This is the first book that explains how you actually go about doing good bioethics. John McMillan develops an account of the nature of bioethics; he reveals how a number of methodological spectres have obstructed bioethics; and then he shows how moral reason can be brought to bear upon practical issues via an 'empirical, Socratic' approach.
The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment have conducted visits and written reports criticising the surgical castration of sex offenders in the Czech Republic and Germany. They claim that surgical castration is degrading treatment and have called for an immediate end to this practice. The Czech and German governments have published rebuttals of these criticisms. The rebuttals cite evidence about clinical effectiveness and point out this is an intervention that must be requested (...) by the sex offender and cannot occur without informed consent. This article considers a number of relevant arguments that are not discussed in these reports but which are central to how we might assess this practice. First, the article discusses the possible ways in which sex offenders could be coerced into castration and whether this is a decisive moral problem. Then, it considers a number of issues relevant to determining whether sex offenders are harmed by physical castration. The article concludes by arguing that sex offenders should not be coerced into castration, be that via threats or offers, but that there is no reason to think that this is occurring in the Czech Republic or Germany. In some cases, castration might be useful for reconfiguring a life that has gone badly awry and where there is no coercion, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment are mistaken about this being degrading treatment. (shrink)
The discussion of whether psychopaths are morally responsible for their behaviour has long taken place in philosophy. In recent years this has moved into scientific and psychiatric investigation. Responsibility and Psychopathy discusses this subject from both the philosophical and scientific disciplines, as well as a legal perspective.
The COVID-19 pandemic will generate vexing ethical issues for the foreseeable future and many journals will be open to content that is relevant to our collective effort to meet this challenge. While the pandemic is clearly the critical issue of the moment, it’s important that other issues in medical ethics continue to be addressed as well. As can be seen in this issue, the Journal of Medical Ethics will uphold its commitment to publishing high quality papers on the full array (...) of medical ethics. At the same time, JME aims to be a premiere home for ground-breaking scholarship on the ethical issues raised by COVID-19. Toward this end, we have a number of papers that are freely available online and for which production has been fast-tracked.1–5 A challenge for authors who want to write about the pandemic is the rapidly evolving nature of the situation and the time it takes for journal content to be reviewed and published, even when fast-tracked. For that reason, all authors who would like to submit a paper on the pandemic can also submit a post to the JME blog prior to submitting a full paper to the journal. Those interested in writing for the JME blog should contact one of its editors, Hazem Zohny or Mike King. Over the last 3 weeks, 30 high-quality commentaries on the pandemic have been posted to the blog. These posts are circulated widely via the JME Twitter and Facebook feeds and have stimulated significant …. (shrink)
How psychopaths and their capacity for moral action are viewed is not only philosophically interesting but is also important and relevant for policy. The philosophical discussion of psychopathy has focussed upon the psychological faculties that are prerequisites for moral responsibility and empirical findings regarding psychopathy that are relevant to philosophical accounts of moral understanding and motivation. However, there are legitimate worries about whether psychopathy is a robust scientific construct, and there are risks attached to reifying psychopathy or other psychiatric constructs. (...) We defend the concept of psychopathy by pointing out the relevance of empirical studies about it for our ordinary practices of ascribing moral responsibility and folk psychological accounts of moral understanding and motivation. (shrink)
The non-identity problem arises when an intervention or behavior changes the identity of those affected. Delaying pregnancy is an example of such a behavior. The problem is whether and in what ways such changes in identity affect moral considerations. While a great deal has been written about the non-identity problem, relatively little has been written about the implications for physicians and how they should understand their duties. We argue that the non-identity problem can make a crucial moral difference in some (...) circumstances, and that it has some interesting implications for when it is or is not right for a physician to refuse to accede to a patient's request. If a physician is asked to provide an intervention (identity preserving) that makes a person worse off, then such harm provides a good reason for the physician to refuse to provide the intervention. However, in cases where different (identity-altering) interventions result in different people having a better or worse life, physicians should normally respect patient choice. (shrink)
John Rawls begins a Theory of Justice with the observation that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1. The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour of persons. The justice issues it raises are diverse, (...) profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics. The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6 They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of Defense Robert McNamara used enemy body counts as a measure …. (shrink)
