Medical Ethics, Misc

Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with (...) ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D. (shrink)

One recurring criticism of the best interests standard concerns its vagueness, and thus the inadequate guidance it offers to care providers. The lack of an agreed definition of ‘best interests’, together with the fact that several suggested considerations adopted in legislation or professional guidelines for doctors do not obviously apply across different groups of persons, result in decisions being made in murky waters. In response, bioethicists have attempted to specify the best interests standard, to reduce the indeterminacy surrounding medical decisions. (...) In this paper, we discuss the bioethicists’ response in relation to the state's possible role in clarifying the best interests standard. We identify and characterise two clarificatory strategies employed by bioethicists —elaborative and enumerative—and argue that the state should adopt the latter. Beyond the practical difficulties of the former strategy, a state adoption of it would inevitably be prejudicial in a pluralistic society. Given the gravity of best interests decisions, and the delicate task of respecting citizens with different understandings of best interests, only the enumerative strategy is viable. We argue that this does not commit the state to silence in providing guidance to and supporting healthcare providers, nor does it facilitate the abuse of the vulnerable. Finally, we address two methodological worries about adopting this approach at the state level. The adoption of the enumerative strategy is not defeatist in attitude, nor does it eventually collapse into (a form of) the elaborative strategy. (shrink)

Hundreds of millions of rare biospecimens are stored in laboratories and biobanks around the world. Often, the researchers who possess these specimens do not plan to use them, while other researchers limit the scope of their work because they cannot acquire biospecimens that meet their needs. This situation raises an important and underexplored question: how should scientists allocate biospecimens that they do not intend to use? We argue that allocators should aim to maximise the social value of the research enterprise (...) when allocating scarce biospecimens. We provide an ethical framework for assessing the social value of proposed research projects and describe how the framework could be implemented. (shrink)

The literature on conscientious objection in medicine presents two key problems that remain unresolved: Which conscientious objections in medicine are justified, if it is not feasible for individual medical practitioners to conclusively demonstrate the genuineness or reasonableness of their objections? How does one respect both medical practitioners’ claims of conscience and patients’ interests, without leaving practitioners complicit in perceived or actual wrongdoing? My aim in this paper is to offer a new framework for conscientious objections in medicine, which, by bringing (...) medical professionals’ conscientious objection into the public realm, solves the justification and complicity problems. In particular, I will argue that: an “Uber Conscientious Objection in Medicine Committee” —which includes representatives from the medical community and from other professions, as well as from various religions and from the patient population—should assess various well-known conscientious objections in medicine in terms of public reason and decide which conscientious objections should be permitted, without hearing out individual conscientious objectors; medical practitioners should advertise their conscientious objections, ahead of time, in an online database that would be easily accessible to the public, without being required, in most cases, to refer patients to non-objecting practitioners. (shrink)

Physicians frequently ask whether they should give patients what they want, usually when there are considerations pointing against doing so, such as medicine’s values and physicians’ obligations. It has been argued that the source of medicine’s values and physicians’ obligations lies in what has been dubbed “the internal morality of medicine”: medicine is a practice with an end and norms that are definitive of this practice and that determine what physicians ought to do qua physicians. In this paper, I defend (...) the claim that medicine requires a morality that is internal to its practice, while rejecting the prevalent characterization of this morality and offering an alternative one. My approach to the internal morality of medicine is constructivist in nature: the norms of medicine are constructed by medical professionals, other professionals, and patients, given medicine’s end of “benefitting patients in need of prima facie medical treatment and care.” I make the case that patients should be involved in the construction of medicine’s morality not only because they have knowledge that is relevant to the internal morality of medicine—namely, their own values and preferences—but also because medicine is an inherently relational enterprise: in medicine the relationship between physician and patient is a constitutive component of the craft itself. The framework I propose provides an authoritative morality for medicine, while allowing for the incorporation, into that very morality, of qualified deference to patient values. (shrink)

