserves the respect for autonomy motivating the presumption in the first place. (shrink)

Resnik and Pugh recently explored the ethical implications of routinely integrating environmental concerns into clinical decision-making. While we share their concern for the holistic well-being of patients, our response offers a different clinical and bioethical stance on green informed consent and patient autonomy. Contrary to the authors’ lack of data to support their concerns about provider and patient willingness to engage in climate-related conversations, we provide evidence supporting their sustainability engagement and stress the importance of a proactive, anticipatory approach in (...) healthcare to align with evolving societal values. If climate change is perceived as a politicised issue, though it is not inherently so, healthcare providers are professionally trained to address sensitive subjects and have a duty to inform patients about potential health risks. Recognising the environmental crisis as a health crisis underscores the direct connection between environmental hazards and patients’ well-being. Our perspective advocates for integrating individual considerations, societal responsibilities and systemic changes to promote environmentally sustainable healthcare. (shrink)

The field of medical ethics, such as the discipline of ethics in general, has traditionally focused on moral dilemmas and quandaries at the expense of ‘everyday’ moral issues. The methodologies, norms and principles of the field reflect this. Although the principle of double effect works well in adjudicating the provision of life-shortening medications to relieve pain, it fails to guide the vast majority of mundane moral decisions that providers make daily. This article contends that exemplarist medical ethics provides action guidance (...) on everyday medical ethical issues. Further, it offers an ethical methodology that is not tethered to a comprehensive doctrine of the good. The paper develops an account of, and draws on Zagzebski’s exemplarist moral theory. It then describes how medical providers can morally deliberate by appealing to exemplars. I contend there are three modes of exemplarist action guidance: dialogue, emulation and substituted judgement. It demonstrates how each of these modes guides moral deliberation regarding quotidian medical ethical issues. The article then turns to a moral exemplar of medical practice, Dr. Jim O’Connell, who Tracy Kidder profiles in his 2023 book, Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to Homeless People. The advantages and challenges of this approach are delineated before a brief conclusion. (shrink)

It is a dominant dictum in ethics that ‘ought implies can’ (OIC): if an agent morally ought to do an action, the agent must be capable of performing that action. Yet, with current technological developments, such as in direct-to-consumer genomics, big data analytics and wearable technologies, there may be reasons to reorient this ethical principle. It is our modest aim in this article to explore how the current wave of allegedly disruptive innovation calls for a renewed interest for this dictum. (...) As an effect of prevention and prediction oriented technological innovation, an increased focus on assumedly controllable lifestyle risks may be anticipated. For lay people who might turn into patients, this may entail a reinforced behavior-based individual responsibilisation. Holding on to the OIC dictum, such responsibilisation seems to require that individuals can actually control what is framed as ‘lifestyle risks’ when there is not always a reliable consensus about what one should do. As such, reference to OIC may be mobilised in function of a political task of designing institutions so as to enable such choice and control. (shrink)

In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first (...) demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account. (shrink)

This paper combines considerations from ethics, medicine and public health policy to articulate and defend a systematic case for mask wearing mandates (MWM). The paper argues for two main claims of general interest in favour of MWM. First, MWM provide a more effective, just and fair way to tackle the ongoing COVID-19 pandemic than policy alternatives such as laissez-faire approaches, mask wearing recommendations and physical distancing measures. And second, the proffered objections against MWM may justify some exemptions for specific categories (...) of individuals, but do not cast doubt on the justifiability of these mandates. Hence, unless some novel decisive objections are put forward against MWM, governments should adopt MWM. (shrink)

How could we better use public inquiries to stem the recurrence of healthcare failures? The question seems ever relevant, prompted this time by the inquiry into how former nurse Letby was able to murder newborns under National Health Service care. While criminality, like Letby’s, can be readily condemned, other factors like poor leadership and culture seem more often regretted than reformed. I would argue this is where inquiries struggle, in the space between ethics and law—with what is awful but lawful. (...) In response, we should learn from progress with informed consent. Inquiries and civil litigation have seen uninformed ‘consent’ shift from being undesirable to unlawful. If better leadership and culture were sole drivers here, we would likely be doing far better in many other areas of healthcare too. Instead, one could argue that progress on consent has been made by reducing _epistemic injustice_—by naming and addressing _epistemic_ issues in ways that enhance _social power_ for patients. If this is an ingredient that transforms clinician–patient working, might it also shift conduct within other key relationships, by showing up what else should become unlawful and why? Naming _medical paternalism_ may have helped with consent reform, so I continue this approach, first naming two areas of epistemic injustice: _management feudalism_ and _legal chokeholds_. Remedies are then considered, including the democratisation of management and reforms to legal ethics, legislation and litigation. In brief, public inquiries may improve if they also target epistemic injustices that should become unlawful. Focus on informed consent and epistemic relationships has improved the medical profession. Likewise, it could help healthcare leaders shift from fiat towards consent, and their lawyers from a stifling professional secrecy towards the kind of candour a prudent public expects. (shrink)

Canada has recently published a new Clinical Practice Guideline on the diagnosis and management of brain death. It states that consent is not necessary to carry out the interventions required to make the diagnosis. A supporting article not only sets out the arguments for this but also contends that ‘UK laws similarly carve out an exception, excusing clinicians from a prima facie duty to get consent’. This is supplemented by the claim that recent court decisions in the UK similarly confirm (...) that consent is not required, referencing two judgements in _Battersbee_. We disagree with the authors’ interpretation of the law on consent in the UK and argue that there is nothing in _Battersbee_ to support the conclusion that consent to testing is not necessary. Where there is a disagreement about testing for brain death in the UK, court authorisation is required. (shrink)

The reality of current clinical practice in the UK is that where a patient’s family refuses to agree to testing for brain stem death (BD), such cases will ultimately end up in court. This situation is true of both adults and children and reinforced by recent legal cases. While recourse to the courts might be regrettable in such tragic cases, if public trust in the medical diagnosis of BD is to be maintained all aspects of the process must be conducted (...) in a way that is transparent and open to scrutiny. This is not an ‘ineffective expenditure’ of resources, but an essential element of a human rights-compliant legal system. (shrink)

The geographically inequitable distribution of physicians has long posed a serious social problem in Japan. The government tackled this problem by establishing and managing Jichi Medical University (JMU) and regional quotas (RQs) for medical schools. JMU/RQs recruit local students who hope to work as physicians in rural areas, educate them for 6 years without tuition (JMU) or with scholarship (RQs), and after graduation, assign them to their home prefectures for 9 years, including 4–6 years of rural service. JMU/RQs entrants now (...) occupy 11.6% of all medical school entrants. While JMU/RQs have been shown to be highly effective in securing physicians for rural areas, ethical issues related to these policies have been raised, such as whether the government truly needs to implement these policies using tax money, and whether it is acceptable to limit the personal freedoms of the physicians. In this paper, we discuss these issues from the perspectives of social justice, utilitarianism, luck egalitarianism, liberty, medical professionalism and consistency with national health insurance and the Japanese Constitution. We conclude that JMU/RQs are necessary and ethically valid policies, and also propose some institutional improvements to better secure the integrity and maturity of these systems. (shrink)

The overwhelming weight of legal authority in the USA and Canada holds that consent is not required for brain death testing. The situation in England and Wales is similar but different. While clinicians in England and Wales may have a prima facie duty to obtain consent, lack of consent has not barred testing. In three recent cases where consent for brain death testing was formally presented to the court, lack of consent was not determinative, and in one case the court (...) questioned whether the clinicians were even required to seek consent from the parents of a child at all. (shrink)

Green bioethics is an area of research and scholarship that examines the impact of healthcare practices and policies on the environment and emphasises environmental values, such as ecological sustainability and stewardship. Some green bioethicists have argued that healthcare providers should inform patients about the environmental impacts of treatments and advocate for options that minimise adverse impacts. While disclosure of information pertaining to the environmental impacts of treatments could facilitate autonomous decision-making and strengthen the patient–provider relationship in situations where patients have (...) clearly expressed environmental concerns, it may have the opposite effect in other situations if makes patients feel like they are being judged or manipulated. We argue, therefore, that there is not a generalisable duty to disclose environmental impact information to all patients during the consent process. Providers who practice green bioethics should focus on advocating for system-level changes in healthcare financing, organisation and delivery and use discretion when bringing up environmental concerns in their encounters with patients. (shrink)

With the introduction of artificial intelligence (AI) to healthcare, there is also a need for professional guidance to support its use. New (2022) reports from National Health Service AI Lab & Health Education England focus on healthcare workers’ understanding and confidence in AI clinical decision support systems (AI-CDDSs), and are concerned with developing trust in, and the trustworthiness of these systems. While they offer guidance to aid developers and purchasers of such systems, they offer little specific guidance for the clinical (...) users who will be required to use them in patient care. This paper argues that clinical, professional and reputational safety will be risked if this deficit of professional guidance for clinical users of AI-CDDSs is not redressed. We argue it is not enough to develop training for clinical users without first establishing professional guidance regarding the rights and expectations of clinical users. We conclude with a call to action for clinical regulators: to unite to draft guidance for users of AI-CDDS that helps manage clinical, professional and reputational risks. We further suggest that this exercise offers an opportunity to address fundamental issues in the use of AI-CDDSs; regarding, for example, the fair burden of responsibility for outcomes. (shrink)

Genomic medicine has the potential to contribute to the development of an array of novel technologies within the clinical armoury, making possible early detection and management of high-risk conditions such as cancer. While significant impact has already been felt in the context of rare inherited single gene disorders, much of the advancement in patient care through genomic medicine more broadly is going to be made possible by research involving large data sets that enable analyses of multiple genetic variants that contribute (...) to risk of common diseases. 1 As well as informing diagnosis and treatment of these diseases, these advances will support prediction and prevention. Considering risk prediction, combining data from multiple variants can produce a polygenic (or integrated) score (PGS/IGS). This will provide more accurate prediction than simply relying on environmental risk factors. While still in their early stages of development and implementation, it is clear that translation... (shrink)

