It is argued that the current policy of the British Medical Association (BMA) on conscientious objection is not aligned with recent human rights developments. These grant a right to conscientious objection to doctors in many more circumstances than the very few recognised by the BMA. However, this wide-ranging right may be overridden if the refusal to accommodate the conscientious objection is proportionate. It is shown that it is very likely that it is lawful to refuse to accommodate conscientious objections that (...) would result in discrimination of protected groups. It is still uncertain, however, in what particular circumstances the objection may be lawfully refused, if it poses risks to the health and safety of patients. The BMA's policy has not caught up with these human rights developments and ought to be changed. (shrink)

The paper considers the recently published British Medical Association Guidance on ethical issues arising in relation to rationing of treatment during the COVID-19 Pandemic. It considers whether it...

This personal view draws attention to the lack of regard, given by the BMA in its new guidance, to the symptomatic benefit of clinically assisted nutrition and hydration in patients who are not imminently dying. This article aims to identify how ignoring symptomatic benefit is a serious oversight and cause for concern given that this document, endorsed by the General Medical Council and courts, is created with the purpose of providing a framework for best interests decision-making. The new BMA guidance (...) on CANH, which is endorsed by the GMC,1 follows up on the Supreme Court case of An NHS Trust v Y,2 that any removal of CANH from a patient in prolonged disorder of consciousness no longer requires the approval of the court unless there is disagreement or the decision is finely balanced. The decision in …. (shrink)

The doctor-patient relationship -- Consent, choice, and refusal : adults with capacity -- Treating adults who lack capacity -- Children and young people -- Confidentiality -- Health records -- Contraception, abortion, and birth -- Assisted reproduction -- Genetics -- Caring for patients at the end of life -- Euthanasia and physician assisted suicide -- Responsibilities after a patient's death -- Prescribing and administering medication -- Research and innovative treatment -- Emergency situations -- Doctors with dual obligations -- Providing treatment and (...) care in detention settings -- Education and training -- Teamwork, referral, delegation, and shared care -- Public health dimensions of medical practice -- Reducing risk, clinical error, and poor performance. (shrink)

This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical (...) medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children—male or female—to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful. (shrink)

The working party on euthanasia set up by the British Medical Association produced its report in 1988 (1). The first of its terms of reference was 'to examine the ethical problems relating to euthanasia, terminal illness, and suicide' and as far as active voluntary euthanasia (AVE) is concerned it failed conspicuously to do its job. The purpose of this article is not to restate the case for AVE but to examine the reason for the failure. (Figures in square brackets refer (...) to sections in the report.). (shrink)

Making decisions when caring for children and young people involves a delicate balancing of the child’s rights and needs as well as the rights of the parents. Those who look to the law for guidance will find that it is often unclear. The courts have asserted the parents’ rights to make decisions concerning the child’s treatment, in so far as these accord with the child’s welfare. Children have the right to be consulted about decisions concerning their welfare. Some people see (...) an anomaly in relation to treatment in that, while a court has overruled in the case of a competent child’s right to refuse treatment, a child considered competent may initiate consultation and consent to treatment without their parents’ knowledge or consent. The child’s right to confidentiality appears to override the parent’s right to the information parents need if they are to be aware of, let …. (shrink)

The BMA’s recent discussion paper A rational way forward for the NHS in England, while wishing to free the English NHS from day-to-day politics, merely shifts the locus of the political conflict.In May this year, the British Medical Association published a discussion paper entitled “A rational way forward for the NHS in England”, outlining the association’s suggestions for reform of the English NHS.1The paper is worth reading for its insightful dissection and analysis of the current problems of the English NHS, (...) as well as for its interesting but not totally unexpected conflation of professional and clinical with medical in most of the report. Many of the recommendations are eminently sensible, but some of the suggestions for reconfiguration of the highest-level structures of the English NHS are problematic and unrealistic. What the BMA wants is to free the English NHS from the influence of day-to-day politics by the establishment of a constitution and an independent board of governors, while keeping it free at the point of delivery and paid by general taxation. This is expressed in the first five of the total of 24 recommendations that outline the BMA proposals …. (shrink)

The British Medical Association (BMA) has called upon the General Medical Council (GMC) to instruct all medical schools to provide identifiable and substantial courses on medical ethics in their undergraduate curricula. The author reviews a postgraduate scheme of study in the ethics of health-care and suggests that it could provide some useful guidelines for teaching the subject at the undergraduate level.