The first editorial in the Journal of Medical Ethics described an ambition to be a ‘forum for the reasoned discussion of moral issues arising from the provision of medical care’.1 While that statement of intent might seem broad, it is one that has been reaffirmed by successive editors of the journal.2–4 It is an aim that aligns with the mission statement of JME and The Institute of Medical Ethics, to promote ‘ethical reflection and conduct in scientific research and medical conduct.’ (...) It is an end worthy of some reflection because it illuminates how the journal has developed and implies a conception of what good medical ethics is. During his time as editor, Raanan Gillon was a champion for philosophical medical ethics and he wrote an excellent and influential book on that topic.5 In the July issue of JME, Julian Savulescu, Tom Douglas and Dominic Wilkinson affirm the importance of philosophical medical ethics and ably demonstrate why it matters in the Charlie Gard case.6 Does that mean papers published in the JME must be philosophical? In one sense, clearly no and in another yes. Good medical ethics is not philosophy. The degree of scepticism, the narrow focus on a search for truth, the technical nature of some philosophy and it not needing to deliver normative or practical ethical conclusions mean that a narrowly philosophical approach is unlikely to be good medical ethics. JME has never been a narrowly philosophical journal and the perils of this were described well by its first editor: > We therefore intend to put editorial weight behind what we consider to be carefully argued and well informed judgments and not to allow every value …. (shrink)
This article considers two related and fundamental issues about morality in a virtual world. The first is whether the anonymity that is a feature of virtual worlds can shed light upon whether people are moral when they can act with impunity. The second issue is whether there are any moral obligations in a virtual world and if so what they might be. -/- Our reasons for being good are fundamental to understanding what it is that makes us moral or indeed (...) whether any of us truly are moral. Plato grapples with this problem in book two of The Republic where Socrates is challenged by his brothers Adeimantus and Glaucon. They argue that people are moral only because of the costs to them of being immoral; the external constraints of morality. -/- Glaucon asks us to imagine a magical ring that enables its wearers to become invisible and capable of acting anonymously. The ring is in some respects analogous to the possibilities created by online virtual worlds such as Second Life, so the dialogue is our entry point into considering morality within these worlds. These worlds are three dimensional user created environments where people control avatars and live virtual lives. As well as being an important social phenomenon, virtual worlds and what people chose to do in them can shed light on what people will do when they can act without fear of normal sanction. -/- This paper begins by explaining the traditional challenge to morality posed by Plato, relating this to conduct in virtual worlds. Then the paper will consider the following skeptical objection. A precondition of all moral requirements is the ability to act. There are no moral requirements in virtual worlds because they are virtual and it is impossible to act in a virtual world. Because avatars do not have real bodies and the persons controlling avatars are not truly embodied, it is impossible for people to truly act in a virtual world. We will show that it is possible to perform some actions and suggest a number of moral requirements that might plausibly be thought to result. Because avatars cannot feel physical pain or pleasure these moral requirements are interestingly different from those of real life. Hume’s arguments for why we should be moral apply to virtual worlds and we conclude by considering how this explains why morality exists in these environments. (shrink)
There’s no doubt that medical ethics should be ‘grounded’, in the sense that it aims to make a practical, normative contribution to significant ethical issues in medicine. There are a number of ways in which ethics can do that, two of which feature in this issue of the Journal of Medical Ethics. One way is by responding to significant new policy or legal developments that will have an impact on clinical practice. This issue discusses two legal developments that matter to (...) patients and healthcare professionals: the sanctions applied to Dr Bawa-Garba and the Supreme Court’s ruling on the withdrawal of artificial nutrition and hydration. A second way of grounding ethical analysis in the reality and complexity of ethical issues is by using empirical methods. There are two papers in this issue from Canada that illustrate how the subtleties of complex ethical issues can be teased out via qualitative methods. Medical tourism is an important and rapidly developing phenomenon that raises a set of interesting and tricky ethical issues.1 It has been discussed in the Journal of Medical Ethics before and its implications for end of life, dentistry and other health interventions have been explored.2 3 Reproductive tourism occurs in many countries and the complications it can create for issues such as the citizenship of resulting children have been discussed at some length in the JME.4 5 Reproductive tourism is a good example of an area where it is particularly important for ethical analysis to be grounded in the facts and reality of a situation and an empirical approach to ethics is therefore a good option for this topic. In this issue, Couture et …. (shrink)
This article argues that hope is of value in clinical ethics and that it can be important for clinicians to be sensitive to both the risks of false hope and the importance of retaining hope. However, this sensitivity requires an understanding of the complexity of hope and how it bears on different aspects of a well-functioning doctor-patient relationship. We discuss hopefulness and distinguish it from three different kinds of hope, or ‘hopes for’, and then relate these distinctions back to differing (...) accounts of autonomy. This analysis matters because it shows how an overly narrow view of the ethical obligations of a clinician to their patient, and autonomy, might lead to scenarios where patients regret the choices they make. (shrink)