This paper is an exploration of the state of ‘clinical unease’ experienced by clinicians in contexts where professional judgement—grounded in clinical knowledge, critical reflection and a sound grasp of the law—indicates that there is more than one ethically defensible way to proceed. The question posed is whether the courts can be viewed as an appropriate vehicle to settle clinical unease by providing a ruling that clarifies the legal and ethical issues arising in the case, even in situations where there is (...) no dispute between the patient (or her proxies) and the healthcare team. The concept of ‘clinical unease’ is framed with reference to the broader experience of clinical decision-making, and distinguished from other widely discussed phenomena in the healthcare literature like moral distress and conscientious objection. A number of reported cases are briefly examined where the courts were invited to rule in circumstances of apparent ‘unease’. The respective responsibilities of clinicians and courts are discussed: in particular, their capability and readiness to respond to matters of ethical concern. Four imagined clinical scenarios are outlined where a clinical team might welcome a court adjudication, under current rules. Consideration is given to the likelihood of such cases being heard, and to whether there may be better remedies than the courts. There are final reflections on what clinicians may actually wish for in seeking court involvement, and on whether a willingness to engage with the experience of clinical unease may lead to greater sensitivity towards the value perspectives of others. (shrink)

Targeted modifications of the human epigenome, epigenome editing (EE), are around the corner. For EE, techniques similar to genome editing (GE) techniques are used. While in GE the genetic information is changed by directly modifying DNA, intervening in the epigenome requires modifying the configuration of DNA, for example, how it is folded. This does not come with alterations in the base sequence (‘genetic code’). To date, there is almost no ethical debate about EE, whereas the discussions about GE are voluminous. (...) Our article introduces EE into bioethics by translating knowledge from science to ethics and by comparing the risks of EE with those of GE. We, first (I), make the case that a broader ethical debate on EE is due, provide scientific background on EE, compile potential use-cases and recap previous debates. We then (II) compare EE and GE and suggest that the severity of risks of novel gene technologies depends on three factors: (i) the choice of an ex vivo versus an in vivo editing approach, (ii) the time of intervention and intervention windows and (iii) the targeted diseases. Moreover, we show why germline EE is not effective and reject the position of strong epigenetic determinism. We conclude that EE is not always ethically preferable to GE in terms of risks, and end with suggestions for next steps in the current ethical debate on EE by briefly introducing ethical challenges of new areas of preventive applications of EE (III). (shrink)

In the face of environmental crises such as climate change, pollution and biodiversity loss—which all adversely impact on health—Gils-Schmidt and Salloch explore whether physicians can be justified in taking climate issues into account in clinical care.1 While their approach centres on the ‘climate-sensitive’ decisions, physicians can carry out on the micro-level of clinical decision-making, they encourage further discussions on how climate-related issues can be included across different levels of decision-making in healthcare. We propose a list of tasks and a model (...) to assist with navigating the range of factors and structural elements an environmentally sensitive ethics must address. Stephen Gardiner’s notion of a perfect moral storm is central to understanding these issues.2 Gardiner describes how a perfect moral storm occurs in the centre of three overlapping conditions for human action and policymaking in the face of climate change. This storm is driven by: (1) a lack of interest among current generations to meet global needs and accommodate the well-being of future generations, (2) a lack of ecological concerns for other parts of nature than humans and (3) weak ethical and political theories and institutions shaping policy decisions on issues with severe implications across borders and generations. Moreover, these conditions are embedded in the existing, complex world of ethically unjustified power imbalances and social injustice. The growing awareness of healthcare’s climate footprint has amplified and accelerated global, grassroots action to make healthcare more environmentally friendly. This includes incorporating environmental impacts into quality improvement methodologies, building communities of practice to explore how to make …. (shrink)

In the paper, titled ‘Choosing death in unjust conditions: hope, autonomy and harm reduction,’ Wiebe and Mullin argue that people living in unjust social conditions are sufficiently autonomous to request medical assistance in dying (MAiD). The ethical issue is that some people may request MAiD primarily because of unjust social conditions, not their illness, disease, disability or decline in capability. It is easily agreed that people living in unjust social conditions can be autonomous. Nevertheless, Wiebe and Mullin fail to appreciate (...) that autonomy is only a necessary condition for MAiD. In addition to autonomy, one must decide that providing assisted dying to a patient because they are living in unjust social conditions is ethical. Central to making this ethical decision is the principle of non-maleficence, famously articulated as ‘do no harm.’ The authors admit that performing MAiD in response to unjust social circumstances is harmful, but they justify this harmful action by appealing to the principle of harm reduction. A fundamental flaw of their approach is that it relies on the legislative definition of intolerable suffering, which is based on circular reasoning and given that 99.2% of patients that have applied for MAiD satisfied this criterion, it is essentially equivalent to no standard/criterion. Canadian society is struggling with the ethical implications of its permissive MAiD programme, and, fundamental to this debate, will be determining the proper balance between autonomy and non-maleficence for people living in unjust social conditions. (shrink)

In their paper titledChoosing death in unjust conditions: hope, autonomy and harm reduction,Wiebe and Mullin argue against the stance of diminished autonomy in chronically ill, disabled patients living in unjust sociopolitical environments who pursue medical assistance in dying (MAiD). They suggest that it would be paternalistic to deny these people this choice and conclude that MAiD should actually be seen as a form of harm reduction for them.This response to their article argues that basing discussions surrounding this important topic on (...) a single bioethical concept does not address the needs of this cohort and is restrictively siloed. The discussion should include considerations of human rights and the need for legislative reforms to address social conditions, in addition to traditional bioethical principles. Work in this area needs to become interdisciplinary and collaborative as well as integrate input from the patients themselves. The concept of the dignity of these patients, in its broadest sense, needs to be infused into the discussion in order to optimise the exploration for solutions for this cohort.The stance of MAiD as harm reduction, in this context, does not meet the definition of harm reduction, nor does it represent a commitment to the best interests of these patients. (shrink)

We have all become used to the rapid change around us, and with it, the shifting landscape of medical ethics. It appears, however, that the acceleration phase of change in biomedical sciences is only just beginning, and we need to be prepared for new challenges ahead. This issue of the journal considers several of them: in epigenome editing, 1 in bioprinting 2 and in cryonics. 3 With all of these developments, we need to be doing our ethical thinking proactively rather (...) than reactively; and we need to consider not only what we think the ethical problems might be but what frameworks we have for arguing how we should address them. There are several approaches that could be taken 4 each with their own advantages and limitations. The most fun—and the one we are perhaps best at—is to consider hypothetical scenarios, the ethical controversies associated with... (shrink)

The technical possibilities of biomedicine open up the opportunity to intervene in ageing itself with the aim of mitigating, reducing or eliminating it. However, before undertaking these changes or rejecting them outright, it is necessary to ask ourselves if what would be lost by doing so really has much value. This article will analyse the desirability of ageing from an individual point of view, without circumscribing this question to the desirability or undesirability of death. First, we will present the three (...) most widely used arguments to reject biomedical interventions against ageing. We will argue that only the last of these arguments provides a consistent answer to the question of the desirability of ageing. Second, we will show that the third argument falls prey to a conceptual confusion that we will call the paradox of ageing: although ageing entails negative health effects, it leads to a life stage with valuable goods. Both valuations, one positive and the other negative, refer to two different dimensions of ageing: the chronological and the biological. We will defend that, by not adequately distinguishing these two types of ageing, it does not become apparent that all the valuable goods exclusive to ageing derive only from its chronological dimension. Third, we will argue that, if we just conceive ageing biologically, it is undesirable. We will elaborate on the two kinds of undesirable effects biological ageing has: direct and indirect. Finally, we will respond to potential objections by adducing that these are insufficient to weaken our argument. (shrink)

We have recently stated the reasons why we claim that biological ageing is undesirable. Räsänen has responded to our article by arguing that this process has certain desirable aspects and, therefore, our position is inconsistent. Räsänen develops two arguments to defend his position. We will call the first the argument from the totality of the ageing process and the second the argument from the reduced goods of the ageing process. In this reply, we will give reasons to show that both (...) arguments fail. The first, on the one hand, starts from a dubious conception of ageing and, on the other hand, even accepting this conception, its reformulation is morally empty. The second incurs in an absurd conclusion. (shrink)

In their article, van Gils Schmidt and Salloch defend the claim that physicians have a duty to protect the climate. The logic of the argument in broad terms is that (i) there is a relationship between climate change and the burden of disease, (ii) the healthcare sector is a significant emitter of global greenhouse gasses, thereby enhancing the burden of disease and (iii) since doctors are advocates of health and stakeholders in the healthcare sector, they have a duty to respond (...) to climate change. The authors recognise the ‘ethical basis for the claim of healthcare professionals having a special responsibility in climate change is far from being obvious’. The theoretical framework they choose for making this tentative link more apparent is Korsgaard’s theory of practical identities. The main argument of the authors seems to be that practical identities are pluralistic—a person can identify as a physician and environmentalist simultaneously—and the normative positions attributable to these identities may come into conflict. More than that, they claim that being an environmentalist is increasingly becoming …. (shrink)

In a recent article in this journal, Kowalik argues that compulsory vaccination unjustifiably infringes on the autonomy of vaccine refusers. While accepting Kowalik’s central premises, we argue that, when appropriately expanded in scope, autonomy considerations do not undermine the justifiability of compulsory vaccination. Vulnerable individuals—including the very old, the very young and those with compromised immune systems—face an omnipresent risk of contracting a potentially fatal vaccine-preventable illness and are thus prevented from accessing public goods by coercive pressure. Consequently, when we (...) consider an appropriately broad scope of autonomy constraints, autonomy considerations do not undermine the case for mandating vaccination. (shrink)

In this article, we provide an ethical analysis of the first porcine cardiac xenotransplant, performed in Maryland, USA in early 2022. David Bennett was offered the experimental procedure after he was deemed ineligible for human heart transplantation and mechanical circulatory support, based on a history of non-compliance. It was reported that Mr Bennett’s previous instances of non-compliance were for medically non-life-threatening conditions years earlier, where the risks of non-compliance were not as high. We argue that, in Mr Bennett’s case, a (...) history of non-compliance in a different context, should not necessarily rule him ineligible for a potentially life-saving treatment now. Furthermore, using previous non-compliance to exclude individuals from donor organs may have the unintended effect of placing the burden of testing xenotransplantation on those who are already disadvantaged. We then argue that it is not enough to rely on patient consent to ethically justify xenotransplantation research. Taking a broad ethical perspective is crucial when mapping a clinical pathway for xenotransplantation. (shrink)

Cryonics is the preservation of legally dead human bodies at the temperature of liquid nitrogen in the hope that future technologies will be able to revive them. In philosophical debates surrounding this practice, arguments often focus on prudential implications of cryopreservation, or moral arguments on a societal level. In this paper, we claim that this debate is incomplete, since it does not take into account a significant relational concern about cryonics. Specifically, we argue that attention should be paid to the (...) potential implications of cryopreservation for the mourning processes of surviving loved ones. Cryopreservation increases the likelihood of disruption of the practical and mental tasks involved in a successful mourning process, which can negatively impact survivors of the cryopreserved patient. To illustrate my argument, we will draw on a case study from the 2019 documentaryHope Frozen. We aim to introduce this concern, in order to gain a more complete view on the potential implications of cryopreservation. (shrink)