In June 2021, the BMA published its report on moral distress and moral injury in UK doctors.1 The report includes definitions of the terms ‘moral distress’ and ‘moral injury’ as well as a summary of how the concepts have developed over time. There is also an analysis of the BMA’s pan-profession survey of moral distress and moral injury of doctors in the UK, the first of its kind. The impact of COVID-19 and recommendations for tackling moral distress also feature. Many (...) may be unfamiliar with the concepts of ‘moral distress’ and ‘moral injury’. These terms are relatively new, and debate is ongoing in academic circles on the best way to understand them.2 Some use the terms interchangeably. The BMA defines moral distress as the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action. Even without an understanding of the morally correct action, moral distress can arise from the sense of a moral transgression. More simply, it is the feeling of unease stemming from situations where institutionally required behaviour does not align with moral principles. This can be as a result of a lack of power or agency, or structural limitations, such as insufficient staff, resources, training or time. The individual suffering from moral distress need not be the one who has acted or failed to act; moral distress can be caused by witnessing moral transgressions by others. Moral injury can arise where sustained moral distress leads to impaired function or longer-term psychological harm. Moral injury can produce profound guilt and shame, and in some cases also a sense of betrayal, anger and profound ‘moral disorientation’. It has also been linked to severe mental health issues. There is increasing recognition across the UK of the problem …. (shrink)

Although some previous studies have investigated the relationship between moral foundations and moral judgment development, the methods used have not been able to fully explore the relationship. In the present study, we used Bayesian Model Averaging (BMA) in order to address the limitations in traditional regression methods that have been used previously. Results showed consistency with previous findings that binding foundations are negatively correlated with post-conventional moral reasoning and positively correlated with maintaining norms and personal interest schemas. In addition to (...) previous studies, our results showed a positive correlation for individualizing foundations and post-conventional moral reasoning. Implications are discussed as well as a detailed explanation of the novel BMA method in order to allow others in the field of moral education to be able to use it in their own studies. (shrink)

The recently published BMA Guidelines on Withholding and Withdrawing Medical Treatment encourage a balance between deriving maximal benefit from medical treatment, and achieving as natural a death as possible in the circumstances. I argue that the concepts of burdensomeness, natural death and medicalised death are of greater fundamental importance than that of intention, and do not help constitute a moral distinction between withdrawal of treatment and active assistance to die. Nor should they continue to ground the corresponding legal distinction. In (...) the situations of both treatment withdrawal and active assistance to die, disease causation, human agency and moral responsibility are related in the same way. In both situations, we can intend that a person die for the right reasons, based on a concern for natural death.However, the law is reluctant to impose positive obligations on people, in contrast to the protection of negative rights. For example, the Northern Territory’s Rights of the Terminally Ill Act (1996) provided for assisted death as a lawful exception to an otherwise unlawful act, rather than as an enforceable right like the right to refuse unwanted medical treatment. Nevertheless, that the enforceability of a positive right to assisted death is difficult to conceive, is itself the product of a particular historical/moral/religious frame of reference currently under deconstruction. Genuine natural death statutes would consolidate the important principles supported here, and could apply uniform safeguards to all death-hastening decisions. (shrink)

We explored the relationship between 24 character strengths measured by the Global Assessment of Character Strengths (GACS), which was revised from the original VIA instrument, and moral functioning comprising postconventional moral reasoning, empathic traits and moral identity. Bayesian Model Averaging (BMA) was employed to explore the best models, which were more parsimonious than full regression models estimated through frequentist regression, predicting moral functioning indicators with the 24 candidate character strength predictors. Our exploration was conducted with a dataset collected from 666 (...) college students at a public university in the Southern United States. Results showed that character strengths as measured by GACS partially predicted relevant moral functioning indicators. Performance evaluation results demonstrated that the best models identified by BMA performed significantly better than the full models estimated by frequentist regression in terms of AIC, BIC, and cross-validation accuracy. We discuss theoretical and methodological implications of the findings for future studies addressing character strengths and moral functioning. (shrink)

The british Medical Association wants to criminalise all boxing. This article examines the logic of the arguments it uses and finds them wanting. The move from medical evidence about the risk of brain damage to the conclusion that boxing should be banned is not warranted. The BMA's arguments are a combination of inconsistent paternalism and legal moralism. Consistent application of the principles implicit in the BMA's arguments would lead to absurd consequences and to severe limitations being put on individual freedom.