Answers to the questions of what justifies conscientious objection in medicine in general and which specific objections should be respected have proven to be elusive. In this paper, I develop a new framework for conscientious objection in medicine that is based on the idea that conscience can express true moral claims. I draw on one of the historical roots, found in Adam Smith’s impartial spectator account, of the idea that an agent’s conscience can determine the correct moral norms, even if (...) the agent’s society has endorsed different norms. In particular, I argue that when a medical professional is reasoning from the standpoint of an impartial spectator, his or her claims of conscience are true, or at least approximate moral truth to the greatest degree possible for creatures like us, and should thus be respected. In addition to providing a justification for conscientious objection in medicine by appealing to the potential truth of the objection, the account advances the debate regarding the integrity and toleration justifications for conscientious objection, since the standard of the impartial spectator specifies the boundaries of legitimate appeals to moral integrity and toleration. The impartial spectator also provides a standpoint of shared deliberation and public reasons, from which a conscientious objector can make their case in terms that other people who adopt this standpoint can and should accept, thus offering a standard fitting to liberal democracies. (shrink)

Transhumanism is a movement that seeks to transcend certain limits inherent in the human condition as we know it. However, does it justify leaving aside the dignity of current human beings to fulfill the desire to increase human potential and improve the human being as such to obtain other human beings? Does it justify passing over the dignity of women in order to obtain new human beings through fertilization? To answer these questions we have made a sweep over the ideas (...) of transhumanism that drives this type of techniques, to later understand the vision that women have in the use of in vitro fertilization, the hidden discrimination under these procedures and the clarification of the true emancipation and restoration of women’s rights in rela- tion to the use of in vitro fertilization. -/- El transhumanismo es un movimiento que busca trascender ciertos límites inherentes a la condición humana como la conocemos. Sin embargo, ¿justifica dejar de lado la dignidad de los seres humanos actuales por cumplir el deseo de aumentar el potencial humano y mejorar al ser humano como tal para obtener otros seres humanos?, ¿justifica pasar por encima de la dignidad de una mujer para obtener nuevos seres humanos a través de la fertilización in vitro? Para responder a estas preguntas hemos hecho un barrido sobre las ideas del transhumanismo que impulsa este tipo de técnicas, para luego comprender la visión que se tiene de la mujer en el uso de la fertilización in vitro, la discriminación oculta bajo estos procedimientos y la aclaración de la verdadera emancipación y restablecimiento de los derechos de la mujer en relación con el uso de la fertilización in vitro. (shrink)

Is the “act itself” of separating a pregnant woman and her previable child neither good nor bad morally, considered in the abstract? Recently, Maureen Condic and Donna Harrison have argued that such separation is justified to protect the mother’s life and that it does not constitute an abortion as the aim is not to kill the child. In our article on maternal–fetal conflicts, we agree there need be no such aim to kill (supplementing aims such as to remove). However, we (...) argue that to understand “abortion” as performed only where the death of the child is intended is to define the term too narrowly. Respect for the mother, the fetus, and the bond between them goes well beyond avoiding any such aim. We distinguish between legitimate maternal treatments simply aimed at treating or removing a damaged part of the woman and illegitimate treatments that focus harmfully on the fetal body and its presence within the mother’s body. In obstetrics as elsewhere, not all side effects for one subject of intervention can be outweighed by intended benefits for another. Certain side effects of certain intended interventions are morally conclusive. (shrink)

Preventive vaccination can protect not just vaccinated individuals, but also others, which is often a central point in discussions about vaccination. To date, there has been no systematic study of self- and other-directed motives behind vaccination. This article has two major goals: first, to examine and distinguish between self- and other-directed motives behind vaccination, especially with regard to vaccinating for the sake of third parties, and second, to explore some ways in which this approach can help to clarify and guide (...) vaccination debates and policy. I propose conceiving of vaccination in terms of three basic elements: the vaccination decision-maker, the vaccine recipient and the primary beneficiary. I develop a taxonomy based on the relations between these elements to distinguish four kinds of vaccination: self-protective, paternalistic, altruistic and indirect. I finally discuss the case of human papillomavirus vaccine regulation for men and women to show how each kind of vaccination is associated with and raises specific ethical questions. (shrink)