In their upcoming article, Henk Jasper van Gils-Schmidt and Sabine Salloch highlight the supposed responsibilities of healthcare professionals in addressing the global health challenges posed by climate change. They argue that healthcare professionals’ duties to future generations and their ‘climate-related obligations’ have been neglected, primarily due to potential conflicts with other responsibilities, such as providing optimal care to current patients and maintaining patient trust. The authors suggest that these competing obligations should be viewed as part of the multifaceted identities individuals (...) hold, encompassing roles as both physicians and environmentalists, each with normative and competing commitments. They propose that a transformative shift in physicians’ professional ethos, expanding from the predominant focus on individual patients to include obligations towards climate protection, could pave the way for identifying effective mechanisms to address these challenges. While acknowledging the authors’ emphasis on sustainable healthcare practices, we argue that a duty to climate protection as part of healthcare professionals’ identity lacks ethical support. We identify serious concerns that stem from the transformative shift in physicians’ professional ethos, particularly in the authors’ presentation of reasons for action. First, envisaging a stable disposition that compels healthcare professionals to ensure optimal care conditions for both immediate and potential future encounters is unrealistic. Such a scenario would necessitate a nuanced and multifaceted evaluation, weighing …. (shrink)

This article provides an analysis of bioprinting personalised medical device technology and its ethical challenges to regulation and research ethics. I argue the inclusion of bioprinting applications within existing regulatory frameworks does not adequately address the technologies disruption to the traditionally siloed activities of research and treatment. Using the conceptual framework of liminality, I offer a meaningful way to engage with this technology and address some identified concerns with how it will be categorised and the appropriate recognition of its evidentiary (...) thresholds. I demonstrate these concerns through the exploration of limited conventional research methodologies tasked with the production of generalisable knowledge, specifically population-based evidence that is derived from Randomised Clinical Trials. I use Australian regulatory amendments introduced in 2021 as an example of current regulatory trajectories and highlight why I believe this approach to be insufficient. The significance of this argument will be to demonstrate the disruption of bioprinting applications to current approaches in medical policy, and how various jurisdictions are enacting regulation that is not fit for purpose. (shrink)

The patient’s autonomy and well-being are sometimes seen as central to the ethical justification of voluntary euthanasia (VE) and physician-assisted suicide (PAS). While respecting the patient’s wish to die plausibly promotes the patient’s autonomy, it is less obvious how alleviating the patient’s suffering through death benefits the patient. Death eliminates the subject, so how can we intelligibly maintain that the patient’s well-being is promoted when she/he no longer exists? This article interrogates two typical answers given by philosophers: (a) that death (...) confers a well-being benefit in the sense that it actualises a comparatively better life course for the patient (ie, a shorter life with less net suffering), and (b) that death is beneficial because non-existence which entails no suffering is superior to an existence filled with suffering. A close examination of the two senses in which the patient might incur a well-being benefit reveals problems that preclude physicians delivering VE/PAS in the name of beneficence. (shrink)

García-Barranquero et al explore the desirability of human ageing. They differentiate between chronological and biological views of ageing and contend that the positive aspects of ageing are solely linked to chronological ageing. Consequently, the authors embrace the potential for technological interventions in biological ageing. Contrary to their stance, I argue that there are sometimes desirable aspects associated with biological ageing. Therefore, proposals aiming to eliminate, mitigate or diminish biological ageing are not without problems.

Medicine is no stranger to patience. In fact, the word ‘patient’ has an etymology stemming from the Latin word ‘patiens’, describing the one who tolerates suffering.1 In this sense, the cornerstone of medicine, the patient–physician relationship, reflects passive language, ‘to suffer’. This suffering must be understood, and should be most intimately understood by those who provide care that is beyond a patient’s reach. The case of patients and their loved ones requesting medically futile care at the end of life is (...) one where further treatment is replaced by patience and, more rarely, the patience of medical teams is replaced by futile treatment. At the heart of this debate is not only the denial of futile care but also the need for understanding the extent of patience that must be endured as a result of it. Burns and Truog2 remark on this ethical dilemma: > The best solution – although perhaps also the most difficult – is…tolerating the demands for care that we believe to be futile, and finding ways to better support the emotional needs of each other in those rare cases where we are called on to provide this care. The concept of futility in care represents medical intervention with limited, or no, chance of resulting in what is regarded as a clinically successful outcome. Since the American Medical Association’s endorsement of the lack of consensus on futile care in 1999, this integral conflict remains.3 This is a conflict of understanding. I believe this understanding can be strengthened by acknowledging the Arabic word for patience, ‘ sabr ’, along …. (shrink)

Gils-Schmidt and Salloch recognise that human and climate health are inextricably linked, and that mitigating healthcare-associated climate harms is essential for protecting human health.1 They argue that physicians have a duty to consider how their own practices contribute to climate change, including during their interactions with patients. Acknowledging the potential for conflicts between this duty and the provision of individual patient care, they propose the application of Korsgaard’s neo-Kantian account of practical identities to help navigate such scenarios. In this commentary, (...) we argue that by focusing attention on this physician–patient level, the authors overlook the complexity of climate change, both within the healthcare sector and beyond. We recognise the importance of individual agency in tackling this issue, and we also recognise that the authors do briefly acknowledge the importance of considering these broader complexities; however, we emphasise the need for climate and health discussions/action to be situated in a wider framework of systemic change. Our concern is that overemphasis on patient-level interactions risks normalising the prioritisation of individual-level approaches to addressing climate change, detracting from such a broader approach. Physician training emphasises the need for trust, confidentiality and shared decision-making in the doctor–patient relationship. …. (shrink)

Räsänen draws a distinction between chronological age and biological age and argues that biological ageing is (sometimes) desirable. To demonstrate this, he asks us to consider the case of April, who like Karel Čapek’s Elina Makropulos, has stopped biologically ageing. Unlike Makropulos, though, April’s biological ageing was halted before puberty, so she will never mature into adulthood. Räsänen contends this case shows ageing can be desirable, but this equivocates between maturing and ageing. Here I argue biological ageing, or the wear (...) and tear normally associated with chronological ageing, isprima facieundesirable, but that maturing can beprima faciedesirable. (shrink)

The medical profession is observing a rising number of calls to action considering the threat that climate change poses to global human health. Theory-led bioethical analyses of the scope and weight of physicians’ normative duty towards climate protection and its conflict with individual patient care are currently scarce. This article offers an analysis of the normative issues at stake by using Korsgaard’s neo-Kantian moral account of practical identities. We begin by showing the case of physicians’ duty to climate protection, before (...) we succinctly introduce Korsgaard’s account. We subsequently show how the duty to climate protection can follow from physicians’ identity of being a healthcare professional. We structure conflicts between individual patient care and climate protection, and show how a transformation in physicians’ professional ethos is possible and what mechanisms could be used for doing so. An important limit of our analysis is that we mainly address the level of individual physicians and their practical identities, leaving out important measures to respond to climate change at the mesolevels and macrolevels of healthcare institutions and systems, respectively. (shrink)

We are extremely grateful for the insightful and thought-provoking commentaries on our feature article.1 We have distilled four themes emerging from the commentaries, and we would also like to address one misunderstanding of our argument that has appeared. In our article, we explicitly acknowledge that major decisions relevant for climate protection take place at the mesolevels and macrolevels of healthcare, a point raised again in some of the commentaries.2–4 Climate protection is a societal issue, and we thank these authors for (...) the concrete proposals of potential models to guide action. Yet, to us, it still makes sense to reflect simultaneously on the responsibilities that physicians have themselves. Without wanting to put the main responsibility on them, we argue it is important to start thinking about the scope of action that physicians actually have (or not have). As we have argued the need for climate action comes ever more into focus of society, we wanted to explore whether the professional ethics of the medical professionals needs to be amended. Our argument is that this is the case, based on the reasons that climate change has a big health impact while simultaneously the health system has a strong climate impact. Based on the World Medical Association (WMA) Declaration of Geneva the focus on the individual patient is clear, but this and other important codices do also include a public health perspective. The (model) Professional Code for Physicians in Germany, for example, states in its first article that ‘Physicians serve the health of …. (shrink)

In this essay, we consider questions arising from cases in which people request medical assistance in dying (MAiD) in unjust social circumstances. We develop our argument by asking two questions. First, can decisions made in the context of unjust social circumstance be meaningfully autonomous? We understand ‘unjust social circumstances’ to be circumstances in which people do not have meaningful access to the range of options to which they are entitled and ‘autonomy’ as self-governance in the service of personally meaningful goals, (...) values and commitments. People in these circumstances would choose otherwise, were conditions more just. We consider and reject arguments that the autonomy of people choosing death in the context of injustice is necessarily reduced, either by restricting their options for self-determination, through their internalisation of oppressive attitudes or by undermining their hope to the point that they despair.Second, should MAiD be available to people in such circumstances, even when a sound argument can be made that the agents in question are autonomous? In response, we use a harm reduction approach, arguing that even though such decisions are tragic, MAiD should be available. Our argument engages with relational theories of autonomy as well as recent criticism raised against them and is intended to be general in application, although it emerges in response to the Canadian legal regimen around MAiD, with a focus on recent changes in Canada’s eligibility criteria to qualify for MAiD. (shrink)

The commentaries in response to our feature paper1 are indicative of the varied perspectives that can be taken towards artificial amnion and placenta technology (AAPT) and more specifically its relationship with pregnancy (loss). Kennedy rightly argues that empirical research is essential for understanding the experiences of pregnancy loss and AAPT2 and our own advocacy of empirical research is evident in previous work.3–5 Kennedy also acknowledges the current impossibility of researching AAPT experiences since it has not yet been applied in clinical (...) settings. It is precisely for this reason that we draw on the reported experiences of neonatal intensive care (NICU) parents since they present the closest analogy which can be drawn with the technology.1 What we reject in Kennedy’s response, however, is the claim that the experiences of NICU parents have been ‘exploited’ by us.2 Studies documenting the experiences of NICU parents were drawn on to indicate that our considerations are more than mere speculation. As stated, the experiences of NICU parents, particularly the pregnant individual who experiences pregnancy loss, are the closest indication we have of how AAPT and what it entails may be experienced. To claim that this data is being exploited by us is to undermine the very purpose that such research is undertaken—to indicate how future care may be improved. It would be much more harmful to not use this information. While we believe that experiences of …. (shrink)

