When is it permissible to allow a newborn infant to die on the basis of their future quality of life? The prevailing official view is that treatment may be withdrawn only if the burdens in an infant's future life outweigh the benefits. In this paper I outline and defend an alternative view. On the Threshold View, treatment may be withdrawn from infants if their future well-being is below a threshold that is close to, but above the zero-point of well-being. I (...) present four arguments in favor of the Threshold View, and identify and respond to several counterarguments. I conclude that it is justifiable in some circumstances for parents and doctors to decide to allow an infant to die even though the infant's life would be worth living. The Threshold View provides a justification for treatment decisions that is more consistent, more robust, and potentially more practical than the standard view. (shrink)

The experiences described in the VIP transcripts are incredibly varied and yet frequently explicitly labelled by participants as "voices." How can we make sense of this? If we reflect carefully on uses of the word "voice", we see that it can express at least two entirely different concepts, which pick out categorically different phenomena. One concept picks out a speech sound (e.g. "This synthesizer has a "voice" setting"). Another concept picks out a specific agent (e.g. "I hear two voices: one (...) is a ten year-old boy…"). This chapter explores how these two concepts are related to one another in the context of voice-hearing. (shrink)

In this paper, I will present and advocate a view about what we are doing when we attribute delusion, namely, say that someone is delusional. It is an “expressivist” view, roughly analogous to expressivism in meta-ethics. Just as meta-ethical expressivism accounts for certain key features of moral discourse, so does this expressivism account for certain key features of delusion attribution. And just as meta-ethical expressivism undermines factualism about moral properties, so does this expressivism, if correct, show that certain attempts to (...) objectively define delusion are misguided. I proceed as follows. I start by examining different attempts at defining delusion, separating broadly psychiatric attempts from epistemic ones. I then present a change of approach, according to which we question whether the term “delusion” is in the business of (merely) describing reality. I then support this proposal, first, by borrowing standard lines of argument from meta-ethics (including ontological reluctance, intrinsic motivation, and deep disagreement) but also, by inference to the best explanation of some the features we see when we try to theorise about delusion (namely that it is hard to define, and that our delusion attributions are elicited by a plurality of norms). (shrink)

A particular feature of this book is substantial "Stretch and Challenge" material throughout which allows students to develop further.

One of the most contentious ethical issues in the neonatal intensive care unit is the withdrawal of life-sustaining treatment from infants who may otherwise survive. In practice, one of the most important factors influencing this decision is the prediction that the infant will be severely intellectually disabled. Most professional guidelines suggest that decisions should be made on the basis of the best interests of the infant. It is, however, not clear how intellectual disability affects those interests. Why should intellectual disability (...) be more important than physical disability to the future interests of an infant? Is it discriminatory to base decisions on this? This paper will try to unravel the above questions. It seems that if intellectual disability does affect the best interests of the child it must do so in one of three ways. These possibilities will be discussed as well as the major challenges to the notion that intellectual disability should have a role in such decisions. The best interests of the child can be affected by severe or profound intellectual disability. It is, though, not as clear-cut as some might expect. (shrink)

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

Ouvrage philosophique sur ce qu'est le Monde, et non sur ce qu'il convient d'y faire.".

Preimplantation genetic diagnosis and some prenatal screening programmes have been criticized for being 'eugenic'. This paper aims to analyse this criticism and to evaluate one of the main ethical arguments lying behind it. It starts with a discussion of the meaning of the term 'eugenics' and of some relevant distinctions: for example, that between objections to eugenic ends and objections to certain means of achieving them. Next, a particular argument against using preimplantation genetic diagnosis to 'screen out' disability is considered, (...) one based on the Equal Value Principle, which says that we should value disability and non-disability equally. It is argued that present practice and policy probably do violate the Equal Value Principle, but that this principle is itself unsound. (shrink)

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

In bioethical discussions of preimplantation genetic diagnosis and prenatal screening, accusations of eugenics are commonplace, as are counter-claims that talk of eugenics is misleading and unhelpful. This paper asks whether “eugenics talk”, in this context, is legitimate and useful or something to be avoided. It also looks at the extent to which this linguistic question can be answered without first answering relevant substantive moral questions. Its main conclusion is that the best and most non-partisan argument for avoiding eugenics talk is (...) the Autonomy Argument. According to this, eugenics talk per se is not wrong, but there is something wrong with using its emotive power as a means of circumventing people’s critical–rational faculties. The Autonomy Argument does not, however, tell against eugenics talk when such language is used to shock people into critical–rational thought. These conclusions do not depend on unique features of eugenics: similar considerations apply to emotive language throughout bioethics. (shrink)