In February 2020, the British Medical Association will be surveying members for their views on what the BMA’s position on physician-assisted dying should be. The BMA is currently opposed to physician-assisted dying in all its forms, a position that was agreed in 2006 at the annual representative meeting, the Association’s policy-making conference.1 As previously reported in Ethics briefing,2 the decision to survey members follows a motion passed at last year’s ARM which called on the BMA to “carry out a poll (...) of members to ascertain their views on whether the BMA should adopt a neutral position with respect to a change in the law on assisted dying”. The results from the survey will not determine BMA policy. Rather, the results be published ahead of this year’s ARM and provided to those attending to inform a debate and discussion on the BMA’s policy position. More information about the survey, including a briefing pack of useful information, and information for BMA members on how to participate can be found online at www.bma.org.uk/PAD. ### High Court rejects Judicial reviews on assisted suicide The High Court has refused permission for two separate challenges to the law on assisted suicide in the UK to proceed to a full hearing. In the first case, Phil Newby, who has motor neuron disease, applied for judicial review of the law on assisted suicide and asked for the court to carry out a detailed examination of what he termed “legislative facts” – that is, an examination of the existing evidence on the “costs, risks and benefits” of regulating assisted suicide – including a cross-examination of relevant expert witnesses.1 Handing down the judgement, Lord Justice Irwin and Mrs Justice May, held that assisted dying …. (shrink)

Legal battles continue in the UK over the Government’s plans to transport asylum seekers arriving on British shores to Rwanda in East Africa. Originally announced as a system for ‘processing’ asylum seekers, the Government has subsequently made it clear that there would not be an option for asylum seekers to return to the UK. The arrangement forms part of a deal between the UK and Rwanda, with the UK promising to invest £120 m in economic growth and development in Rwanda, (...) along with financing the cost of the ‘offshored’ asylum operation.1 The Government states that the policy is designed to break the business model of people traffickers involved in facilitating hazardous trips across the Channel in small, overcrowded and unseaworthy craft, leading to multiple drownings. Critics argue that the policy will do nothing to stop desperate people from seeking refuge in the UK, that transferring already traumatised people to Rwanda – which has been criticised for its human rights record – is inhumane and potentially outwith international law. Medical bodies, including the BMA, along with refugee organisations have expressed serious concerns about the health impact of such a system of ‘offshoring’. An equivalent system in Australia has been notorious for the devastating health impacts on those ‘offshored’ to the Pacific islands of Manus and Naura. Unusually in the UK the offshoring proposals have been greeted by unanimous condemnation by the Church of England. The lawfulness of the process is also subject to question. On the 14 July, a plane carrying a small number of asylum seekers to Rwanda was halted shortly before take-off following an intervention by the European Court of Human Rights. The ECtHR, part of the Council of Europe, of which the UK is still a member, said an Iraqi man known as KN faced ‘a real …. (shrink)

Differences in guidance from various organisations is preventing uniform standards of practiceThe emphasis in medical law and ethics on protecting the patient’s right to choose is at an all time high. Apart from circumscribed situations, for instance where the Mental Health Act 19831 is applicable, the only justification for medically treating an adult patient against his or her wishes is on the basis of common law, using the principle of best interests, and only when he or she lacks capacity to (...) refuse treatment. As a result, it is important that clinicians should be able to assess capacity to refuse treatment. Given that judgements of incapacity involve deciding that a person does not have the ability to refuse treatment, a great deal of care needs to go into the assessment and characterisation of incapacity.There is divergence between the characterisation of capacity that is used by the courts and that which is recommended by the British Medical Association . The BMA usefully expands on the first element of capacity as set out in the standard legal definition of capacity in the Re C judgment2 but ignores the other two elements. By doing this, the BMA makes it unclear whether it is rejecting these as relevant to capacity; it also misses the opportunity to expand on these elements in a clinically useful way.We will begin with a description of the BMA’s advice3 and the standard English legal definition of capacity.2,4 Then we will show that there are important discrepancies between these two sources of advice. We think that the BMA ought to clarify its position on capacity in order to safeguard the interests of physicians, healthcare workers, and patients.THE RE C TESTMr C was a patient in a psychiatric secure hospital who had chronic paranoid schizophrenia with …. (shrink)

Yet another medical ethics book has been published, but the difference this time is that I actually like it Sokol and Bergson’s handbook Medical ethics and law—surviving on the wards and passing exams is for medical students and junior doctors preparing for life in medicine and for the inevitable exams. The format of the book closely follows that of the core curriculum for medical ethics and law set out by the BMA in 2004 in Medical ethics today. The book ….