The question of whether any of us can truly be held responsible for what we do is an issue that occupied the ancient Greeks and continues to entertain our leading thinkers. Whether we can be held responsible for our health, or lack thereof, has additional layers of complexity because of the way in which what we do over time impacts our health. Those of us who have ever self-deceptively wondered about the apparent shrinking of our belt or at the fact (...) that the stairs seem to have multiplied are familiar with the idea that our health can change gradually over time as a result of successive choices that we have made. While there are one-off behaviours that can have an impact on health, for example, a single exposure to a very high level of radiation, in general, ill health develops over time, within an environment and complex set of interactions with other people. The implications of that complexity are central to this issue’s Feature Article by Brown and Savulescu.1 They note that there is debate over whether responsibility should play a role in the allocation of healthcare, and, rather than taking a view on that issue, make a number of suggestions about how the concept of responsibility used in healthcare can be enriched by attending to the complex relationship between behaviour and health. …. (shrink)
Policy-makers have attempted to frame the ethical requirements that are relevant to the creation of human beings via reproductive technologies. Various reports and laws enacted in New Zealand, Canada, Australia, and Britain have introduced tests for how we should weigh child welfare when using these technologies. A number of bioethicists have argued that child welfare should be interpreted as a “best interests” test. Others have argued that there are ethical reasons why we should abandon this kind of test. I will (...) argue that at least some of the relevant policy can be interpreted as requiring those wishing to exercise their procreative liberty to have a reasonable plan to care and nurture any resulting child, thereby respecting the internal preconditions of that liberty. This interpretation of child welfare requirements answers some of the ethical worries about a child welfare test. (shrink)
In this chapter we argue that Robert Hare's psychopathy checklist revised (PCL-R) offers a construct of psychopathy that is valid enough for philosophical investigations of the moral and legal responsibility of psychopathic offenders.
Eugenicists in the 1930s and 1940s emphasised our moral responsibilities to future generations and the importance of positively selecting traits that would benefit humanity. In 1935 Herbert Brewer recommended ‘Eutelegenesis’ so that that future generations are not only protected from hereditary disease but also become more intelligent and fraternal than us. The development of these techniques for human use and animal husbandry was the catalyst for the cross fertilization of moral ideas and the development of a critical procreative morality. While (...) eugenicists argued for a new critical morality, religious critics argued against artificial insemination because of its potential to damage important moral institutions. The tension between critical and conservative procreative morality is a feature of the contemporary debates about reproductive technologies. This and some of the other aspects of the early and contemporary debates about artificial insemination and reproductive technologies are discussed in this article. (shrink)
Lord Scarman’s judgment about when someone under the age of 16 years should have the right to make their own medical decisions emphasised the decision-making abilities of the particular child. He said: > …the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed.1 That created a duty on (...) healthcare practitioners to assess whether a particular minor has decision-making abilities at a degree that would enable them to understand the decision to a high extent, sufficient hopefully that they would ‘own’ the decision. In December of 2020, the High Court considered whether young people with gender dysphoria and seeking access to puberty blocking therapy, were likely to pass Scarman’s mature minor test and cast doubt on their ability to fully understand that decision, thereby making it less likely that a healthcare practitioner would decide they are a mature minor for that therapy. The High Court said: > It is highly unlikely that a child aged 13 or under would be competent to give consent to the administration of puberty blockers. It is doubtful that a child …. (shrink)
In my reply to Wertheimer and Miller's paper on coercive offers and payment for research participation1 I claim that ‘… it's not unreasonable to suppose that there is another normative aspect to these cases, over and above the voluntariness of consent. While the parents of children at Willowbrook and the millionaire's mistress might have given consent that was voluntary and informed, they are still wronged by taking up this offer…’2 Furthermore, nowhere in my paper on surgical castration do I claim (...) that coercive offers invalidate consent,3 and I suggest that Bomann-Larsen has come closest to cashing this out correctly with her idea that ‘the wrongness of these coercive offers has more to do with the wilful creation of choices that take advantage of others vulnerabilities…’.4 So, it is puzzling that they object to my analysis of coercion and castration because coercive offers are not readily unpacked as a problem with consent. …. (shrink)
Intensive care units are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients who would benefit from (...) intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care. (shrink)
Some bioethicists are concerned about other bioethicists being paid by corporations. These concerns make sense if you have a particular view about what the most important role of a bioethicist should be. If you believe that a bioethicist should be a moral critic, attempting to expose wrongdoing, then being paid by corporations might compromise this role. It’s plausible to suppose that this can be a role for bioethicists but it’s unreasonable to insist that all bioethicists should be moral critics.