In their paper, Romanis and Adkins delve into the potential impact of artificial amnion and placenta technology (AAPT) on cases of pregnancy loss1 that do not involve procreative loss. First, they call for more recognition of the negative feelings a person might have due to the premature end of their pregnant state. They claim that, should AAPT minimise concerns about prematurity as anticipated, individuals might feel pressured to opt for partial ectogestation to preserve their or their fetus’ well-being; moreover, they (...) point out that the feelings of loss in the context of AAPT are likely to be worse than the ones reported in neonatal intensive care units cases. Finally, they advocate for care pathways focusing on how the transfer of a fetus to the AAPT could affect the pregnant person, with particular attention to managing the grief potentially caused by the pregnancy loss. I praise the authors for such a call to action—especially since partial ectogestation is expected to become a reality in the short-term future—and I share their demands for additional and more attentive care of (formerly) pregnant patients. However, I am concerned that their approach is so focused on negative feelings towards pregnancy loss that it risks becoming …. (shrink)

Kyle van Oosterum and Emma Curran have recently argued that the impairment argument against abortion is weak and accomplishes little. They also claim that impairment fails to explain what makes giving a child fetal alcohol syndrome (FAS) immoral, which is an important premise of the argument. Here, I explain that the impairment argument is not as weak as they believe. Further, I argue that impairment offers a superior explanation for what makes giving a child FAS immoral than their proposal based (...) on creative beneficence. (shrink)

In their article, Romanis and Adkins delineate pregnancy loss and procreative loss to show that the former is possible without the latter, as in the case of artificial amnion and placenta technology.1 Here, we are interested in examining the reverse—procreative loss without pregnancy loss—to further tease apart these two types of loss. We discuss two cases: being forced to continue a pregnancy despite fetal demise due to abortion restrictions and choosing to selectively reduce a multifetal pregnancy. Our analysis buttresses the (...) authors’ conclusion: due to our fetal-centric conception of pregnancy, we are only able to value pregnancy instrumentally (ie, for the fetus), not intrinsically. Understanding pregnancy as an embodied state rather than a process that not only acknowledges the intrinsic value of pregnancy for pregnant people but also encourages society to intrinsically value pregnant people is important. In 2022, the Supreme Court of the United States removed the constitutional right to an abortion in Dobbs v Jackson Women’s Health Organization, shifting the responsibility of determining abortion regulations to individual US states.2 Due to the Dobbs decision, there …. (shrink)

Romanis and Adkins discuss pregnancy loss in relation to artificial amnion and placenta technology (AAPT) for treatment of extremely preterm infants.1 I agree with the authors that AAPT, although it is expected to provide better care for extremely preterm infants, will also be challenging for parents. I, therefore, commend Romanis and Adkins for promoting a more holistic care that includes parents and pregnant persons. However, I believe that they create two false dichotomies, one between the pregnant person/parent and the fetus/child (...) and one between current neonatal intensive care unit (NICU) and AAPT that hinder holistic care. Romanis and Adkins correctly point out that much of the discourse and care surrounding preterm deliveries focuses mainly on the infant. I agree with Romanis and Adkins that true holistic care should also include the parents rather than focusing exclusively on the child. However, the language they use to petition for more inclusive care can be problematic and counteractive to achieve holistic care. The problem is that they accuse any fetal/child consideration of being fetal-centric and, in the same breath, they state that it is something to be challenged. This attitude is problematic as it feeds into the rhetoric of the maternal–fetal conflict. This is a common rhetoric in reproductive and neonatal care used mainly in situations …. (shrink)

In ‘The Pregnancy Rescue Case: why abortion is immoral’, Hendricks presents The Pregnancy Rescue Case. In this reply I argue that even if it would be better (i.e., less bad) for the abortion to be prevented in The Pregnancy Rescue Case, that does not mean that typical abortions are impermissible. I also argue that there is a possible explanation, consistent with the pro-choice view and empirically testable, as to why people would think it better for the abortion to be prevented (...) in The Pregnancy Rescue Case. (shrink)

The pregnancy rescue case (PRC) is supposed to show that when forced between preventing a fetus from being killed and preventing someone from remaining unwillingly pregnant, we are morally required to do the former. If this is true, then Hendricks argues that the typical abortion is morally wrong. I pose four problems for PRC and how Hendricks uses it here. First, one might simply deny the intuition Hendricks takes PRC to pump for reasons having to do with the moral status (...) of the fetus. Second, even if it is true that we should prevent the fetus from being killed in PRC, this might not tell us much about the moral permissibility of abortion in typical cases because there are important differences between PRC and the typical abortion. Third, I propose some modifications to PRC that would better isolate whether fetal personhood does any work to pump the target intuition. Fourth, I argue that PRC only succeeds if we presuppose that Thomson’s defence is unsound, but presupposing this comes at too high a cost. (shrink)

We argue that, in certain circumstances, doctors might beprofessionallyjustified to provide abortions even in those jurisdictions where abortion is illegal. That it is at least professionally permissible does not mean that they have an all-things-considered ethical justification or obligation to provide illegal abortions or that professional obligations or professional permissibility trump legal obligations. It rather means that professional organisations should respect and indeed protect doctors’ positive claims of conscience to provide abortions if they plausibly track what is in the best (...) medical interests of their patients. It is the responsibility of state authorities to enforce the law, but it is the responsibility of professional organisations to uphold the highest standards of medical ethics, even when they conflict with the law. Whatever the legal sanctions in place, healthcare professionals should not be sanctioned by the professional bodies for providing abortions according to professional standards, even if illegally. Indeed, professional organisation should lobby to offer protection to such professionals. Our arguments have practical implications for what healthcare professionals and healthcare professional organisations may or should do in those jurisdictions that legally prohibit abortion, such as some US States after the reversal ofRoe v Wade. (shrink)

In cases in which we must choose between either (i) preventing a woman from remaining unwillingly pregnant or (ii) preventing a fetus from being killed, we should prevent the fetus from being killed. But this suggests that in typical cases abortion is wrong: typical abortions involve preventing a woman from remaining unwillingly pregnant over preventing a fetus from being killed. And so abortion is typically wrong—and this holds whether or not fetuses are persons.

We discuss a case where clinical genomic investigation of muscle weakness unexpectedly found a genetic variant that might (or might not) predispose to kidney cancer. We argue that despite its off-target and uncertain nature, this variant should be discussed with the man who had the test, not because it is medical information, but because this discussion would allow the further clinical evaluation that might lead it to becoming so. We argue that while prominent ethical debates around genomics often take ‘results’ (...) as a starting point and ask questions as to whether to look for and how to react to them, the construction of genomic results is fraught with ethical complexity, although often couched as a primarily technical problem. We highlight the need for greater focus on, and appreciation of, the ethical work undertaken daily by scientists and clinicians working in genomic medicine and discuss how public conversations around genomics need to adapt to prepare future patients for potentially uncertain and unexpected outcomes from clinical genomic tests. (shrink)

Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that (...) are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries. (shrink)

Romanis and Adkins explore the near-term prospect of artificial amnion and placenta technology (AAPT) which is being developed to supplement the gestational process following the premature ending of a pregnancy.1 While fetal-centric narratives prevail in discussions surrounding AAPT, the authors subvert this trend by centering the experience of pregnant persons with respect to pregnancy loss. The overarching aim of their paper is to move beyond a ‘philosophical understanding of pregnancy towards practical-orientated conclusions regarding the care pathways surrounding [AAPT]’ (Romanis and (...) Adkins,1 p1). This commentary will critically examine the viability of this aim. Romanis and Adkins use the term ‘pregnancy loss’ to refer to the phenomenon where individuals experience a complex set of emotions following the premature ending of pregnancy, despite the survival of the gestated entity. Following Golish and Powell, the authors note how parents may experience contradictory emotions, such as joy mixed with grief, as well as a range of negative feelings including shame, disappointment and a sense of failure.2 At present, this phenomenon has been recognised among parents, particularly the (formerly) pregnant person, in the context of neonatal intensive care units (NICUs) when the infant survives preterm delivery and …. (shrink)

I discuss an influential argument put forward by Hatherley in theJournal of Medical Ethics. Drawing on influential philosophical accounts of interpersonal trust, Hatherley claims that medical artificial intelligence is capable of being reliable, but not trustworthy. Furthermore, Hatherley argues that trust generates moral obligations on behalf of the trustee. For instance, when a patient trusts a clinician, it generates certain moral obligations on behalf of the clinician for her to do what she is entrusted to do. I make three objections (...) to Hatherley’s claims: (1) At least one philosophical account of interagent trust implies that medical AI is capable of being trustworthy. (2) Even if this account should ultimately be rejected, it does not matter much because what we care mostly about is that medical AI is reliable. (3) It is false that trust in itself generates moral obligations on behalf of the trustee. (shrink)

Several European countries have recently started taking steps to protect access to abortion. France is one of these, with a bill having made its way through the legislature to enshrine the ‘liberté garantie’ (‘guaranteed freedom’) to an abortion in its constitution. It is the first country in the world to explicitly include abortion access in its constitution. Although abortion was decriminalised in France in 1975, proponents of the bill stated that they were motivated by protecting freedom for future generations (rather (...) than any perceived current threats)—the French minister for justice described this as characteristic of constitutional lawmaking.1 Enshrining such a freedom within the constitution was not without opposition. Although the bill passed through the Assemblée in January 2024 with 99 votes in favour and 13 against,2 it followed 8 hours of debate in which a number of issues were discussed. The Sénat (the upper house of Parliament) was initially thought to be more likely to oppose the bill. The bill was carried through the Sénat, however, with its Law Commission indicating prior to debate that it would not oppose making abortion a constitutional freedom, despite ‘some reservations’ about the text of the bill.3 Some of the issues raised in the Assemblée related to the language used, with some parliamentarians preferring to constitutionalise the ‘droit’ (right) to abortion; in line with language used in previous debates on the subject, rather than the term ‘liberté’ that was settled on.4 Other concerns were raised about the appropriateness of ‘preventative constitutionalisation’,5 the potential impact on a clinician’s ability to exercise conscientious objection6 and fears of creating an imbalance more generally between women’s …. (shrink)