An Amnesty International briefing, published in July 2020, highlights the grave risks health workers are facing globally, particularly in the face of the COVID-19 pandemic.1 The report uses data from 63 countries across the world from January to June 2020 and is rich with examples. While recognising that information about the pandemic is constantly evolving, and each country is in a separate phase of the outbreak, Amnesty International draws attention to several troubling trends. By virtue of the role undertaken by (...) health workers, they face a greater exposure to COVID-19, which has contributed to many of the concerns they now deal with. The briefing notes the evidence of the higher death rate from health workers compared with the general population in countries ranging from Denmark to Argentina, while also pointing out the significantly higher death rate in BAME health workers raised by the BMA in the UK.2 PPE shortages had been reported in nearly all of the 63 countries analysed. Many health workers globally stated that they had to buy their own PPE and others described cases of ‘improvisation’, when suitable PPE was not available, such as using bin bags or raincoats. Furthermore, health workers in several countries had experienced increases in workload with formal measures to extend health workers’ contracted hours passed in some countries as well as further changes to their terms and conditions of service. There were also reports of increased mental stress, particularly from those working in ICUs; the increased work and stress is not being matched with suitable compensation or remuneration. Despite many countries passing special benefits for health workers, it was commonly stated that these benefits had not been received yet or that they did not apply to all health workers, with cleaners and other lower-paid yet vital roles excluded. Deeply concerning …. (shrink)

With recent guidance from the BMA and RCP on the withdrawal of nutrition from patients, and how the cause of death is being recorded (1), and the case of Vincent Lambert (2), the debate surrounding withdrawal of care and treatment has been rekindled in Catholic circles. In this article, I wish to highlight some of traditional principles that form the basis of such decision-making. I discuss these within the context of the withdrawal of nutrition and hydration (NaH), as well as (...) ventilation, to elucidate the key points. (shrink)

The main idea animating the present paper is that the general aim of debates, such as the one involving the notorious case of the Master Argument, is the ponderation of logical principles by confronting them with some set of assertions and other endorsed principles on the meaning explanation of connectives, quantifiers and modality. As suggested by Seel (2017), the point of the specific case of the MA is about examining Aristotle’s notion of possibility – as implemented by the Possibility Principle (...) (i.e., If it is necessary that if A then B, then B is possible if A is) and the Possibility Rule (i.e., If A is possible, and if B follows from the assumption of A, then B is is possible) in the context of a dialectical debate where it has been asserted that a given proposition is possible, even it is neither true now nor it will ever be, and where at the same time the irrevocability of the past has been endorsed. This suggests to study the MA debate in a setting based on Marion’s (2020) reconstruction of Aristotle’s Dialectical Bouts, adapted to propositions affected by modalities. The setting of Dialectical Bouts for the MA proposed includes•Propositions affected by Reichenbach’s (1948, § 5) three-folded temporal reference, namely: the point of speech S, the point of reference R and the point of the event E. This constitutes our take on Vuillemin’s (1977, 1979, 1984, 1996) suggestion of a “double indexation”.•The dialogical meaning explanation for modalities understood as involving hypotheticals. •The dialogical rules that settle the commitments undertaken when endorsing Aristotle’s Possibility Principle. In fact, in relation to the notion of possibility at work in Vuillemin’s (1996) reconstruction we explored different formulations of the Possibility Rule. Still, there remains a dearth of researches confronting the different formulations of the Possibility Rule with the texts studied by Crubellier (2010) and Rosen and Malink (2012). More generally and coming back to my remarks above, one of the most fruitful insights that can be gained from Vuillemin’s writings on the MA, is that such kind of debates provide an instance of a general pattern for reasoning that I shall call Dialectical Bouts of Material Admissibility (BMA). The rationale behind such kind of argumentation-pattern is to examine the incorporation of new (epistemological, ontological or logical) principles against the background of the commitments undertaken by endorsing a specific set of assertions and meaning explanations. They display the kind of abductive procedure stressed by Crubellier’s (2014) study of syllogism. Under this perspective Ebbinghaus’s (1964) casting of the inferential moves that reduce imperfect syllogisms to perfect ones as implementing an admissibility procedure, represents a logical generalization of the material procedures at stake in the Dialectical Bouts of Material Admissibility. Furthermore if, as stressed by Duthil-Novaes (2005) Medieval Obligations represent a development of Aristotelian Bouts aimed at the ludic exercise of consistency maintenance, DMA should be rather linked to the Islamic tradition of dialectical theory [jadal, munāẓara, ādāb al-baḥth], aimed at the epistemological task of what Young (2017) calls the forging of principles, including legal and deontic ones. In a more contemporary setting, DMA can be related to Brandom’s (2000, pp. 66-77) considerations on Non-Conservative Extensions, where the point of dialectical procedures is put under public Socratic scrutiny the discovery and elucidation of concepts. This general point on Dialectical Bouts of Material Admissibility can be seen as underlying Vuillemin’s project of linking the study of the MA with the classification of philosophical systems.The present paper does not contain a fully developed study on such Dialectical Bouts, but it is rather is an invitation to pick up the gauntlet that Jules Vuillemin threw into the ring. (shrink)