There will always be debates in medical ethics about whether any particular value can be considered foundational, but there are reasons for thinking that ‘trust’ is the ground upon which many other important values is built. Sisela Bok remarks: > If there is no confidence in the truthfulness of others, is there any way to assess their fairness, their intentions to help or to harm? How, then, can they be trusted? Whatever matters to human beings, trust is the atmosphere in (...) which it thrives.1 p31 The idea that trust in what others tell us is the bedrock on which human relationships and other values are built seems plausible, but how trust is created, nurtured and sustained is perhaps the challenge for medical ethics. Annette Baier noted that trust occurs within the context of a relationship of some sort, be that with another person or an institution. > “Trust me!” is for most of us an invitation which we cannot accept at will—either we do already trust the one who says …. (shrink)
Bentham’s famous remark was a response to the assertation of natural rights that did not depend on law or some other foundation for their normative force.1 Whatever we make of that claim, it flags a problem for making and evaluating rights-based arguments in medical ethics. He wasn’t trying to say that rights are all meaningless, nor that we can readily do without them. Rather, it’s an objection to a particular way of asserting rights where they are taken to express free (...) standing claims that don’t require further defence or justification. Whether or not the rise of human rights in medical law has enriched the ability of the courts to deal with complex issues in a nuanced way is debatable, but there’s no doubting their prominence and unavoidability.2 For medical ethics, rights analysis requires paying heed to the kind of rights in play when arguing about ethics, as well as what’s distinctive about rights analysis. For many, rights operate as strong moral assertions intended to override other, less weighty, considerations and Ronald Dworkin claimed that we should view rights as a way of expressing particularly important claims that should constrain the state in its actions.3 Rights imply duties and focussing on a right's correlative duty can …. (shrink)
Psychopathy, as articulated in Hare’s PCL-R, appears to reliably pick out a forensic category of troubled people. This chapter considers the use and utility of PCL-R by focussing upon two interrelated questions. Does philosophical investigation direct attention toward the issues that should interest us about psychopathy? Is being diagnosed as psychopathic or having ASPD clinically useful, as well as for judicial and sentencing purposes? While the research programmes that developed following the attention paid to psychopathy are warranted, more attention could (...) be directed to the varied nature of psychopathy and the presentations of it that Cleckley described in the Mask of Sanity. It is important to understand psychopathy as it affects lives, as well as a forensic problem. (shrink)
The kind of expertise someone who specialises in ethics has, or indeed whether it makes sense to talk of moral expertise, is keenly debated and is a far from settled issue. It has been of interest to moral philosophers, partly because of the light it might shine on the nature of morality.1 2 It has also been debated within medical ethics, with some arguing against the idea that expertise in moral philosophy translates into ethical expertise and others arguing that skills (...) in ethical justification can be viewed as ethical expertise.3 4 This issue of the Journal of Medical Ethics includes a number of papers that demonstrate the importance of ethical expertise and some of the distinctive elements of it. Public involvement in research is seen in a number of countries as something valuable and in some, such as Australia, it can be a criterion for research grants. The UK National Standards for Public Involvement in Research are discussed in this issue of JME and McCoy et al provide a good illustration of why ethical expertise is important for framing public policy.5 The appeal of stakeholders having some say into research projects, particularly when they are funded via taxation is easy to understand, so who would not see public involvement as a good thing? However, McCoy et al claim that while there is a substantial and growing literature on public involvement in research that tends to emphasise the importance of public involvement, it doesn’t explain how or what this looks like when …. (shrink)