Selgelid and Koplin’s article ‘Kidney Sales and the Burden of Proof’ (K&S 2019) presents a series of detailed and persuasive arguments, intended to demolish my own arguments against the prohibition of organ selling. And perhaps they might succeed, if the case described by the authors were anything like the one I actually make. However, notwithstanding the extensive quotations and the detailed explanations of the way I supposedly argue, this account of my position comprehensively mistakes both the conclusions I reach and (...) the arguments I give for them. -/- I know that there are around many misconceptions about my views on this subject, but I have always hoped they could not survive a reading of what I had actually written. I have just—after a gap of many years—looked again at the two most recent of the texts Koplin and Selgelid refer to, and it goes without saying that I can see various things I could now do better; but I do still find these misinterpretations hard to understand. And since anyone with nothing to go on but this article would reasonably conclude that the original texts were not worth reading, I am grateful to the editors for the opportunity to try to set the record straight. -/- I presume not many readers would be interested in a detailed comparative commentary on the texts, showing where this account gets my intentions wrong. I shall try instead to explain how what I do mean—and what I think I say—diverges from what is said here, and then go on to a brief outline of what my arguments and conclusions really are. I hope this may also give some sense of why, for all the opposition I have encountered since I was first drawn into this debate, I persist in thinking that the work I have been doing is important not only for this topic but for analysis in practical ethics more generally. (shrink)

Janet Radcliffe Richards’ The Ethics of Transplants outlines a novel framework for moral inquiry in practical contexts and applies it to the topic of paid living kidney donation. In doing so, Radcliffe Richards makes two key claims: that opponents of organ markets bear the burden of proof, and that this burden has not yet been satisfied. This paper raises four related objections to Radcliffe Richards’ methodological framework, focusing largely on how Radcliffe Richards uses this framework in her discussion of kidney (...) sales. We conclude that Radcliffe Richards’ method of inquiry hinders our ability to answer the very question that it ought to help us resolve: What is there best reason to do, all things considered? (shrink)

This paper summarizes the seminar AI in Medicine in Context: Hopes? Nightmares? that was held at the Centre for Ethics at the University of Toronto on October 17, 2017, with special guest assistant professor and neurosurgeon Dr. Sunit Das. The paper discusses the key points from Dr. Das' talk. Specifically, it discusses about Dr. Das' perspective on the ethical and moral issues that was experienced from applying artificial intelligence (AI) in law and how such issues can also arise when applying (...) AI to medicine, and concludes with a brief discussion on how such issues can be prevented. (shrink)

Aryeh Goldberg compellingly argues for a Narrative Coherence Standard (NCS) to bolster existing methods of assessing patients' mental capacity. But his account fails to distinguish between the cognitive abilities of children and adults; consequently, worries may be raised about the scope of the NCS, in particular when we consider child patients. In this article, I argue the NCS cannot plausibly apply to children. Since children's self-conception does not arrive fully formed — but rather is a product of both incomplete cognitive (...) development and socializing factors — I claim children may not possess a sufficiently intimate knowledge of self, and therefore a sufficiently coherent sense of self, as Goldberg demands. Therefore, we should either revise the NCS to accommodate children, adopt an incremental view of consent, or revert to the relevant form of the MacArthur competence criteria to establish children’s capacity to consent. (shrink)

Despite their shared origins, medicine and dentistry are not always two sides of the same coin. There is a long history in medical philosophy of defining disease and various medical models have come into existence. Hitherto, little philosophical and phenomenological work has been done considering dental caries and periodontitis as examples of disease and illness. A philosophical methodology is employed to explore how we might define dental caries and periodontitis using classical medical models of disease – the naturalistic and normativist. (...) We identify shared threads and highlight how the features of these highly prevalent dental diseases prevent them fitting in either definition. The article describes phenomenology and the current thought around the phenomenology of illness, exploring how and why these dental illnesses might integrate into a phenomenological model. We discover that there are some features particular to dental caries and periodontitis: ubiquity, preventability and hyper-monitorablility. Understanding the differences that these dental diseases have compared to many other classically studied diseases leads us to ethical questions concerning how we might manage those who have symptoms and seek treatment. As dental caries and periodontitis are common, preventable and hyper-monitorable, it is suggested that these features affect the phenomenology of these illnesses. For example, if we experience dental illness when we have consciously made decisions that have led to it, do we experience them differently to those rarer illnesses that we cannot expect? Other diseases share these features are discussed. This paper highlights the central differences between the classical philosophical notion of disease in medicine and the dental examples of caries and periodontitis. It suggests that a philosophical method of conceptualising medical illness - phenomenology - should not be applied to these dental illnesses without thought. A phenomenological analysis of any dental illness is yet to be done and this paper highlights why a separate strand of phenomenology should be explored, instead of employing those that are extant. The article concludes with suggestions for further research into the nascent field of the phenomenology of dental illness and aims to act as a springboard to expose the dental sphere to this philosophical method of analysis. (shrink)