Countries that abolished donor anonymity have imposed age limits for access to certain types of information by donor offspring. In the UK and the Netherlands, a debate has started on whether these age limits should be lowered or abolished all together. This article presents some arguments against lowering the age limits as a general rule for all donor children. The focus is on whether one should give a child the right to obtain the identity of the donor at an earlier (...) age than is presently stipulated. The first argument is that there is no evidence that a change in age will increase the total well-being of the donor offspring as a group. The second argument stresses that the rights language used for the donor-conceived child isolates the child from his or her family and this is unlikely to be in the best interest of the child. Finally, lowering the age limit reintroduces the genetic father in the family and expresses the bionormative ideology that contradicts gamete donation as a practice. (shrink)

In this paper, we explore how the prospect of artificial placenta technology (nearing clinical trials in human subjects) should encourage further consideration of the loss experienced by individuals when their pregnancy ends unexpectedly. Discussions of pregnancy loss are intertwined with procreative loss, whereby the gestated entity has died when the pregnancy ends. However, we demonstrate how pregnancy loss can and does exist separate to procreative loss in circumstances where the gestated entity survives the premature ending of the pregnancy. In outlining (...) the value that can be attached to pregnancy beyond fetal-centric narratives, we illustrate how pregnancy loss, separate to procreative loss, can be experienced. This loss has already been recognised among parents who have experienced an unexpected early ending of their pregnancy, resulting in their child being cared for in neonatal intensive care unit. Artificial placentas, however, may exacerbate these feelings and make pregnancy loss (without procreative loss) more visible. We argue that pregnancy is an embodied state in which gestation is facilitated by the body but gestation itself should be recognised as a process—and one that could be separable from pregnancy. In demarcating the two, we explore the different ways in which pregnancy loss can be understood. Our objective in this paper goes beyond contributing to our philosophical understanding of pregnancy towards practical-orientated conclusions regarding the care pathways surrounding the artificial placenta. We make recommendations including the need for counselling and careful consideration of the language used when an artificial placenta is used. (shrink)

Genetic testing has familial implications. Counsellors find themselves in (moral) conflict between medical confidentiality (towards the patient) and a potential right or even duty to warn at-risk relatives. Legal regulations vary between countries. English literature about German law is scarce. We reviewed the literature of relevant legal cases, focussing on German law, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This article aims to familiarise counsellors with their responsibilities, compare the situation between countries and point out (...) legally unresolved areas.According to the German Genetic Diagnostics Act (Gendiagnostikgesetz) in case of an ‘avoidable or treatable’ genetic disorder, geneticists ought to confine themselves to the obligated advice to the patient. Whether a breach of the duty of confidentiality can be justified in exceptional cases by ‘necessity as justification’ for actively informing relatives at risk remains legally unclear. In case of a ‘neither avoidable nor treatable’ genetic disease, geneticists should also refrain from actively informing relatives as the justifiable state of emergency does not permit to break the duty of confidentiality. (shrink)

Preterm birth is defined as delivery occurring before 37 weeks gestation.1 Infants born prematurely have increased risks of morbidity and mortality throughout life, especially during the first year. These risks increase as the gestational age at birth decreases.2 Additionally, there are significant racial and ethnic differences in preterm birth rates. In 2022, the rate of preterm birth among non-Hispanic black women was approximately 50% higher than that observed in non-Hispanic white women.1 The outcomes for these infants are also disparate–preterm birth (...) and low birth weight are the second-leading causes of infant mortality (deaths before 1 year of age). Notably, among preterm neonates, infants born to non-Hispanic black women have a mortality rate more than double that of infants born to non-Hispanic white mothers.3 Importantly, there is a small but significant group of neonates that can be classified as severely premature (those born <28 weeks). Infants born before 28 weeks have varied and uncertain outcomes. While this group accounts for only 0.4% of preterm births, it also accounts for 40% of deaths among preterm neonates.4 As noted by Romanis and Adkins, the advent of artificial amnion and placenta technology (AAPT) holds promise for its potential to address the physiologic complications and mortality risks of extreme prematurity by introducing amniotic substitutes that mimic in vivo placental oxygenation and substrate delivery. In contrast …. (shrink)

One of the most important motifs within (medical) ethics is scarcity: where essential (health) resources are scarce, urgent ethical questions arise. Over the last decade, at least 250 papers addressing the allocation of scarce health resources have been published in the Journal of Medical Ethics alone.1 In the typical set-up, the authors introduce a situation of scarcity and then review and adjudicate the available or recommended courses of action, sometimes through the lens of a pet normative ethical theory. It is (...) much less common for (medical) ethicists to focus their enquiries on the origins of scarcity. Why aren’t there sufficient health resources to go around? Who caused the scarcity, and how should they be held responsible? These questions are also firmly within the remit of the discipline. Discussions of scarcity tend to circumvent these difficult questions by focussing on exceptional cases in Global North settings, where scarcity is relatively rare, and is sometimes defensible or insoluble. For example: it would be wasteful for a hospital to overstock expensive, bulky, energetically intensive, specialist equipment whose supply would only be challenged under the most extreme and unforeseen circumstances (eg, a pandemic), and there may never be sufficient usable donor organs to meet the demand for transplants. Much less attention is given to under-resourced settings, generally in the Global South, where scarcity is common, and is often both indefensible and soluble. The literature appears to favour what is ‘unusual’ and ‘interesting’ in some contexts, rather than what is commonplace, and by that fact more worrying, in others. This division of attention entrenches the idea that scarcity is a fixed feature of certain places and lives. Why do medical ethicists so often fight shy of these meta-questions? They are, of course, harder and messier. More work and greater care are needed to contextualise …. (shrink)

Giubiliniet aloffer some helpful reflections on the conscientious provision of medical care and whether and in what circumstances professional associations ought to support the conscientious provision of abortion in circumstances where abortion is banned or heavily restricted. I have several reservations, however, about the argument developed in the article. First, the essay makes questionable use of the case of Savita Halappanavar to justify its central argument about conscientious provision. Second, there is an apparent inconsistency between this article and the authors’ (...) statements elsewhere about the conscientious refusal of care. Third, there are risks that attend to professional associations supporting practitioners who break the law, and yet Giubiliniet aldo not give sufficient attention to this. This response will briefly discuss these three concerns. (shrink)

Blackshaw and Hendricks have recently developed and defended the impairment argument against abortion, arguing that the immorality of giving a child fetal alcohol syndrome (FAS) provides us with reason to believe that abortion is immoral. In this paper, we forward two criticisms of the impairment argument. First, we highlight that, as it currently stands, the argument is very weak and accomplishes very little. Second, we argue that Blackshaw and Hendricks are fundamentally mistaken about what makes giving a child FAS immoral. (...) Once we acknowledge this, it is clear that our intuitions about giving a child FAS provide no support for the supposed immorality of abortion. (shrink)

De Marco and colleagues claim that the standard account of invasiveness as commonly encountered ‘…does not capture all uses of the term in relation to medical interventions1 ’. This is open to challenge. Their first example is ‘non-invasive prenatal testing’. Because it involves puncturing the skin to obtain blood, De Marco et al take this as an example of how an incision or insertion is not sufficient to make an intervention invasive; here is a procedure that involves an incision, but (...) it is regarded as non-invasive. However, this ignores the context, and the term should really be understood in reference to the fetus. It is hard to believe healthcare professionals regard taking blood to measure, for example, ferritin levels as invasive but taking blood to look for fragments of fetal DNA as not. If anyone uses the term thinking it is not invasive to the mother, the solution would be to call it invasive, not redefine what is invasive. De Marco and colleagues’ second example is describing electroconvulsive therapy (ECT) as invasive. However, this is not borne out by their referenced papers. The first cited source is about non-invasive brain stimulation2 and only contains a single sentence about ECT. This sentence may suggest that their view is that ECT …. (shrink)

In their forthcoming article, ‘What makes a medical intervention invasive?’ De Marco, Simons, and colleagues explore the meaning and usage of the term ‘invasive’ in medical contexts. They describe a ‘Standard Account’, drawn from dictionary definitions, which defines invasiveness as ‘incision of the skin or insertion of an object into the body’. They then highlight cases wherein invasiveness is employed in a manner that is inconsistent with this account (eg, in describing psychotherapy) to argue that the term invasiveness is often (...) used to explicitly or implicitly reference interventions that do not fall under the standard account. The authors offer an alternative ‘schematic’ definition of invasiveness, whereby medical interventions entail an underlying context-independent property of ‘basic invasiveness’ and may be understood both relative to each other and to a context-specific threshold of what is ‘invasive’.1 We propose that the meaning of terms such as ‘invasiveness’ is necessarily heterogeneous, and that what is implied by its usage will certainly depend on context, particularly in medical settings. Hence, the creation of a unifying definition is less critical than clarification of the implied and intended meanings of each instance of the term’s use. We further argue that interpreting the use of terms like ‘invasiveness’ in medical practice is complicated by the embedding of each use of this term in a different ‘language game’, whereby words and their meanings are understood by an in-group familiar with …. (shrink)

The classification of medical interventions as either invasive or non-invasive is commonly regarded to be morally important. On the most commonly endorsed account of invasiveness, a medical intervention is invasive if and only if it involves either breaking the skin (‘incision’) or inserting an object into the body (‘insertion’). Building on recent discussions of the concept of invasiveness, we show that this standard account fails to capture three aspects of existing usage of the concept of invasiveness in relation to medical (...) interventions—namely, (1) usage implying that invasiveness comes in degrees, (2) that the invasiveness of an intervention can depend on the characteristics of the salient alternative interventions, and (3) that medical interventions can be invasive in non-physical ways. We then offer the beginnings of a revised account that, we argue, is able to capture a wider range of existing usage. Central to our account is a distinction between two properties: basic invasiveness and threshold invasiveness. We end by assessing what the standard account gets right, and what more needs to be done to complete our schematic account. (shrink)

We are grateful to the commentators for their close reading of our article 1 and for their challenging and interesting responses to it. We do not have space to respond to all of the objections that they raise, so in this reply, we address only a selection of them. Some commentaries question the usefulness of developing an account of the sort we provide, 2 or of revising the Standard Account (SA) in doing so. 3–5 Our schema is intended to provide (...) a framework for developing a full account of invasiveness that captures existing uses of the term. On the assumption that the term is used somewhat reliably and consistently–and we are inclined to agree with some of our commentators 3 4 that people are not terribly confused or mistaken in how they employ the term–an account that captures these... (shrink)

Despite their clearly demonstrated safety and effectiveness, approved vaccines against COVID-19 are commonly mistrusted. Nations should find and implement effective ways to boost vaccine confidence. But the implications for ethical vaccine development are less straightforward than some have assumed. Opponents of COVID-19 vaccine challenge trials, in particular, made speculative or empirically implausible warnings on this matter, some of which, if applied consistently, would have ruled out most COVID-19 vaccine trials and many non-pharmaceutical responses.