The context in which the British Medical Association first considered publishing specific guidelines on decisions about attempting cardiopulmonary resuscitation , in the early 1990s, needs to be remembered. At that time the subject was often seen as far too sensitive to be mentioned to patients. Many hospitals had no formal policy about how CPR decisions should be made, apart from an expectation that these were purely medical matters. Advance decision making about CPR, where it existed, appears to have been generally (...) on an ad hoc basis by doctors. Patients, their relatives and the rest of the health care team were often unaware of it. After several cases in which nurses had been disciplined–unfairly in the eyes of some–for complying with their patients' known wishes about non-resuscitation in cases where no advance medical decision had been recorded, there was a demand for guidance.The BMA was approached by nurses' representatives with a view to publishing some very basic advice. This advice, issued in 1993 jointly with the Royal College of Nursing, and in association with the Resuscitation Council, was under 1000 words. Whether this brevity reflects difficulties in achieving consensus or lower expectations about what was required is a matter for speculation. Throughout the 1990s the guidance was distributed widely and used as a basis for many hospitals' local policies. Recently, however, the demands on the BMA and other professional bodies for ethical advice have changed and grown. Discussion of sensitive decisions about potentially life-prolonging interventions is now …. (shrink)

Justice, one of the four Beauchamp and Childress prima facie basic principles of biomedical ethics, is explored in two excellent papers in the current issue of the journal. The papers stem from a British Medical Association essay competition on justice and fairness in medical practice and policy. Although the competition was open to all comers, of the 235 entries both the winning paper by Alistair Wardrope1 and the highly commended runner-up by Zoe Fritz and Caitríona Cox2 were written by practising (...) doctors—a welcome indication of the growing importance being accorded to philosophical reflection about medical practice and practices within medicine itself. Both papers are thoroughly thought provoking and represent two very different approaches to the topic. Each deserves a careful read. The competition was a component of a BMA 2019/2020 ‘Presidential project’ on fairness and justice and asked candidates to ‘use ethical reasoning and theory to tackle challenging, practical, contemporary, problems in health care and help provide a solution based on an explained and defended sense of fairness/justice’. In this guest editorial I’d like to explain why, in 2018 on becoming president-elect of the BMA, I chose the theme of justice and fairness in medical ethics for my 2019–2020 Presidential project—and why in a world of massive and ever-increasing and remediable health inequalities biomedical ethics requires greater international and interdisciplinary efforts to try to reach agreement on the need to achieve greater ‘health justice’ and to reach agreement on what that commitment actually means and on what in practice it requires. First, some background. As president I was offered the wonderful opportunity to pursue, with the organisation’s formidable assistance, a ‘project’ consistent with the BMA’s interests and values. As a hybrid of general medical practitioner and philosopher/medical ethicist, and as a firm defender of the Beauchamp …. (shrink)

Ethical guidance from the British Medical Association about treating doctor–patients is compared and contrasted with evidence from a qualitative study of general practitioners who have been patients. Semistructured interviews were conducted with 17 GPs who had experienced a significant illness. Their experiences were discussed and issues about both being and treating doctor–patients were revealed. Interpretative phenomenological analysis was used to evaluate the data. In this article data extracts are used to illustrate and discuss three key points that summarise the BMA (...) ethical guidance, in order to develop a picture of how far experiences map onto guidance. The data illustrate and extend the complexities of the issues outlined by the BMA document. In particular, differences between experienced GPs and those who have recently completed their training are identified. This analysis will be useful for medical professionals both when they themselves are unwell and when they treat doctor–patients. It will also inform recommendations for professionals who educate medical students or trainees. (shrink)