Brummett and Salter propose a useful and timely taxonomy of clinical ethics expertise (2019). As the field becomes further “professionalized” this taxonomy is important, and the core of it is right. It needs some refinement around the edges, however. In their conclusion, Brummett and Salter rightly point out that there is a significant difference between the ethicist whose recommendations are procedure- and process-heavy, consensus-driven, and dialogical and the authoritarian ethicist whose recommendations flow from “private moral views” (Brummett and Salter, 2019). (...) This admission doesn’t go far enough. Brummett and Salter’s taxonomy fails to capture the notion that offering recommendations whose normative force is moral is different in kind from recommendations whose normative force is non-moral, such as those recommendations that are free of moral content or justified by convention. The difference is in kind, not scale. I argue further that clinical ethics expertise, if possible, consists at least in offering recommendations whose normative force is moral. These two claims imply that the taxonomy fails to cut clinical ethics expertise at the joints: the ethicist who offers justified non-moral normative recommendations is a different kind of ethicist from the one who offers justified moral normative recommendations, yet both are categorized as clinical ethics experts. I finish by offering a refinement of the taxonomy that more precisely categorizes clinical ethicists. (shrink)

Under the standard formulation of the Doctrine of Double Effect, an act is permissible only if it is the result of an intention to do good and not the result of an intention to do bad. Many find that this absurdly ties the act’s permissibility to the agent’s character and not to features of the act itself. In light of such criticism, some philosophers have reformulated the doctrine so that it holds that an act is permissible given that it results (...) from an intention to do good by some agent. I argue that this appeal to possible intentions to do good fails. There is no modal or moral reason to privilege intentions to do good over those to do bad, and without privileging them, this version of the Doctrine of Double Effect leads to contradiction. In many scenarios, if a possible intention to do good is considered to be sufficient for permissibility, then in that same scenario a possible intention to do bad should be sufficient for impermissibility. However, one and the same act can have both possible intentions to do good and possible intentions to do bad. Thus, the principle leads to the contradictory ruling that one and the same act is both permissible and impermissible. (shrink)

Patient preference predictors aim to solve the moral problem of making treatment decisions on behalf of incapacitated patients. This commentary on a case of an unrepresented patient at the end of life considers 3 related problems of such predictors: the problem of restricting the scope of inputs to the models (the “scope” problem), the problem of weighing inputs against one another (the “weight” problem), and the problem of multiple reasonable solutions to the scope and weight problems (the “multiple reasonable models” (...) problem). Each of these problems poses challenges to reliably implementing patient preference predictors in important, high-stakes health care decision making. This commentary also suggests a way forward. (shrink)

The process of medicalization has been analyzed in the medical humanities with disapprobation, with much emphasis placed on its ability to reinforce existing social power structures to ill effect. While true, this is an incomplete picture of medicalization. I argue that medicalization can both reinforce and disrupt existing social hierarchies within the clinic and outside of it, to ill or good effect. We must attend to how this takes place locally and globally lest we misunderstand how medicalization mediates power and (...) justice. I provide concrete examples of how this occurs by considering dysesthesia ethiopsis, autism, chronic fatigue syndrome, depression, and HIV/AIDS. (shrink)

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, especially when (...) principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)

In states where Physician Assisted Dying (PAD) is legal, physicians occasionally receive requests for this form of end-of-life care. Here, I describe the ethically ambiguous sphere and why PAD falls into it. I argue that, given the ethical ambiguity of PAD, physicians should consider patient autonomy as the highest value in the four principles approach and act as informers and educators.