While the era following the Bland decision in 19931 might be thought of as the time when concepts such as ‘futility’ were placed under pressure and scrutiny, it’s an idea that has been debated for at least forty years. In a 1983 JME commentary Bryan Jennett distinguishes three kinds of reason why Cardiopulmonary Resuscitation might be withheld: > ‘… that CPR would be futile because it is very unlikely to be successful; that quality of life after CPR is likely to (...) be changed to so poor a level as to be a greater burden than the benefit gained from prolongation of life, and that quality of life is already so poor due to chronic or terminal disease that life should not be prolonged by CPR.’ pp-142-1432 This crisp definition seems as applicable as it did then, but it was not the final word on the concept. Mitchell, Kerridge and Lovat explore, as others did in the post-Bland and Quinlan eras, how ‘futility’ might apply to those in a …. (shrink)
When Beauchamp and Childress articulated the necessary and sufficient conditions for informed consent, they might have thought that would be the final word on what informed consent is.1 It’s emphasis in the Belmont Report,2 the Nuremberg Code,3 the Helsinki Declaration4 and numerous codes of professional ethics seems more than sufficient for emphasising its importance. Nonetheless, its place as the central issue for medical ethics appears undiminished and Pubmed lists 6192 publications with ‘Informed Consent’ in the title since 1979. One view (...) of this is that medical ethics has channelled too much intellectual effort into consent, perhaps at the expense of other important ethical issues. Papers in this issue of the Journal of Medical Ethics suggest that the discussion of consent continues because of the need to consider what it means in new contexts, how it can be a challenge in some contexts, how it is related to tough theoretical issues about the value of choice and autonomy and how it can blend into other debates. The development of biobanking and the challenges it presents about which variant of consent should apply have been discussed in the JME before. One option is for consent to be ‘broad’, meaning that when consent is given for the collection of tissue the ‘type’ of future secondary uses are specified but not the specific research studies, on the basis that the potential benefits are significant, the risks low and the costs of gaining consent for every use of tissue significant. Hofmann has argued against broad consent on the basis that being ‘informed’ is a crucial aspect of …. (shrink)
The drift toward behavioral accounts of the cluster of psychological and behavioral traits that were interchangeably referred to as psychopathy, sociopathy and anti-social personality is interesting and well worth exploring. Justman's correct that before the work of the Feighner group and the adoption of Antisocial Personality Disorder in the Diagnostic and Statistical Manual of Mental Disorders -III, the choice of concept did not seem to be vital and in the Mask of Sanity, Cleckley mentions all three terms and does not (...) seem to think much hangs on which term we choose.It seems correct that many held the absence of guilt to be the psychological marker of psychopathy... (shrink)
There are some distinct methodological challenges, and possible pitfalls, for neuroethics when it evaluates neuroscientific results and links them to issues such as moral or legal responsibility. Some problems emerge in determining the requirements for responsibility. We will show how philosophical proposals in this area need to interact with legal doctrine and practice. Problems can occur when inferring normative implications from neuroscientific results. Other problems arise when it is not recognized that data about brain anatomy or physiology are relevant to (...) the ascription of responsibility only when they are significantly correlated with the psychological capacities contemplated by the legal formulations of responsibility. We will demonstrate this by considering two significant cases concerning psychopathy. Some paradigms that aim at measuring higher-order capacities, such as moral understanding, have limited validity. More robust paradigms for the study of learning in restricted controlled conditions, on the other hand, have limited ecological validity across individuals and context to be of any use for the law. (shrink)
This book explains the ethical and conceptual tensions in the use of psychopathy in different countries, including America, Canada, the UK, Croatia, Australia, and New Zealand. It offers an extensive critical analysis of how psychopathy functions within institutional and social contexts. Inside, readers will find innovative interdisciplinary analysis, written by leading international experts. The chapters explore how different countries have used this diagnosis. A central concern is whether psychopathy is a mental disorder, and this has a bearing upon whether it (...) should be used. The book’s case studies will help readers understand the problems associated with psychopathy. Academics and students working in the philosophy of psychiatry, bioethics, and moral psychology will find it a valuable resource. In addition, it will also appeal to mental health professionals working in forensic settings, psychologists with an interest in the ethical implications of the use of psychopathy as a construct and particularly those with a research interest in it. (shrink)