Should people be assisted to die or be given euthanasia when they are suffering from terminal medical conditions? Should they be assisted to die when they are suffering but do not have a ‘diagnosable medical illness?’ What about assisted dying for psychiatric conditions? And is there a difference morally between assisted suicide, voluntary active euthanasia and voluntary passive euthanasia?These are deep questions directly addressed or in the background of the productive discussion between Varelius and Young.1 ,2 Their focus is whether (...) doctors should assist people to die who are ‘tired of life’ and experiencing ‘existential suffering’. An example was Edward Brongersma, an 86-year-old man, who was tired of life but with no serious medical condition, who was assisted by Dr Philip Sutorius to commit suicide in 1998. In the Netherlands, where euthanasia is legal, the Dutch Supreme Court ruled in 2002 that this was wrong because "edical expertise, by its nature, does not extend to questions and complaints that do not have a sick- ness or ailment—mental or physical—as their source.3"Sutorius was convicted, but not punished.Robert Young, considering this case, concurs, concluding, "a physician may justifiably consider that an individual who is ‘tired of life’ should consult a non-medical, professional counsellor, and if that produces no change in outlook, choose suicide. Outside Switzerland, an individual who makes that choice has to then be determined enough to do so unassisted .2"I will argue that there is, within current medical ethics and human rights, a method of assisted suicide which could fall within the limits of the law. But first I will review some recent cases involving requests for dying. I will then discuss an alternative which some may argue addresses these cases, and those of …. (shrink)

Around a third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision (...) should not be performed on children who are not competent to make their own decisions.If the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around a third of all men would have been harmed. This is an extraordinary public health injury. Presumably, many would be entitled to compensation.The fact that relatively few people think that the situation is as bad as this indicates that most people implicitly believe that circumcision is not generally a significant harm, if a harm at all. One might thus conclude either that: It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.Or 2. If circumcision is against the interests of an infant or young child, it is only mildly so.In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child becomes an adult to make his or her own decision about circumcision. And procedures which are not clearly in a child's interests should not be performed on that child. However, religious …. (shrink)

The COVID-19 pandemic has highlighted the difficult task of balancing access to misinformation with respect for patient decision-making. Due to its innate antagonism, the paradigm of “physician paternalism” versus “patient autonomy” may not adequately capture the clinical relationship. The authors hypothesized that most patients would, in fact, prefer significant physician input as opposed to unopinionated information when making medical decisions. There is a lack of empirical data corroborating this in the United States. To that end, a survey was distributed to (...) 650 individuals through Amazon Mechanical Turk, of which 499 responses met pre-determined quality criteria. Most respondents believed their doctor's insight would be better than their own if injured or gravely ill. When asked to affirm preferences separately, a significantly higher proportion of respondents preferred guidance from their doctor when making medical decisions compared to being presented with unopinionated information ( p < 0.001). Encouragingly, 93.1% believed that the doctor's primary goal was their health. When asked directly to compare physician guidance to unopinionated information, 69.1% respondents stated they would prefer physician guidance. We found a consistent association between educational/economic background and affirmative responses ( p < 0.001), suggesting particular attention should be paid to patients that are disadvantaged with respect to these demographic factors. The belief in a shared goal, and a consistent preference for physician input, suggests that patients endorse a more collaborative view of the clinical dynamic than is suggested by the paternalism-autonomy paradigm. This pilot study suggests physicians should not be afraid to communicate conviction with regard to treatment decisions. (shrink)

The exponential rise in transgender self-identification invites consideration of what constitutes an ethical response to transgender individuals’ claims about how best to promote their well-being. In this paper, we argue that ‘accepting’ a claim to medical transitioning in order to promote well-being would be in the person’s best interests iff at the point of request the individual is correct in their self-diagnosis as transgender (i.e., the distress felt to reside in the body does not result from another psychological and/or societal (...) problem) such that the medical interventions they are seeking will help them to realise their preferences. If we cannot assume this—and we suggest that we have reasonable grounds to question an unqualified acceptance in some cases—then ‘acceptance’ potentially works against best interests. We propose a distinction between ‘acceptance’ and respectful, in-depth exploration of an individual’s claims about what promotes their well-being. We discuss the ethical relevance of the unconscious mind to considerations of autonomy and consent in working with transgender individuals. An inquisitive stance, we suggest, supports autonomous choice about how to realise an embodied form that sustains well-being by allowing the individual to consider both conscious and unconscious factors shaping wishes and values, hence choices. (shrink)