We aim to establish the following claim: other factors held constant, the relative weights of the epistemic burdens of competing treatment options serve to determine the options that patient surrogates pursue. Simply put, surrogates confront an incentive, ceteris paribus, to pursue treatment options with respect to which their knowledge is most adequate to the requirements of the case. Regardless of what the patient would choose, options that require more knowledge than the surrogate possesses (or is likely to learn) will either (...) be neglected altogether or deeply discounted in the surrogate’s incentive structure. We establish this claim by arguing that the relation between epistemic burdens and incentives in decision-making is a general feature of surrogate decision-making. After establishing the claim, we draw out some of the implications for surrogate decision-making in medicine and offer philosophical and psychological explanations of the phenomenon. (shrink)

Ever since the debate concerning euthanasia was ignited, the distinction between active and passive euthanasia – or, letting die and killing – has been marked as one of its key issues. In this paper I will argue that a) the borderline between act and omission is an altogether blurry one, and it gets even vaguer when it comes to euthanasia, b) there is no morally significant difference between active and passive euthanasia, and c) if there is any, it seems to (...) favor active instead of passive euthanasia. Therefore, while the distinction between active and passive euthanasia might be meaningful in terms of description, if it is considered to be endowed with moral weight and used on purpose of justifying one type of euthanasia instead of the other, it becomes morally problematic and misleading. (shrink)

In the United States, roughly 1 out of 4 births takes place at a hospital certified as Baby-Friendly. This paper offers a multi-disciplinary perspective on the Baby-Friendly Hospital Initiative (BFHI), including empirical, normative, and historical perspectives. Our analysis is novel in that we trace how medical practices of “quality improvement,” which initially appear to have little to do with breastfeeding, may have shaped the BFHI. Ultimately, we demonstrate that a rich understanding of the BFHI can be obtained by tracing how (...) norms of gender/motherhood interact with, and are supplemented by, other normative, historical, and institutional realities. We conclude with suggestions for practical revisions to the BFHI. (shrink)

This article explores the Nuffield Council on Bioethics’ recent report about non-invasive prenatal testing. Given that such testing is likely to become the norm, it is important to question whether there should be some ethical parameters regarding its use. The article engages with the viewpoints of Jeff McMahan, Julian Savulescu, Stephen Wilkinson and other commentators on prenatal ethics. The authors argue that there are a variety of moral considerations that legitimately play a significant role with regard to (prospective) parental decision-making (...) in the context of NIPT, for example, views on the morality of abortion and understandings of the impact of disability on quality of life. The variable nature of such considerations, both singularly and combined, suggests that any approach to NIPT should be sensitive to and understanding of similarly variable parental assessments and decisions. The implications of the approach developed for current and future policies in this area are explored, along with the impact of such arguments on ideas about procreative beneficence. (shrink)

Individual health assessments (IHAs) for asymptomatic individuals provide a challenge to traditional distinctions between patient care and non-medical practice. They may involve undue radiation exposure, lead to false positives, and involve high out-of-pocket costs for recipients. A recent paper (Journal of the American College of Radiology 13(12): 1447–1457.e1, 2016) has criticised the use of IHAs and argued that recipients should be classified as ‘presenters’, not ‘patients’, to distinguish it from regular medical care. I critique this classificatory move, on two grounds: (...) one, it is conceptually suspect. Two, it obviates the medical ethics framework for IHAs, potentially exposing recipients of IHAs to lower standards of oversight and protection. Responsible regulation of IHAs will be easier to ethically justify if those seeking IHAs are considered patients and not merely presenters. (shrink)

Since philosophy is a notoriously difficult subject, one may think that the concept of adding rigor to a philosophy course is misguided. Isn’t reading difficult texts by Immanuel Kant or Friedrich Nietzsche enough to categorize a class as academically rigorous? This question is based on the misguided assumption that academic rigor has only to do with course content. While course content is a component of academic rigor, other aspects such as higher-order thinking, as well as how an instructor designs and (...) grades assignments, contribute to the level of academic rigor in a course. The author provides several ways to increase the level of academic rigor in a philosophy course based upon Bloom’s Taxonomy using examples from an introductory ethics course and then provides recommendations as to how to grade to promote academic rigor. (shrink)