A book for nurses, doctors and all who provide end of life care, this essential volume guides readers through the ethical complexities of such care, including current policy initiatives, and encourages debate and discussion on their controversial aspects. dived into two parts, it introduces and explains clinical decision making-processes about which there is broad consensus, in line with guidance documents issued by WHO, BMA, GMC, and similar bodies. The changing political and social context where 'patient choice' has become a central (...) idea, and the broadened scope of potients' best interests, have added to the complexity of decision-making in end of life care. The authors discuss issues widely encountered by GPs, nurses, and hospital clinicians. These include patient choice, consent, life-prolonging treatment, and symptom relief including sedation. Part rwo explores the more controversial current end of life care initiatives, such as advance care planning preferred place of care and death, euthanais and assited suicide, extended ideas of 'best interests', and the view that there are therapeutic duties to the relatives of Throughout their discussion the authors draw attention to loose ends and contradictions in some of the proposals. Examining the current policy of comsumerist choice, they reject its place in the health service, proposing a a realistic, fair, humane and widely adoptable system of end of life care. As knowledge of ethical theories is required in training courses, and the vocabulary of ethical theory is widespread in current discussions a substantial appendix on ethical theories and terms is available online. Written by the same authors as The Philosophy of Palliative Care: Critique and Reconstruction, which won the Medical Journalists' Association Specialits Book Award 2007, this new book for non-specialists is essential reading for all health care professionals involved in providing end of life care. (shrink)

Background There is broad international agreement from clinicians and academics that healthcare rationing should be undertaken as explicitly as possible, and the BMA have publicly supported the call for more accountable priority setting for some time. However, studies in the UK and elsewhere suggest that clinicians experience a number of barriers to rationing openly, and the information needs of patients at the point of provision are largely unknown. Methodology In-depth interviews were undertaken with NHS professionals working at the community level (...) of provision, and with patients and professionals receiving or providing treatment for morbid obesity and breast cancer (n=52). Results Nearly all patients wanted to know about healthcare rationing and had high expectations of their clinical professionals to provide all relevant information about treatment options. However, professionals did not always understand these information requirements, and cases of implicit rationing were common. The existence of relevant national guidance was not always known about, meaning that patients were often reliant on other sources of information about treatment options, which included the popular media, the internet, patient advocacy groups and informal networks of support. Discussion Clinical professionals need to understand patients' need for detailed information when it comes to rationing, and to understand that they are the main gateway for this to be provided. However, disclosure could be distressing for both patients and professionals, and thus the most sensitive and acceptable ways to make this information available requires further investigation. (shrink)

In the United Kingdom, the debate about how best to meet the shortfall of organs for transplantation has persisted on and off for many years. It is often presumed that the answer is simply to alter the law to a system of presumed consent. Acting perhaps on that presumption in his annual report launched in July, the Chief Medical Officer, Sir Liam Donaldson, advocated a system of organ donation based on presumed consent, the so-called “opt-out” system.1 He is calling for (...) a change in the law in England and Wales whereby consent to organ donation is presumed, making a person’s organs automatically available for transplantation after death, unless they registered objections to this while alive. Subsequently, the British Medical Association lent its support to the introduction of such a system.2 The BMA contends that “the practice of presumed consent legislation has had a significant effect on the number of cadaveric donors per million population.”2It is often taken for granted that there must be a correlation between the enactment of legislation on presumed consent and an increase in organ donation and procurement. However, the correlation is not as straightforward as it might seem. It may be that other practical measures to encourage organ donation could be implemented without changing the Human Tissue Act 2004, an Act which has been in force for barely a year.An analysis by Abadie and Gay demonstrated that “presumed consent legislation has a positive and sizeable effect on organ donation rates”,3 but they themselves admitted that the correlation between rates of donation and presumed consent legislation is “not completely unequivocal”.3 It is true that among the most successful cases in procurement rates are countries with presumed consent legislation . However, since some of the …. (shrink)