As John McMillan notes in January’s editorial,1 many countries are reflecting on how they responded to the COVID-19 pandemic, what went wrong and how responses to such system shocks can be better managed in the future. However, while it is tempting to think that the COVID-19 pandemic is over and that what is now needed is a reflection on how countries could have responded better, some of the underlying issues and problems COVID-19 both highlighted and created are still with us. (...) The legacy of the pandemic has continued particularly for healthcare workers at all levels, who have had to continue providing services with little time to rest and reflect and with new ‘shocks’ to the systems to cope with. For example, in England, industrial action by junior doctors has put already fragile systems under pressure, and the issues that staff are campaigning about remain unaddressed. Many of these issues are not distinctive to COVID-19, but as has been noted, ‘From an ethical perspective, the COVID-19 pandemic is like a prism: it helps us see the spectrum of …. (shrink)

Individuals unvaccinated against COVID-19 (C19) experienced prejudice and blame for the pandemic. Because people vastly overestimate C19 risks, we examined whether these negative judgements could be partially understood as a form of scapegoating (ie, blaming a group unfairly for an undesirable outcome) and whether political ideology (previously shown to shape risk perceptions in the USA) moderates scapegoating of the unvaccinated. We grounded our analyses in scapegoating literature and risk perception during C19. We obtained support for our speculations through two vignette-based (...) studies conducted in the USA in early 2022. We varied the risk profiles (age, prior infection, comorbidities) and vaccination statuses of vignette characters (eg, vaccinated, vaccinated without recent boosters, unvaccinated, unvaccinated-recovered), while keeping all other information constant. We observed that people hold the unvaccinated (vs vaccinated) more responsible for negative pandemic outcomes and that political ideology moderated these effects: liberals (vs conservatives) were more likely to scapegoat the unvaccinated (vs vaccinated), even when presented with information challenging the culpability of the unvaccinated known at the time of data collection (eg, natural immunity, availability of vaccines, time since last vaccination). These findings support a scapegoating explanation for a specific group-based prejudice that emerged during the C19 pandemic. We encourage medical ethicists to examine the negative consequences of significant C19 risk overestimation among the public. The public needs accurate information about health issues. That may involve combating misinformation that overestimates and underestimates disease risk with similar vigilance to error. (shrink)

Psychedelic treatments, particularly 3,4-methylenedioxymethamphetamine (MDMA)-assisted and psilocybin-assisted therapies, have recently seen renewed interest in their clinical potential to treat various mental health conditions. Clinical trials for both MDMA-assisted and psilocybin-assisted therapies have shown to be highly efficacious for post-traumatic stress disorder and major depression. Recent research trials for psychedelic-assisted therapies (PAT) have demonstrated that although they are resource-intensive, their effects are rapid-acting, durable and cost-effective. These results have generated enthusiasm among researchers seeking to investigate psychedelic therapies in active-duty service members (...) of the US military, particularly those with treatment refractory mental health conditions. At the same time, psychedelics remain in early stages of clinical investigation, have not yet achieved regulatory approval for general clinical use and may confer unique psychological and neurobiological effects that could raise novel ethical considerations when treating active-duty service members. Should psychedelics achieve regulatory approval, military relevant considerations may include issues of access to these treatments, appropriate procedures for informed consent, confidentiality standards, and possible unanticipated mental health risks and other psychological sequelae. A service member’s deployability, as well as their ability to return to full military duty following PAT, may also be of unique concern. The authors argue that MDMA-assisted therapy currently represents a promising treatment that should be more rapidly investigated as a clinical therapy for service members while still taking a measured approach that accounts for the many military-specific uncertainties that remain. (shrink)

Over 50% of the world population will develop a psychiatric disorder in their lifetime.1 In the realm of psychiatric treatment, two primary modalities have been established: pharmacotherapy and psychotherapy. Yet, pharmacological interventions often take precedence as the initial treatment choice despite their comparable outcomes, severe side effects and disputed evidence of their efficacy. This preference for medication foregrounds a vital re-examination of what it means to be invasive in medical treatments, namely in psychiatric care. De Marco et al challenge the (...) standard account of invasiveness, presenting considerations that transcend the traditional criteria of physical intrusion.2 Through case studies centred on treatments for schizophrenia and depression, we aim to (1) reinforce De Marco et al ’s challenge to the standard account of invasiveness and (2) extend the dialogue to the moral imperative of redefining mental invasiveness. Our aims are to broaden the definition of mental invasiveness, aligning with De Marco et al ’s emphasis on context sensitivity, and to include the severity of side effects as a critical factor in this assessment. Redefining what is considered invasive in psychiatric treatment has profound implications for patient care and medical decision-making. Labelling treatments, namely medications, as invasive encourages both patients and healthcare providers to approach these options with a heightened level of scrutiny and care. This is …. (shrink)

Employment-based vaccine mandates have worse consequences for existing than prospective employees. Prospective employees are not yet dependent on a particular employment arrangement, so they are better positioned to respond to such mandates. Yet despite this asymmetry in consequences, Smith argues that if vaccine mandates are justified for prospective employees, they are similarly justified for existing employees. This paper responds to Smith’s argument. First, Smith holds that bona fide occupational requirements are actions that are necessary for the safe and effective completion (...) of one’s job. As such, they apply to existing and prospective employees alike. However, I argue that the existence of effective alternative interventions precludes vaccination from being considered a bona fide occupational requirement under current circumstances. Second, Smith holds that if a requirement is justified for prospective employees, it is justified for existing employees, despite the asymmetry in consequences. However, I argue that since vaccination is not a bona fide requirement, the asymmetry in the harms of mandates experienced by prospective versus existing employees entails an asymmetry in the justification required to mandate vaccination for each group. As such, vaccination can be considered a requirement for prospective employees while not being required for existing employees. (shrink)

To counter the imbalance in vaccine distribution during the COVID-19 pandemic, Albertsen and more recently Germaniet alhave suggested a new system of taxation coined as ‘VaxTax’ that would force higher-income countries to fund the access of low-income and middle-income countries (LMICs) to new vaccines in times of pandemic. I will argue that this idea faces numerous challenges of ethical, sociopolitical and economical nature that may hinder any effort to solve the numerous health challenges that LMICs face. I argue that while (...) it is an interesting idea, it is neither sufficient nor will it ever be easily implemented because of socioeconomic or practical reasons. (shrink)

Ethical debates around genetic enhancement tend to include an argument that the technology will eventually be fairly accessible once available. That we can fairly distribute genetic enhancement has become a moral defence of genetic enhancement. Two distribution solutions are argued for, the first being equal distribution. Equality of access is generally believed to be the fairest and most just method of distribution. Second, equitable distribution: providing genetic enhancements to reduce social inequalities. In this paper, I make two claims. I first (...) argue that the very assumption that genetic enhancements can be distributed fairly is problematic when considering our understanding of gene–environment interactions, for example, epigenetics. I then argue that arguments that genetic enhancements are permissible because the intended benefits can be distributed fairly as intended are misinformed. My first claim rests on the assertion that genetic enhancements do not enhance traits in a vacuum; genes are dependent on conducive environments for expression. If society cannot guarantee fair environments, then any benefit conferred from being genetically enhanced will be undermined. Thus, any argument that the distribution of genetic enhancements will be fair and that the technology is therefore morally permissible, is mistaken. (shrink)

The main goal of publicly funded biomedical research is to generate social value through the creation and application of knowledge that can improve the well-being of current and future people. Prioritising research with the greatest potential social value is crucial for good stewardship of limited public resources and ensuring ethical involvement of research participants. At the National Institutes of Health (NIH), peer reviewers hold the expertise and responsibility for social value assessment and resulting prioritisation at the project level. However, previous (...) research has shown that peer reviewers place more emphasis on a study’s methods (‘Approach’) than on its potential social value (best approximated by the criterion of ‘Significance’). Lower weighting of Significance may be due to reviewers’ views on the relative importance of social value, their belief that social value is evaluated at other stages of the research priority-setting process or the lack of guidance on how to approach the challenging task of assessing expected social value. The NIH is currently revising its review criteria and how these criteria contribute to overall scores. To elevate the role of social value in priority setting, the agency should support empirical research on how peer reviewers approach the assessment of social value, provide more specific guidance for reviewing social value and experiment with alternative reviewer assignment strategies. These recommendations would help ensure that funding priorities align with the NIH’s mission and the obligation of taxpayer-funded research to contribute to the public good. (shrink)

De Marco et al 1 argue that the standard account of medical ‘invasiveness’ (as ‘incision’ or ‘insertion’) fails to capture three aspects of its existing use, namely that invasiveness can come in degrees, often depends on features of alternative medical interventions and can be non-physical. They propose a new schematic account that suggests that medical interventions can possess ‘basic invasiveness’ (which can come in degrees and of which they suggest at least two types: physical and mental), and ‘threshold invasiveness’ which (...) can depend on the alternatives a specific intervention is being compared with. While we agree that the standard account of invasiveness fails to capture existing use and are supportive of their aim, here we express scepticism about the practical utility of De Marco et al ’s revised account. Our scepticism concerns the application of De Marco et al’s revised account in the narrow context of clinician–patient communication and deliberation about medical interventions within clinical practice, which we see as a crucial context for its use. While De Marco et al do not specify the contexts in which their revised account could be used, we assume from their discussion of treatment interventions (e.g. non-invasive prenatal testing, ventilation) and their comparison to ‘more or less invasive’ options, that at least one of the purposes in mind for …. (shrink)

Some organisations make vaccination a condition of employment. This means prospective employees must demonstrate they have been vaccinated (eg, against measles) to be hired. But it also means organisations must decide whether _existing_ employees should be expected to meet newly introduced vaccination conditions (eg, against COVID-19). Unlike prospective employees who will not be _hired_ if they do not meet vaccination conditions, existing employees who fail to meet new vaccination conditions risk being _fired_. The latter seems worse than the former. Hence, (...) objections to vaccination mandates commonly centre on the harms that will be visited on existing employees who are unwilling to be vaccinated. However, because this objection does not necessarily entail the claim that vaccination is unnecessary for the effective and safe performance of certain jobs, those making this objection should have less of an objection, or no objection at all (at least on these grounds), to introducing vaccination requirements in some cases for _prospective_ employees. Yet, in this paper, I shall argue that if one has reason to believe vaccination requirements can be justified for prospective employees, one should also believe they are justified for existing employees _despite_ any asymmetry in consequences experienced by the two groups. As a consequence, common objections made against vaccination mandates grounded solely in the harms that may be experienced by existing employees who are unwilling to be vaccinated should be considered unpersuasive. (shrink)