Introduction In 2013, Dr. J. Muizelaar and Dr. R. Schrot, two neurosurgeons at the University of California Davis Medical Center (UCDMC), were found guilty of research misconduct due to failure to comply with institutional policies as well as Food and Drug Administration (FDA) regulations governing human subjects research. At issue here, however, is the difference between research and innovative therapy in the clinical setting of patient care where clinical judgment is reasonably to be privileged. Methods The UCDMC investigative document is (...) reviewed along with standard literature on clinical ethics and clinical data about glioblastoma multiforme (GBM) cancer. Results In this paper I argue that, by tendentiously focusing on policies, regulations, and procedures governing human subjects research, the UCDMC investigation failed to account for the centrality of clinical judgment and clinical ethics pertinent to judicious review of this matter, especially given the unique clinical context of terminally ill patients having exhausted standard care treatment options for glioblastoma multiforme (GBM) cancer. Conclusions The UCDMC investigation raises serious problems for clinicians who are engaged in innovative therapy in the clinical setting, requiring a regulatory framework separate from the normal Institutional Review Board (IRB) process. (shrink)

Nancy Jecker and Andrew Ko (2017) wish to present an account of personal identity which captures what matters to the patient and places the patient at the center of medical decisions. They focus particularly on medical interventions in the brain that can cause drastic changes in personality; under what circumstances should we say the patient has 'survived' these changes? More specifically, how can we best understand the notion of survival in a way that captures what is of concern to the (...) patient? This goal is laudable, however, their chosen account of narrative identity is ill-suited to this task for one reason in particular; it does not give sufficient guidance in predicting which medical decisions are likely to be experienced as disruptive to identity. (shrink)

Albert Jonsen and Stephen Toulmin have argued that the best way to resolve complex “moral” issues in clinical settings is to focus on the details of specific cases. This approach to medical decision-making, labeled ‘casuistry’, has met with much criticism in recent years. In response to this criticism, Carson Strong has attempted to salvage much of Jonsen’s and Toulmin’s version of casuistry. He concludes that much of their analysis, including Jonsen’s further elaboration about the casuistic methodology, is on the mark. (...) In this essay, the details of Jonsen’s and Toulmin’s version of casuistry and the major criticisms against their approach to clinical decision-making are explicated. Furthermore, it is argued that Strong’s salvage efforts fail to deflect these criticisms. The upshot of this analysis, which includes a few additional criticisms, is that Jonsen’s and Toulmin’s version of casuistry is not an appropriate framework from which to resolve complex “moral” issues in clinical settings. (shrink)

I respond to Jeffrey Bishop’s article ‘Arts of Dying and the Statecraft of Killing’, in this issue, and in particular to his remarks in support of the claim that assisted death should not be legalised.

Most bioethicists who address questions to which global justice matters have not considered the significance of the disputes over the correct theory of global justice. Consequently, the significance of the differences between theories of global justice for bioethics has been obscured. In this paper, I consider when and how these differences are important. I argue that certain bioethical problems can be resolved without addressing disagreements about global justice. People with very different views about global justice can converge on the existence (...) of a duty to aid the very badly off — those in absolute poverty — wherever they may be. However, despite agreement on extreme cases, there should be disagreement over the extent of international obligations to those who are only relatively poor. Consequently, different theories of justice will diverge in their implications for a number of important problems in contemporary bioethics. I close by sketching in more detail two contemporary bioethical issues —concerning pharmaceutical patents and the health worker brain drain —and show how responses to them might be developed by cosmopolitan and statist liberals. (shrink)

The idea of personalised medicine (PM) has gathered momentum recently, attracting funding and generating hopes as well as scepticism. As PM gives rise to differing interpretations, there have been several attempts to clarify the concept. In an influential paper published in this journal, Schleidgen and colleagues have proposed a precise and narrow definition of PM on the basis of a systematic literature review. Given that their conclusion is at odds with those of other recent attempts to understand PM, we consider (...) whether their systematic review gives them an edge over competing interpretations. We have found some methodological weaknesses and questionable assumptions in Schleidgen and colleagues’ attempt to provide a more specific definition of PM. Our perplexities concern the lack of criteria for assessing the epistemic strength of the definitions that they consider, as well as the logical principles used to extract a more precise definition, the narrowness of the pool from which they have drawn their empirical data, and finally their overlooking the fact that definitions depend on the context of use. We are also worried that their ethical assumption that only patients’ interests are legitimate is too simplistic and drives all other stakeholders’ interests—including those that are justifiable—underground, thus compromising any hope of a transparent and fair negotiation among a plurality of actors and interests. As an alternative to the shortcomings of attempting a semantic disciplining of the concept we propose a pragmatic approach. Rather than considering PM to be a scientific concept in need of precise demarcation, we look at it as an open and negotiable concept used in a variety of contexts including at the level of orienting research goals and policy objectives. We believe that since PM is still more an ideal than an achieved reality, a plurality of visions is to be expected and we need to pay attention to the people, reasons and interests behind these alternative conceptions. In other words, the logic and politics of PM cannot be disentangled and disagreements need to be tackled addressing the normative and strategic conflicts behind them. (shrink)