Background: The American Medical Association, the British Medical Association and the Canadian Medical Association have guidelines that specifically discourage physicians from self-prescribing or prescribing to family members, but only the BMA addresses informal prescription requests between colleagues. Objective: To examine the practices of paediatric providers regarding self-prescribing, curbsiding colleagues, and prescribing and refusing to prescribe to friends and family. Methods: 1086 paediatricians listed from the American Academy of Paediatrics 2007 web-based directory were surveyed. Results: 44% of eligible survey respondents returned (...) usable surveys. Almost half of respondents had prescribed for themselves. An equal number had informally requested a prescription from a colleague. Three-quarters stated they had been asked to prescribe a prescription drug for a first-degree or second-degree relative, and 51% had been asked by their spouse. Eighty-six per cent stated that they had refused to write a prescription on at least one occasion for a friend or family member. The following reasons “strongly influenced” their decision to refuse a prescription request: outside of provider’s expertise ; patient’s need for his or her own physician ; not medically indicated ; need for a physical examination. Conclusion: These data confirm that most physicians have engaged in self-prescribing or curbside requests for prescriptions. It can be argued that curbsiding is more morally problematic than self-prescribing because it implicates a third party, and should be discouraged regardless of whether the requester is a colleague, family member or friend. (shrink)

Prolonging neonatal lifeThe paradox that medicine’s success breeds medicine’s problems is well known to readers of the Journal of Medical Ethics. Advances in neonatal medicine have worked wonders. Not long ago, extremely premature birth babies, or those born with very serious health problems, would inevitably have died. Today, neonatologists can resuscitate babies born at ever-earlier stages of gestation. And very ill babies also benefit from advances in neonatal intensive care. Infant lives can be prolonged. Unfortunately, several such babies will not (...) survive for long whatever is done for them. Others will live to leave hospital, but face severe health problems. Doctors have gained the ability to prolong neonatal life. But should they always do so? This question is central to the recent report of the Nuffield Council on Bioethics, Critical care decisions in fetal and neonatal medicine.1 In many quarters, the report received a very positive response, commended in The Lancet as “thoughtful, sensitive and sensible” and welcomed by the premature baby charity BLISS. Critics attacked on both flanks. The report goes too far—ushering in a culture of “throw away babies”. Or it does not go far enough—failing to endorse the Dutch precedent to sanction active neonatal euthanasia.TOO FAR?One of the key recommendations of the report is that guidelines be developed in relation to the institution of intensive neonatal care. It is these guidelines, which have been savaged by some parts of the media. The BMA called them “blanket rules” smothering clinical discretion. The guidelines on resuscitation at birth apply to babies born at the borderline of viability, that is, at or before a gestational age of 25 weeks 6 days. The earlier the baby is born, the lower are the chances that he/she will survive to leave hospital. Before 21 weeks 6 days, none of …. (shrink)

The eclectic problem solving methodology used by the British Medical Association is described in this paper. It has grown from the daily need to respond to doctors’ practical queries and incorporates reference to law, traditional professional codes, and established BMA policies—all of which must be regularly assessed against the benchmark of contemporary societal expectations. The two Jehovah’s Witness scenarios are analysed, using this methodology and in both cases the four principles solution is found to concur with that of the BMA’s (...) approach. The author’s overall conclusion is that although the BMA resorts to a lengthier list of thins to consider, the solutions that emerge are often likely to coincide with the four principles approach. (shrink)

This paper does not attempt to lay out the arguments relating to male circumcision for non-medical reasons. Rather, the aim is to focus more on the process and the problems of a professional body ) attempting to produce any consensus guidelines for its members on an issue which clearly polarises doctors as much as it divides society as a whole. The legal and ethical considerations of male circumcision are inevitably touched upon here but are not the central issue. In 2003, (...) the BMA published professional guidance on this subject. Some thought this a pointless exercise; others saw it as an initiative which simply failed to go far enough. Reservations centred on the fact that the BMA’s guidance—like that of the statutory body, the General Medical Council—explored the issues without either firmly rejecting or accepting non-therapeutic male circumcision. Was it then a fruitless project or a brave start to grasping the nettle? (shrink)

In ‘Professional Hubris and its Consequences’, Eric Vogelstein claims that ‘that there are no good arguments in favor of professional organizations taking genuinely controversial positions on issues of professional ethics’. In this response, I defend two arguments in favour of organisations taking such positions: that their stance‐taking may lead to better public policy, and that it may lead to better practice by medical professionals. If either of those defences succeeds, then Vogelstein's easy path to his conclusion – that professional organisations (...) should not take such stances – is blocked. He or others must instead look to establish that the reasons against stance‐taking on genuine ethical controversies are more compelling than those for it: plausibly a more challenging task. (shrink)