Authors De Marco and colleagues have presented a new model on the concept of invasiveness, redefining both its technical definition and practical implementation.1 While the authors raise valid critiques regarding the discrepancy in definitions, I cannot help but wonder about the purpose of redefining terms for which little confusion, if any, exists? This commentary seeks to scrutinise the rationale supporting the new model in the absence of significant clinical confusion and to explore the implications for clinical practice. Initially, one may (...) notice there is no mention of clinical relevancy, confusion among patients or whether the discrepancy in terms is causing miscommunication. It seems reasonable that some clinical confusion may exist, but so too does a similar imbalance of terms when speaking technically across the specialties; take depression and its definition as a primary example. While I certainly agree with the illustration of non-invasive prenatal testing being compared with venous blood draws as a disparity in terminology, little evidence suggests confusion concerning the nosology.2 The medical community, including both physicians and patients, recognises that the terminology is specifically used within the …. (shrink)

A growing focus on pleasure in human rights discourse has been used to address patterns of sexual exclusion, often when addressing the problems of people with disabilities (PWD). As convincingly argued by Liberman, however, not all PWD suffer from sexual exclusion, and not all who suffer from sexual exclusion are PWD. Danaher and Liberman have thus argued in various ways for a broader range of measures, addressing sexual exclusion. This article builds on previous research and offers a conceptual framework for (...) addressing sexual pleasure and exclusion in terms of human rights. It argues that human rights aim to safeguard autonomy, which is interpreted as multidimensional. It, thus, divides autonomy into the four dimensions of liberty (freedom from threat and coercion), opportunity (options to choose between), capacity (what an agent is capable of doing) and authenticity (the extent to which choices are genuine). Furthermore, it distinguishes between distinct egalitarian strategies, which offer different problems and possibilities, and may be combined. Thus, there is direct egalitarian distribution, indirect egalitarian distribution, baseline or threshold strategies and general promotion strategies. By way of conclusion, the importance of sexual authenticity as the ultimate aim of sexual rights is emphasised. (shrink)

Despite the frequent invocation of ‘false hope’ and possible related moral concerns in the context of assisted reproduction technologies, a focused ethical and conceptual problematisation of this concept seems to be lacking. We argue that an invocation of ‘false hope’ only makes sense if the fulfilment of a desired outcome (eg, a successful fertility treatment) is impossible, and if it is attributed from an external perspective. The evaluation incurred by this third party may foreclose a given perspective from being an (...) object of hope. However, this evaluation is not a mere statistical calculation or observation based on probabilities but is dependent on several factors that should be acknowledgeable as morally relevant. This is important because it allows room for, and encourages, reasoned disagreement and moral negotiation. Accordingly, the object of hope itself, whether or not based on socially embedded desires or practices, can be a topic of debate. (shrink)

Developmentally, adolescence sits in transition between childhood and adulthood. Involving adolescents in their medical decision-making prompts important and complex ethical questions. Originating in the UK, the concept of Gillick competence is a dominant framework for navigating adolescent medical decision-making from legal, ethical and clinical perspectives and is commonly treated as comprehensive. In this paper, we argue that its utility is far more limited, and hence over-reliance on Gillick risks undermining rather than promoting ethically appropriate adolescent involvement. We demonstrate that Gillick (...) only provides guidance in the limited range of cases where legal decisional authority needs to be clarified. The range of cases where use of Gillick actually promotes adolescent involvement is narrower still, because several features must be present for Gillick to be enacted. Each of these features can, and do, act as barriers to adolescent involvement. Within these limited situations, we argue that Gillick is not specific or strong enough and is reliant on ethically contestable principles. Moreover, in most situations in adolescent healthcare, Gillick is silent on the ethical questions around involving adolescents. This is because it focuses on decisional authority—having the final say in decision-making—which is one small subset of the many ways adolescents could be involved in decision-making. The implication of our analysis is that use of Gillick competence tends to limit or undermine adolescent involvement opportunities. We propose that those working with adolescents should be judicious in seeking Gillick’s guidance, instead drawing on and developing alternative frameworks that provide a comprehensive model for adolescent involvement. (shrink)

Miller has recently argued that the standard liberal and moderate positions on abortion are incapable of grounding the claim that ‘all non-disabled adult humans are equal’. The reason, he claims, is such accounts base the intrinsic moral worth of a human being on some property (or set of properties) which comes in degrees. In contrast, he argues that moral equality must reside in some binary property, such as the property of being human. In this paper, I offer three criticisms of (...) Miller’s position. (shrink)

Igwebuike is a traditional knowledge system undergirded by the metaphysical assumption that the world is a totality of interconnected and interrelated entities.1–4 African scholars in West Africa often invoke igwebuike to make sense of African ethical, social and political perspectives that are grounded in the theory of Afro-communitarianism. Afro-communitarianism is primarily a socioethical theory that is concerned with the articulation of the moral relationship between the individual and the community. The term igwebuike is derived from the Igbo root words igwe (...) (number), bu (is) and ike (strength). Thus, the term igwebuike translates as ‘number is strength’.3 4 As an ethical theory, igwebuike espouses the ontological relatedness of the variety of entities in the world and the moral relatedness of all humans by virtue of their common possession of life, with the accompanying human capacity for feeling and thinking. Resultantly, it prescribes solidarity, companionship and identification with others as virtues that promote human flourishing. The reverence for life and humanness explicitly forbids actions that diminish this superlative and irreplaceable quality.5 This concept can be helpful in offering a conceptual framework for making healthcare more …. (shrink)

So-called ‘gain-of-function’ (GOF) research is virological research that results in a virus substantially more virulent or transmissible than its wild antecedent. GOF research has been subject to ethical analysis in the past, but the methods of GOF research have to date been underexamined by philosophers in these analyses. Here, we examine the typical animal used in influenza GOF experiments, the ferret, and show how despite its longstanding use, it does not easily satisfy the desirable criteria for ananimal model. We then (...) discuss the limitations of the ferret model, and how those epistemic limitations bear on ethical and policy questions around the risks and benefits of GOF research. We conclude with a reflection on how philosophy of science can contribute to ethical and policy debates around the risks, benefits and relative priority of life sciences research. (shrink)

Components of artificial intelligence (AI) for analysing social big data, such as natural language processing (NLP) algorithms, have improved the timeliness and robustness of health data. NLP techniques have been implemented to analyse large volumes of text from social media platforms to gain insights on disease symptoms, understand barriers to care and predict disease outbreaks. However, AI-based decisions may contain biases that could misrepresent populations, skew results or lead to errors. Bias, within the scope of this paper, is described as (...) the difference between the predictive values and true values within the modelling of an algorithm. Bias within algorithms may lead to inaccurate healthcare outcomes and exacerbate health disparities when results derived from these biased algorithms are applied to health interventions. Researchers who implement these algorithms must consider when and how bias may arise. This paper explores algorithmic biases as a result of data collection, labelling and modelling of NLP algorithms. Researchers have a role in ensuring that efforts towards combating bias are enforced, especially when drawing health conclusions derived from social media posts that are linguistically diverse. Through the implementation of open collaboration, auditing processes and the development of guidelines, researchers may be able to reduce bias and improve NLP algorithms that improve health surveillance. (shrink)

Disease radically changes the life of many people and satisfies formal criteria for being a transformative experience. According to the influential philosophy of Paul, transformative experiences undermine traditional criteria for rational decision-making. Thus, the transformative experience of disease can challenge basic principles and rules in medical ethics, such as patient autonomy and informed consent. This article applies Paul’s theory of transformative experience and its expansion by Carel and Kidd to investigate the implications for medical ethics. It leads to the very (...) uncomfortable conclusion that disease involves transformative experiences in ways that can reduce people’s rational decision-making ability and undermine the basic principle of respect for autonomy and the moral rule of informed consent. While such cases are limited, they are crucial for medical ethics and health policy and deserve more attention and further scrutiny. (shrink)

Parsa-Parsi et al bring attention to the World Medical Association (WMA) and transparency to its International Code of Medical Ethics (ICoME) revisions.1 We value their report and the revised ICoME but explain here that the ICoME cannot reflect consensus among all WMA members, or the wider medical profession, given structural and epistemic injustices that restrain low-income and middle-income country (LMIC) physicians from participating in activities such as WMA revisions. Such injustices overlook experiences and contributions of those from LMICs and marginalised (...) groups, hindering their access to and influence within medicine.2 They also undermine access to information about, and from, the WMA. Recruiting new members from, and better engaging members in, LMICs would strengthen the WMA and its influence across the medical profession, and better elevate environmental sustainability as a biomedical and bioethical concern. This would be beneficial because there is controversy among physicians, bioethicists and other stakeholders about the relevance of environmental sustainability to medicine.3 4 That its addition to the ICoME was ‘uncontentious’ hints at structural and epistemic injustices in the revision process and homogeneity of those most involved in the revisions. Based on our observations as medical educators, it appears that few medical students and physicians at our institution, and few across the Caribbean and …. (shrink)

After an intensive 4-year process, the World Medical Association (WMA) has revised its International Code of Medical Ethics (ICoME). In their report outlining this process, Parsa-Parsi et al not only describe how the WMA sought to ‘cultivat[e] international agreement’ on a ‘global medical ethos’, but also outline the philosophical framework of the ICoME: how the WMA, as the ‘global representation of the medical profession’, created and revised the ICoME through the process of international professional self-regulation.1 However, there is a significant (...) tension to be found in this framework—one which contrasts the international scope of the ICoME with the supposed source of its legitimacy. Here, we seek to characterise this tension and the doubt which it casts on the legitimacy of the ICoME. (shrink)

The 2023 doctors’ strikes in the UK have elicited a familiar moral outcry that such strikes are morally wrong. We consider five arguments that might be thought to show doctors’ strikes are morally impermissible but show that they all fail. The most we can conclude from such arguments is that doctors’ strikes are morally permissible in a narrower range of circumstances than strikes in other sectors.We then outline two independent but compatible justifications for doctors’ strikes, one that appeals to doctors’ (...) interests in fair pay and working conditions and one that appeals to doctors’ duty to protect public health. We also suggest that doctors’ strikes can be supererogatory when they aim to correct a government failing in its own duty to protect public health. Finally, we assess the 2023 UK doctors’ strikes. We conclude that they are justified and there is a case for considering them supererogatory. (shrink)