In this peer commentary on L. Syd M. Johnson’s “Inference and Inductive Risk in Disorders of Consciousness,” I argue for the necessity of disability education as an integral component of decision-making processes concerning patients with DOC and, mutatis mutandis, all patients with disabilities. The sole qualification Johnson places on such decision-making is that stakeholders are educated about and “understand the uncertainties of diagnosis and prognosis.” Drawing upon research in philosophy of disability, social epistemology, and health psychology, I argue that this (...) educational qualification is insufficient to address systemic ableism and other forms of epistemic bias in quality of life judgments. (shrink)

In ‘What Makes Killing Wrong?’ Sinnott-Armstrong and Miller make the bold claim that killing in itself is not wrong, what is wrong is totally-disabling. In ‘After-Birth Abortion: Why Should the Baby Live?’ Giubilini and Minerva argue for allowing infanticide. Both papers challenge the stigma commonly associated with killing, and emphasize that killing is not wrong at some margins of life. In this paper, we first generalize the above claims to the thesis that there is nothing morally wrong with killing per (...) se, so long as it is instant and unannounced. Then, from the perspective of social evolution, we explain why people refrain from killing others, the general guideline being that it is unadvisable to kill someone with whom you associate a Second Person Perspective (SPP). Finally, drawing from a seminal paper of Press and Dyson on the Iterated Prisoner’s Dilemma, we stress that an SPP without an SP (Second Person), or the other way around, can both lead to unwelcome results. (shrink)

Medical ethicists conventionally assume that the requirement to employ informed consent procedures is grounded in autonomy. It seems intuitively plausible that providing information to an agent promotes his autonomy by better allowing him to steer his life. However, James Taylor questions this view, arguing that any notion of autonomy that grounds a requirement to inform agents turns out to be unrealistic and self-defeating. Taylor thus contends that we are mistaken about the real theoretical grounds for informed consent procedures. Through analysing (...) Taylor's arguments and showing that they do not stand up to scrutiny, it is possible to defend the view that autonomy is a plausible theoretical basis for informed consent, and to enhance our understanding of the relationship between autonomy and informed consent. (shrink)

Euthanasia and assisted suicide have proved to be very contentious topics in medical ethics. Some ethicists are particularly concerned that allowing physicians to carry out these procedures will undermine their professional obligations and threaten the very goals of medicine. However, I maintain that the fundamental goals of medicine not only do not preclude the practice of euthanasia and assisted suicide by physicians, but can in fact be seen to support these practices in some instances. I look at two influential views (...) of the goals of medicine, one based on the broad guiding principles of autonomy, beneficence and nonmaleficence, and the other focusing on several more concrete aims, concluding that both approaches can be seen to support euthanasia and assisted suicide. I then turn to the popular concern that allowing physicians to carry out euthanasia and assisted suicide will lead to widespread abuse. I argue that the possibility for abuse can be minimised if we make the patient's autonomous consent an essential requirement of the practice. (shrink)

Until recently, the problem of traumatic brain injury in sports and the problem of performance enhancement via hormone replacement have not been seen as related issues. However, recent evidence suggests that these two problems may actually interact in complex and previously underappreciated ways. A body of recent research has shown that traumatic brain injuries, at all ranges of severity, have a negative effect upon pituitary function, which results in diminished levels of several endogenous hormones, such as growth hormone and gonadotropin. (...) This is a cause for concern for many popular sports that have high rates of concussion, a mild form of TBI. Emerging research suggests that hormone replacement therapy is an effective treatment for TBI-related hormone deficiency. However, many athletic organizations ban or severely limit the use of hormone replacing substances because many athletes seek to use them solely for the purposes of performance enhancement. Nevertheless, in the light of the research linking traumatic brain injury to hypopituitarism, this paper argues that athletic organizations’ policies and attitudes towards hormone replacement therapy should change. We defend two claims. First, because of the connection between TBI and pituitary function, it is likely many more athletes than previously acknowledged suffer from hormone deficiency and thus could benefit from hormone replacement therapy. Second, athletes’ hormone levels should be tested more rigorously and frequently with an emphasis on monitoring TBI and TBI-related issues, rather than simply monitoring policy violations. (shrink)