Personal autonomy is often lauded as a key value in contemporary Western bioethics. Though the claim that there is an important relationship between autonomy and rationality is often treated as uncontroversial in this sphere, there is also considerable disagreement about how we should cash out the relationship. In particular, it is unclear whether a rationalist view of autonomy can be compatible with legal judgments that enshrine a patient's right to refuse medical treatment, regardless of whether the reasons underpinning the choice (...) are known and rational, or indeed whether they even exist. Jonathan Pugh brings recent philosophical work on the nature of rationality to bear on the question of how we should understand personal autonomy in contemporary bioethics. In doing so, he develops a new framework for thinking about the concept of autonomy, one that is grounded in an understanding of the different roles that rational beliefs and rational desires have to play in it. Pugh's account allows for a deeper understanding of d the relationship between our freedom to act and our capacity to decide autonomously. His rationalist perspective is contrasted with other prominent accounts of autonomy in bioethics, and the revisionary implications it has for practical questions in biomedicine are also outlined. (shrink)

Use of a placebo control in surgical trials is a divisive issue. We argue that, in principle, placebo controls for surgery are necessary in the same way as for medicine. However, there are important differences between these types of trial, which both increase justification and limit application of surgical studies. We propose that surgical randomised placebo-controlled trials are ethical if certain conditions are fulfilled: the presence of equipoise, defined as a lack of unbiased evidence for efficacy of an intervention; clinically (...) important research question; the risk to patients is minimised and reasonable; there is uncertainty about treatment allocation rather than deception; there is preliminary evidence for efficacy, which justifies a placebo-controlled design; and ideally, the placebo procedure should have some direct benefit to the patient, for example, as a diagnostic tool. Placebo-controlled trials in surgery will most often be justified when surgery is performed to improve function or relieve symptoms and when objective outcomes are not available, while the risk of mortality or significant morbidity is low. In line with medical placebo-controlled trials, the surgical trial should be sufficiently powered and standardised so that its results are valid, consent should be valid, the standard treatment or rescue medication should be provided if possible, and after the trial, the patients should be told which treatment they received and there should be provision for post-trial care if the study may result in long-term negative effects. We comment and contrast our guidelines with those of the American Medical Association. (shrink)

Clinician gate-keeping is the process whereby healthcare providers prevent access to eligible patients for research recruitment. This paper contends that clinician gate-keeping violates three principles that underpin international ethical guidelines: respect for persons or autonomy; beneficence or a favourable balance of risks and potential benefits; and justice or a fair distribution of the benefits and burdens of research. In order to stimulate further research and debate, three possible strategies are also presented to eliminate gate-keeping: partnership with professional researchers; collaborative research (...) design and clinician education. (shrink)

This paper argues that the concept of best interests in the context of clinical decisions draws on concepts rooted in the philosophical discipline of axiology. Reflection on the philosophical origins enables a distinction to be drawn between those interests related to clinical goals and those global interests that are axiological in nature. The implication of this distinction is most clearly seen in the context of end of life decisions and it is argued here that greater weight ought to be given (...) to the positive requests, and not merely competent refusals, of patients at the end of life. (shrink)

This paper explores the dilemma faced by mental healthcare professionals in balancing treatment of mental disorders with promoting patient well-being and flourishing. With growing calls for a more explicit focus on patient flourishing in mental healthcare, we address two inter-related challenges: the lack of consensus on defining positive mental health and flourishing, and how professionals should respond to patients with controversial views on what is good for them. We discuss the relationship dynamics between healthcare providers and patients, proposing that ‘liberal’ (...) approaches can provide a pragmatic framework to address disagreements about well-being in the context of flourishing-oriented mental healthcare. We acknowledge the criticisms of these approaches, including the potential for unintended paternalism and distrust. To mitigate these risks, we conclude by suggesting a mechanism to minimize the likelihood of unintended paternalism and foster patient trust. (shrink)

Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse of finite (...) health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients’ right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence, as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment. (shrink)

In central definitions of shared decision-making within medical consultations we find the concept of negotiation used to describe the interaction between patient and professional in case of conflict. It has been noted that the concept of negotiation is far from clear in this context and in other contexts it is used both in terms of rational deliberation and bargaining. The articles explores whether rational deliberation or bargaining accurately describes the negotiation in shared decision-making and finds that it fails to do (...) so on both descriptive and normative grounds. At the end some notes on further analysis is given and it is suggested that the interaction is more accurately described in terms of an internal balancing of values like patient best interest, patient autonomy and patient adherence by the professional that is accepted by the patient. (shrink)