One of the pressures placed upon researchers is the process of ethics review. This frequently provides considerable conflict. The process of review of student projects of little inherent risk is identical to that of their more senior colleagues. In this article I propose that we should be more tolerant of design problems within student research if the overall risk is minimal in order that the student can learn about the process of carrying out research.The frequency and content of papers discussing (...) research ethics review in specialist,1 professional2 3 and lay4 press suggests that many senior researchers find the process challenging. The opinion most frequently expressed is that research ethics committees work to an imprecise set of rules and represent a barrier to significant pieces of clinical research. In particular, specific criticism has been aimed at the review of student research5–8 and the difficulties that students and their supervisors face.In ethics committees we usually police research very carefully, monitoring the detail of projects, including how participants will be selected, what data will be collected, how it will be handled and how the research is funded in addition to the adequacy of the consent process and information that underlies it. My experience as a member of NHS REC and governance committees and, more particularly, coordinator of student research, is that National Research Ethics Service REC usually apply the same standards to student research with little inherent risk as to complex phase 1 studies with significant risk. Guidance in the standard operating procedures for NHS REC is at best unhelpful and at worst supportive of this view. …. (shrink)

The moral and political thought of Herbert Spencer is usually associated with some form of evolutionism. This is unsurprising, since Spencer himself thought of his ideas as founded on evolutionary theory. But it is regrettable, because no one believes in Spencer's form of evolutionism any more, and even if they did, they would not think that it supported his views in the way that he confidently believed. And so Spencer has been largely neglected since his death. His libertarianism is thought (...) to be without foundation, and so few have thought it worth study. But in this paper I try to show that Spencer's moral and political conclusions can be based on some of the non-evolutionary arguments that he offered. Although these arguments are not entirely compelling, they have force in a way that his evolutionary claims do not. (shrink)

It may soon be possible to generate human organs inside of human-pig chimeras via a process called interspecies blastocyst complementation. This paper discusses what arguably the central ethical concern is raised by this potential source of transplantable organs: that farming human-pig chimeras for their organs risks perpetrating a serious moral wrong because the moral status of human-pig chimeras is uncertain, and potentially significant. Those who raise this concern usually take it to be unique to the creation of chimeric animals with (...) ‘humanised’ brains. In this paper, we show how that the same style of argument can be used to critique current uses of non-chimeric pigs in agriculture. This reveals an important tension between two common moral views: that farming human-pig chimeras for their organs is ethically concerning, and that farming non-chimeric pigs for food or research is ethically benign. At least one of these views stands in need of revision. (shrink)

There are no egalitarians in a pandemic. The scale of the challenge for health systems and public policy means that there is an ineluctable need to prioritize the needs of the many. It is impossible to treat all citizens equally, and a failure to carefully consider the consequences of actions could lead to massive preventable loss of life. In a pandemic there is a strong ethical need to consider how to do most good overall. Utilitarianism is an influential moral theory (...) that states that the right action is the action that is expected to produce the greatest good. It offers clear operationalizable principles. In this paper we provide a summary of how utilitarianism could inform two challenging questions that have been important in the early phase of the pandemic: (a) Triage: which patients should receive access to a ventilator if there is overwhelming demand outstripping supply? (b) Lockdown: how should countries decide when to implement stringent social restrictions, balancing preventing deaths from COVID‐19 with causing deaths and reductions in well‐being from other causes? Our aim is not to argue that utilitarianism is the only relevant ethical theory, or in favour of a purely utilitarian approach. However, clearly considering which options will do the most good overall will help societies identify and consider the necessary cost of other values. Societies may choose either to embrace or not to embrace the utilitarian course, but with a clear understanding of the values involved and the price they are willing to pay. (shrink)