In this issue, Ahmadi1 reports on the practice of hymenoplasty—a surgical intervention meant to restore a presumed physical marker of virginity prior to a woman's marriage. As Mehri and Sills2 have stated, these women ‘want to ensure that blood is spilled on their wedding night sheets.’ Although Ahmadi's research was carried out in Iran specifically, this surgery is becoming increasingly popular in a number of Western countries as well, especially among Muslim populations.3 What are the ethics of hymen restoration?Consider the (...) role of the physician. Two of the doctors interviewed by Ahmadi reported being in ‘a perpetual state of guilt because of the surgery's inherent aim at deceiving the groom’ and noted their ‘personal conflict’ at being involved in this deception. Yet: "None of the doctors believed that the surgery was unethical, arguing that the girl could be ‘abused’ and ‘can even die’ if she is discovered not … ". (shrink)

Business Ethics and medical ethics are in principle compatible: In particular, the tools of business ethics can be useful to those doing healthcare ethics. Health care could be conducted as a business and maintain its moral core.

Receiving information about threats to one’s health can contribute to anxiety and depression. In contemporary medical ethics there is considerable consensus that patient autonomy, or the patient’s right to know, in most cases outweighs these negative effects of information. Worry about the detrimental effects of information has, however, been voiced in relation to public health more generally. In particular, information about uncertain threats to public health, from—for example, chemicals—are said to entail social costs that have not been given due consideration. (...) This criticism implies a consequentialist argument for withholding such information from the public in their own best interest. In evaluating the argument for this kind of epistemic paternalism, the consequences of making information available must be compared to the consequences of withholding it. Consequences that should be considered include epistemic effects, psychological effects, effects on private decisions, and effects on political decisions. After giving due consideration to the possible uses of uncertain information and rebutting the claims that uncertainties imply small risks and that they are especially prone to entail misunderstandings and anxiety, it is concluded that there is a strong case against withholding of information about uncertain threats to public health. (shrink)

Williams Syndrome provides a striking test case for discourses on disability, because the characteristics associated with Williams Syndrome involve a combination of “abilities” and “disabilities”. For example, Williams Syndrome is associated with disabilities in mathematics and spatial cognition. However, Williams Syndrome individuals also tend to have a unique strength in their expressive language skills, and are socially outgoing and unselfconscious when meeting new people. Children with Williams are said to be typically unafraid of strangers and show a greater interest in (...) contact with adults than with their peers. This apparently keen social knowledge is a counterexample to the discussion of disability among academic philosophers, especially philosophers of the early modern period. Locke infamously used the example of disability to claim that Descartes’ arguments in favor of innate ideas were incorrect. On the contrary, Williams Syndrome may stand as an example of innate social knowledge; something that could benefit current discourse in philosophy, disability theory, and medical ethics. (shrink)

A review of Holly Fernandez Lynch's book Conflicts of Conscience in Medicine (MIT Press, 2008).

Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture. -/- Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can find (...) themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians. -/- In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture. (shrink)

In 2012, a German court ruled that religious circumcision of male minors constitutes criminal bodily assault. Muslim and Jewish groups responded with outrage, with some commentators pegging the ruling to Islamophobic and anti-Semitic motivations. In doing so, these commentators failed to engage with any of the legal and ethical arguments actually given by the court in its landmark decision. In this brief commentary, I argue that a firm distinction must be drawn between criticisms of religious practices that stem from irrational (...) prejudice and bigoted attitudes and those that are grounded in sound moral reasoning. Given that ritual circumcision is a pre-Enlightenment custom that elevates the inclinations of the community over the rights of the individual, it is hardly surprising that a growing number of post-Enlightenment philosophers and legal scholars are taking an ethical stand against it. As the “circumcision debate” continues, parties on all sides of the issue must remember to reason through the relevant considerations with care and respect. (shrink)