Socially responsible publishers, such as the BMJ Publishing Group, have demonstrated a commitment to health equity and working towards rectifying the structural racism that exists both in healthcare and in medical publishing.1 The commitment of academic publishers to collecting information relevant to promoting equity and diversity is important and commendable where it leads to that result.2 However, collecting sensitive demographic data is not a morally neutral activity. Rather, it carries with it both known and potential risks. Among these are issues (...) around privacy or data misuse, as well as more basic concerns about how, when or why people should be categorised in certain ways and/or prompted to conceive of themselves or their identities in certain terms.3 If such data are to be collected, therefore, their effectiveness in achieving the stated ends must have a sufficiently compelling evidence base so as to justify the various risks involved. And where possible, these risks must also be identified and minimised. As Varcoe et al 4 argue, > While most leaders and healthcare workers and some patients [in their study] envisioned potential benefits associated with having ethnicity data, these benefits were seen as largely contingent upon action being taken to [actually] ameliorate inequities. Overwhelmingly, however, leaders from ethno-cultural communities and patients of diverse identities anticipated potential harm arising both from having ethnicity data and the process of collection. The analysis illustrates that in today’s sociopolitical context, collecting ethnicity data in clinical contexts may engender considerable harm, particularly for racialized, vulnerable patients. (p1569) Varcoe et al refer to ‘ethnicity’ data, which as they note is an ambiguous concept, potentially encompassing such diverse notions as ancestry, language, religion or culture. It is also a term that is in some contexts—for example, the USA—often used interchangeably with a different, more highly charged term: ‘race’. Data …. (shrink)

I have recently offered a defence of human equality, and consequently an argument against abortion. This has been objected to by Bozzo, on the grounds that my account of human equality is unclear and could be grounded in utilitarian or Kantian ethics, that my account struggles to ground the permissibility of therapeutic abortions, and that my proposed foundation for human equality itself is parasitic on a scalar property which generates the same difficulties I am attempting to solve. I provide an (...) account of human equality which cannot easily be grounded in utilitarianism or Kantianism, offer a variety of defences of therapeutic abortion consistent with treating the mother and child equally, and show that even if the value of humanness is ultimately grounded in a scalar quality, my argument succeeds. (shrink)

The World Medical Association (WMA), the global representation of the medical profession, first adopted the International Code of Medical Ethics (ICoME) in 1949 to outline the professional duties of physicians to patients, other physicians and health professionals, themselves and society as a whole. The ICoME recently underwent a major 4-year revision process, culminating in its unanimous adoption by the WMA General Assembly in October 2022 in Berlin. This article describes and discusses the ICoME, its revision process, the controversial and uncontroversial (...) issues, and the broad consensus achieved among WMA constituent members, representing over 10 million physicians worldwide. The authors analyse the ICoME, including its response to contemporary changes and challenges like ethical plurality and globalisation, in light of ethical theories and approaches, reaching the conclusion that the document is a good example of international ethical professional self-regulation. (shrink)

We thank our commentators for their thoughtful responses to our paper1 covering among other issues the relationships of ethics law and professional codes, the tensions between ethical universalism and cultural relativism and the phenomenon of moral judgement required when ethical norms conflict, including the norms of patient care versus obligations to others both now and in the future. Although the comments deserve more extensive discussion, in what follows we respond briefly to specific aspects of each commentary and remind readers that (...) professional codes of ethics are necessarily brief and that the International Code of Medical Ethics (ICoME) explicitly refers to the World Medical Association’s (WMA) mutually concordant and far more extensive ‘body of policies’.2 Sarela raises a fundamental and, as stated in the commentary, unresolved debate: ‘should ethics shape law or is it the converse’?3 We understand the ‘global medical ethos’ represented in the WMA’s revised ICoME to be firmly embedded in the assumption that ethics should shape law and that only where laws are so shaped do people governed by them have an ethical obligation to obey them. For the medical profession, laws permitting participation in torture or other cruel, inhuman or degrading practices and punishments are categorically unethical, and therefore, doctors must not facilitate or participate in them—difficult as it may be for some doctors in some regions or environments to act accordingly. Schantz and Mansoori claim that ‘if a code of ethics is an act of professional self-regulation and professional self-regulation is community-dependent, then a code of ethics cannot be …. (shrink)

Respect for patient autonomy is a central principle of medical ethics. However, there are important unresolved questions about the characteristics of an autonomous decision, and whether some autonomous preferences should be subject to more scrutiny than others. In this paper, we consider whether _inappropriately adaptive preferences_—preferences that are based on and that may perpetuate social injustice—should be categorised as autonomous in a way that gives them normative authority. Some philosophers have argued that inappropriately adaptive preferences do not have normative authority, (...) because they are only a reflection of a person’s social context and not of their true self. Under this view, medical professionals who refuse to carry out actions which are based on inappropriately adaptive preferences are not in fact violating their patient’s autonomy. However, we argue that it is very difficult to articulate a systematic and principled distinction between normal autonomous preferences and inappropriately adaptive preferences, especially if this distinction needs to be useful for clinicians in real-life situations. This makes it difficult to argue that inappropriately adaptive preferences are straightforwardly non-autonomous. Given this problem, we argue that there are significant theoretical issues with contemporary understandings of autonomy in bioethics. We discuss what this might mean for the practice of medicine and for medical ethics education. (shrink)

This paper offers a qualified defence of physician non-compliance with antiabortion legislation in the wake of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization. The paper examines two ethically troubling trends of post-Dobbs legislation: narrow and vague maternal health exemption clauses and mandatory reporting of miscarriages in jurisdictions where patients may criminal prosecution for medically induced abortions. It then examines and defends a professional obligation on the part of physicians to comply with the law. This obligation, however, (...) is defeasible. The paper then argues that physicians’ obligations to comply with the law is defeated when the law is illegitimate and following the law would constitute bad medical practice. Finally, it argues that the ethically troubling trends in post-Dobbs antiabortion legislation may meet these criteria. (shrink)

Parsa-Parsi et al assert that the International Code of Medical Ethics (ICoME) provides a professional standard that overrides conflicting national legal norms.1 While this claim is made in the context of laws that require doctors to participate in ‘acts of torture, or other cruel, inhuman, or degrading practices and punishments’ (para10 of ICoME), the underlying premise that medical ethics supersedes law requires scrutiny. It is clear that medical ethics and law are linked inextricably, but there is unresolved debate about the (...) sequence of this interaction: should ethics shape law; or is it the converse? Important principles, notably respect for patients’ autonomy, have arisen from case law and subsequently been adopted into medical ethics. As pointed out by Beauchamp and Childress, it is only ‘since the mid-1970s (that) the primary justification advanced for requirements of informed consent has been to protect autonomous choice’ (pg.118).2 Whereas, the legal obligation to respect autonomy can be traced to the early 1900s, in the landmark US case of Schloendorff v Society of New York Hospital : ‘Every human being of adult years and sound mind has a right to determine what shall be done with his own body’.1 Moreover, the term informed consent was born in law: it was coined …. (shrink)

Paragraph 12 of the revised International Code of Medical Ethics (ICoME) states that ‘the physician should strive to practise medicine in ways that are environmentally sustainable with a view to minimising environmental health risks to current and future generations.’1 This emphasis on environmental sustainability is in line with popular discourse as well growing scholarly attention in medical ethics for healthcare’s contribution to climate change. Recent research analyses, for instance, the ‘greening’ of informed consent and related bioethical principles.2 3 It is (...) unclear what the duty of practising sustainable healthcare means at the level of doctor–patient interaction. Parsa-Parsi et al flag the potential conflict in the ICoME’s provisions if ‘the actions of physicians are influenced by environmental considerations to the detriment of patients’ (p. 2), noting that the ICoME does not provide a handhold to improve understanding of such tensions. The code ‘does not go into extensive detail, does not include comprehensive explanations nor any rules or guidance on how to reconcile its principles when they conflict’ (p. 4). For Parsa-Parsi et al, not codes, but textbooks have a crucial role to play in resolving this conflict. It is rife that professional codes can lead to internal inconsistencies and …. (shrink)

Parsa-Parsi et al systematically discuss and elucidate contentious and non-controversial ethical issues that emerged during the ICoME (International Code of Medical Ethics) revision process and the consensus they achieved. The ethical issues discussed include the physician’s duty to act in the best interests of patients and to ensure they are protected from the unjustifiable risk of harm, respect for patient autonomy and the duties of physicians during emergencies, among others. This paper examines paragraph 26, which requires doctors to provide only (...) medically justified remote treatment, ensure patients offer informed consent and adequately protect their confidentiality.1 At the peak of the COVID-19 pandemic, many countries in Europe and America implemented remote-by-default healthcare policies. At that time, the policy aimed to ensure that patients enjoyed continued access to care while protecting healthcare professionals’ health and well-being. After the COVID-19 pandemic, this policy remained in place. Regardless of the nature of their ailment, patients have consistently preferred in-person care out of concern that their health issues might not be accurately diagnosed and that they may not receive quality care …. (shrink)

Over 200 health journals call on the United Nations (UN), political leaders and health professionals to recognise that climate change and biodiversity loss are one indivisible crisis and must be tackled together to preserve health and avoid catastrophe. This overall environmental crisis is now so severe as to be a global health emergency. The world is currently responding to the climate crisis and the nature crisis as if they were separate challenges. This is a dangerous mistake. The 28th Conference of (...) the Parties (COP) on climate change is about to be held in Dubai while the 16th COP on biodiversity is due to be held in Turkey in 2024. The research communities that provide the evidence for the two COPs are unfortunately largely separate, but they were brought together for a workshop in 2020 when they concluded that: ‘Only by considering climate and biodiversity as parts of the same... (shrink)

Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamental part of safe and ethical clinical practice. Currently, it is routine for a significant part of the consent process to be delegated to members of the clinical team not performing the procedure (eg, junior doctors). However, it is common for consent-taking delegates to lack sufficient time and clinical knowledge to adequately promote patient autonomy and informed decision-making. Such problems might be addressed in a number of (...) ways. One possible solution to this clinical dilemma is through the use of conversational artificial intelligence using large language models (LLMs). There is considerable interest in the potential benefits of such models in medicine. For delegated procedural consent, LLM could improve patients’ access to the relevant procedural information and therefore enhance informed decision-making.In this paper, we first outline a hypothetical example of delegation of consent to LLMs prior to surgery. We then discuss existing clinical guidelines for consent delegation and some of the ways in which current practice may fail to meet the ethical purposes of informed consent. We outline and discuss the ethical implications of delegating consent to LLMs in medicine concluding that at least in certain clinical situations, the benefits of LLMs potentially far outweigh those of current practices. (shrink)