The rapid development of vaccines against COVID‐19 represents a huge achievement, and offers hope of ending the global pandemic. At least three COVID‐19 vaccines have been approved or are about to be approved for distribution in many countries. However, with very limited initial availability, only a minority of the population will be able to receive vaccines this winter. Urgent decisions will have to be made about who should receive priority for access. Current policy in the UK appears to take the (...) view that those who are most vulnerable to COVID‐19 should get the vaccine first. While this is intuitively attractive, we argue that there are other possible values and criteria that need to be considered. These include both intrinsic and instrumental values. The former are numbers of lives saved, years of life saved, quality of the lives saved, quality‐adjusted life‐years (QALYs), and possibly others including age. Instrumental values include protecting healthcare systems and other broader societal interests, which might require prioritizing key worker status and having dependants. The challenge from an ethical point of view is to strike the right balance among these values. It also depends on effectiveness of different vaccines on different population groups and on modelling around cost‐effectiveness of different strategies. It is a mistake to simply assume that prioritizing the most vulnerable is the best strategy. Although that could end up being the best approach, whether it is or not requires careful ethical and empirical analysis. (shrink)

'This book radically raises the level of debate.

There is a concern that as a result of COVID-19 there will be a shortage of ventilators for patients requiring respiratory support. This concern has resulted in significant debate about whether it is appropriate to withdraw ventilation from one patient in order to provide it to another patient who may benefit more. The current advice available to doctors appears to be inconsistent, with some suggesting withdrawal of treatment is more serious than withholding, while others suggest that this distinction should not (...) be made. We argue that there is no ethically relevant difference between withdrawing and withholding treatment and that suggesting otherwise may have problematic consequences. If doctors are discouraged from withdrawing treatment, concern about a future shortage may make them reluctant to provide ventilation to patients who are unlikely to have a successful outcome. This may result in underutilisation of available resources. A national policy is urgently required to provide doctors with guidance about how patients should be prioritised to ensure the maximum benefit is derived from limited resources. (shrink)

If a doctor is trying to decide whether or not to provide a medical treatment, does it matter ethically whether that treatment has already been started? Health professionals sometimes find it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold). But does that feeling correspond to an ethical difference? In this article, we defend equivalence—the view that withholding and withdrawal of treatment are ethically equivalent when all other factors are equal. We argue that preference for (...) withholding over withdrawal could represent a form of cognitive bias—withdrawal aversion. Nevertheless, we consider whether there could be circumstances in which there is a moral difference. We identify four examples of conditional nonequivalence. Finally, we reflect on the moral significance of diverging intuitions and the implications for policy. We propose a set of practical strategies for helping to reduce bias in end-of-life decision making, including the equivalence test. (shrink)

The meta-problem of consciousness (Chalmers, 2018) is the problem of explaining the behaviours and verbal reports that we associate with the so-called 'hard problem of consciousness'. These may include reports of puzzlement, of the attractiveness of dualism, of explanatory gaps, and the like. We present and defend a solution to the meta-problem. Our solution takes as its starting point the emerging picture of the brain as a hierarchical inference engine. We show why such a device, operating under familiar forms of (...) adaptive pressure, may come to represent some of its mid-level inferences as especially certain. These mid-level states confidently re-code raw sensory stimulation in ways that (they are able to realize) fall short of fully determining how properties and states of affairs are arranged in the distal world. This drives a wedge between experience and the world. Advanced agents then represent these mid-level inferences as irreducibly special, becoming increasingly puzzled as a result. (shrink)

The COVID-19 pandemic has created unusually challenging and dangerous workplace conditions for key workers. This has prompted calls for key workers to receive a variety of special benefits over and above their normal pay. Here, we consider whether two such benefits are justified: a no-fault compensation scheme for harm caused by an epidemic and hazard pay for the risks and burdens of working during an epidemic. Both forms of benefit are often made available to members of the armed forces for (...) the harms, risks and burdens that come with military service. We argue from analogy that these benefits also ought to be provided to key workers during an epidemic because, like the military, key workers face unavoidable harms, risks and burdens in providing essential public good. The amount of compensation should be proportional to the harm suffered and the amount of hazard pay should be proportional to the risk and burden endured. Therefore, key workers should receive the same amount of compensation and hazard pay as the military where the harms, risks and burdens are equivalent. In the UK, a form of no-fault compensation has recently been made available to the surviving families of key workers who suffer fatal COVID-19 infections. According to our argument, however, it is insufficient because it offers less to key workers than is made available to the families of armed services personnel killed on duty. (shrink)

