When I think about America, I think about a great diversity of types of people, from different backgrounds, national origins, races, religions, classes and points of view. The US is made up of descendants of African slaves and recent African immigrants; mid-western farmers and Asian Americans whose families come from nearly every Asian nation; Jewish families from Eastern Europe and Native Americans who have owned our land for centuries before any others. These are only a few of the stories that (...) make up the rich diversity of American society. Diversity is our greatest asset. (shrink)

Artificial intelligence (AI) is increasingly being developed for use in medicine, including for diagnosis and in treatment decision making. The use of AI in medical treatment raises many ethical issues that are yet to be explored in depth by bioethicists. In this paper, I focus specifically on the relationship between the ethical ideal of shared decision making and AI systems that generate treatment recommendations, using the example of IBM’s Watson for Oncology. I argue that use of this type of system (...) creates both important risks and significant opportunities for promoting shared decision making. If value judgements are fixed and covert in AI systems, then we risk a shift back to more paternalistic medical care. However, if designed and used in an ethically informed way, AI could offer a potentially powerful way of supporting shared decision making. It could be used to incorporate explicit value reflection, promoting patient autonomy. In the context of medical treatment, we need value-flexible AI that can both respond to the values and treatment goals of individual patients and support clinicians to engage in shared decision making. (shrink)

Models for clinical ethics case consultation often make reference to ‘balancing’ or ‘weighing’ moral considerations, without further detail. In this paper, we investigate balancing in clinical ethics case consultation. We suggest that, while clinical ethics services cannot resolve ongoing deep philosophical debates about the nature of ethical reasoning, clinical ethicists can and should be more systematic and transparent when balancing considerations in case consultations. We conceptualise balancing on a spectrum from intuitive to deliberative, and argue that good balancing in case (...) consultation involves articulating reasons for giving something more or less weight. We develop a framework of four practical strategies for better balancing in clinical ethics case consultation: intuitions as a launchpad, drilling down, pairwise comparison and group deliberation. (shrink)

In the Australian state of Victoria, legislation allowing voluntary assisted dying (VAD) passed through parliament in November 2017. There was then an eighteen-month period before the start date for patient access to VAD, referred to as the “implementation period.” The implementation period was intended to allow time for the relevant government department and affected organizations to develop processes before the Act came into effect in June 2019. This qualitative interview study investigates the perspectives of a multidisciplinary sample of twelve clinicians (...) from a single metropolitan hospital during this implementation period. Maximum variation sampling was utilized to ensure breadth across discipline (medical, nursing, allied health), speciality, and stated level of support for the VAD legislation. Four key themes were identified from the interview data: preparing for the unknown, ethical diversity within the organization, building a respectful culture, and concerns about the inability of the legislated approach to capture clinical nuances. Overall, these clinicians’ workplace experiences during the implementation period were shaped by the ethical diversity within their organization and a sense of uncertainty about how the VAD legislation would integrate with the practical realities of their clinical setting. The concept of “ethical diversity” could be a useful one for supporting staff in an organization during a VAD implementation period. (shrink)

This paper reviews the ethical literature on conflicts between health professionals and parents about medical decision-making for children. We present the results of a systematic review which addressed the question ‘when health professionals and parents disagree about the appropriate course of medical treatment for a child, under what circumstances is the health professional ethically justified in overriding the parents’ wishes?’ We identified nine different ethical frameworks that were put forward by their authors as applicable across various ages and clinical scenarios. (...) Each of these frameworks centred on a different key moral concept including harm, constrained parental autonomy, best interests, medically reasonable alternatives, responsible thinking and rationality. (shrink)

BackgroundIn June 2019, the Australian state of Victoria joined the growing number of jurisdictions around the world to have legalised some form of voluntary assisted dying. A discourse of safety was prominent during the implementation of the Victorian legislation.Main textIn this paper, we analyse the ethical relationship between legislative “safeguards” and equal access. Drawing primarily on Ruger’s model of equal access to health care services, we analyse the Victorian approach to voluntary assisted dying in terms of four dimensions: horizontal equity, (...) patient agency, high quality care, and supportive social norms. We argue that some provisions framed as safeguards in the legislation create significant barriers to equal access for eligible patients.ConclusionsWhile safety is undoubtedly ethically important, we caution against an overemphasis on safeguarding in voluntary assisted dying legislation given the implications for equal access. (shrink)

Bioethics, Volume 35, Issue 7, Page 696-703, September 2021.