BackgroundDecisions about withdrawal of life support for infants have given rise to legal battles between physicians and parents creating intense media attention. It is unclear how we should evaluate when life is no longer worth living for an infant. Public attitudes towards treatment withdrawal and the role of parents in situations of disagreement have not previously been assessed.MethodsAn online survey was conducted with a sample of the UK public to assess public views about the benefit of life in hypothetical cases (...) similar to real cases heard by the UK courts. We then evaluated these public views in comparison with existing ethical frameworks for decision-making.ResultsOne hundred and thirty participants completed the survey. The majority agreed that an infant’s life may have no benefit when well-being falls below a critical level. Decisions to withdraw treatment were positively associated with the importance of use of medical resources, the infant’s ability to have emotional relationships, and mental abilities. Up to 50% of participants in each case believed it was permissible to either continue or withdraw treatment.ConclusionDespite the controversy, our findings indicate that in the most severe cases, most people agree that life is not worth living for a profoundly disabled infant. Our survey found wide acceptance of at least the permissibility of withdrawal of treatment across a range of cases, though also a reluctance to overrule parents’ decisions. These findings may be useful when constructing guidelines for clinical practice. (shrink)

When is life-sustaining treatment not in the best interests of a minimally conscious child? This is an extremely difficult question that incites seemingly intractable debate. And yet, it is the question courts in England and Wales have set out to answer in disputes about appropriate medical treatment for children.

Robotic or automatic milking systems are novel technologies that take over the labor of dairy farming and reduce the need for human–animal interactions. Because robotic milking involves the replacement of ‘conventional’ twice-a-day milking managed by people with a system that supposedly allows cows the freedom to be milked automatically whenever they choose, some claim robotic milking has health and welfare benefits for cows, increases productivity, and has lifestyle advantages for dairy farmers. This paper examines how established ethical relations on dairy (...) farms are unsettled by the intervention of a radically different technology such as AMS. The renegotiation of ethical relationships is thus an important dimension of how the actors involved are re-assembled around a new technology. The paper draws on in-depth research on UK dairy farms comparing those using conventional milking technologies with those using AMS. We explore the situated ethical relations that are negotiated in practice, focusing on the contingent and complex nature of human–animal–technology interactions. We show that ethical relations are situated and emergent, and that as the identities, roles, and subjectivities of humans and animals are unsettled through the intervention of a new technology, the ethical relations also shift. (shrink)

Despite a long and venerable tradition, the material constitution almost disappeared from constitutional scholarship after the Second World War. Its marginalisation saw the rise of a normative and legalistic style in constitutional law that neglected the role of social reality and political economy. This collection not only retrieves the history and development of the concept of the material constitution, but it tests its theoretical and practical relevance in the contemporary world. With essays from a diverse range of contributors, the collection (...) demonstrates that the material constitution speaks to several pressing issues, from the significance of economic development in constitutional orders to questions of constitutional identity. Offering original analyses supported by international case studies, this book develops a new model of constitutional reality, one that informs our understanding of the world in profound ways. (shrink)

In the first wave of the COVID-19 pandemic, healthcare workers in some countries were forced to make distressing triaging decisions about which individual patients should receive potentially life-saving treatment. Much of the ethical discussion prompted by the pandemic has concerned which moral principles should ground our response to these individual triage questions. In this paper we aim to broaden the scope of this discussion by considering the ethics of broader structural allocation decisions raised by the COVID-19 pandemic. More specifically, we (...) consider how nations ought to distribute a scarce life-saving resource across healthcare regions in a public health emergency, particularly in view of regional differences in projected need and existing capacity. We call this the regional triage question. Using the case study of ventilators in the COVID-19 pandemic, we show how the moral frameworks that we might adopt in response to individual triage decisions do not translate straightforwardly to this regional-level triage question. Having outlined what we take to be a plausible egalitarian approach to the regional triage question, we go on to propose a novel way of operationalising the ‘save the most lives’ principle in this context. We claim that the latter principle ought to take some precedence in the regional triage question, but also note important limitations to the extent of the influence that it should have in regional allocation decisions. (shrink)

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage or at the development stage. The Catholic Church’s position is that, if there are alternatives, (...) Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies. (shrink)