This historic book may have numerous typos and missing text. Purchasers can download a free scanned copy of the original book (without typos) from the publisher. Not indexed. Not illustrated. 1902 Excerpt:...earth. r' = radius of moon, or other body. P = moon's horizontal parallax = earth's angular semidiameter as seen from the moon. f = moon's angular semidiameter. Now = P (in circular measure), r'-r = r (in circular measure);.'. r: r':: P: P', or (radius of earth): (radios of (...) moon):: (moon's parallax): (moon's semidiameter). Examples. 1. Taking the moon's horizontal parallax as 57', and its angular diameter as 32', find its radius in miles, assuming the earth's radius to be 4000 miles. Here moon's semidiameter = 16';.-. 4000::: 57': 16';.-. r = 400 16 = 1123 miles. 2. The sun's horizontal parallax being 8"8, and his angular diameter 32V find his diameter in miles. ' Am. 872,727 miles. 3. The synodic period of Venus being 584 days, find the angle gained in each minute of time on the earth round the sun as centre. Am. l"-54 per minute. 4. Find the angular velocity with which Venus crosses the sun's disc, assuming the distances of Venus and the earth from the sun are as 7 to 10, as given by Bode's Law. Since (fig. 50) S V: VA:: 7: 3. But Srhas a relative angular velocity round the sun of l"-54 per minute (see Example 3); therefore, the relative angular velocity of A V round A is greater than this in the ratio of 7: 3, which gives an approximate result of 3"-6 per minute, the true rate being about 4" per minute. Annual ParaUax. 95. We have already seen that no displacement of the observer due to a change of position on the earth's surface could apparently affect the direction of a fixed star. However, as the earth in its annual motion describes an orbit of about 92 million miles radius round the sun, the different positions in space from which an observer views the fixed stars from time to time throughout the year must be separated... (shrink)

There has recently been interest in applying the techniques of systematic review to bioethics literature. In this paper, I identify the three models of systematic review proposed to date in bioethics: systematic reviews of empirical bioethics research, systematic reviews of normative bioethics literature, and systematic reviews of reasons. I argue that all three types yield information useful to scholarship in bioethics, yet they also face significant challenges particularly in relation to terminology and time. Drawing on my recent experience conducting a (...) systematic review, I suggest that complete comprehensiveness may not always be an appropriate goal of a literature review in bioethics, depending on the research question. In some cases, all the relevant ideas may be captured without capturing all the relevant literature. I conclude that systematic reviews in bioethics have an important role to play alongside the traditional broadbrush approach to reviewing literature in bioethics. (shrink)

Should punishment be abated for offenders suffering from amnesia? Philosophers have largely overlooked this question. Extant views cluster around a straightforward answer: deserving punishment depends on remembering one’s crime. However, arguments for that view rely on implausible assumptions; the view also implies that offenders could manipulate how much punishment they deserve. Instead, uneasiness about punishing amnesiacs should be traced to distinctive grounds for showing mercy. Amnesiacs who cannot access their past motives are unable to fully comprehend their own role in (...) bringing punishment upon themselves and unable to situate their decisions within a satisfying narrative arc of their lives. (shrink)

Birchley9s critique of the harm threshold for overriding parental decisions is successful in demonstrating that the harm threshold, like the best interests standard, suffers from the problem of indeterminacy. However, his focus on critiquing empirical rather than normative arguments for the harm threshold means that his broad conclusion that it is ‘ill-judged’ is not justified. Advocates of the harm threshold can accept that the concept of harm to a child is indeterminate, yet still invoke strong normative arguments for this way (...) of responding to parental decisions that conflict with medical recommendations. I suggest that Birchley9s discussion, rather than showing that the harm threshold is mistaken, instead highlights the importance of developing a comprehensive account of children9s interests, for proponents of a best interests approach and for advocates of the harm threshold. (shrink)

In jurisdictions where voluntary assisted dying is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this (...) protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture. There are no data in this work. (shrink)

The recent interest in systematic review methods in bioethics has highlighted the need for greater transparency in all literature review processes undertaken in bioethics projects. In this article, I articulate features of a good bioethics literature review that does not aim to be systematic, but rather to capture and analyse the key ideas relevant to a research question. I call this a critical interpretive literature review. I begin by sketching and comparing three different types of literature review conducted in bioethics (...) scholarship. Then, drawing on Dixon-Wood's concept of critical interpretive synthesis, I put forward six features of a good critical interpretive literature review in bioethics: answering a research question, capturing the key ideas relevant to the research question, analysing the literature as a whole, generating theory, not excluding papers based on rigid quality assessment criteria, and reporting the search strategy. (shrink)

Hesperides Press are republishing these classic works in affordable, high quality, modern editions, using the original text and artwork.

The claim that human reproductive cloning constitutes an affront to human dignity became a familiar one in 1997 as policymakers and bioethicists responded to the announcement of the birth of Dolly the sheep. Various versions of the argument that reproductive cloning is an affront to human dignity have been made, most focusing on the dignity of the child produced by cloning. However, these arguments tend to be unpersuasive and strongly criticised in the bioethical literature. In this paper I put forward (...) a different argument that reproductive cloning is an affront to human dignity, one that looks beyond the dignity of the child produced. I suggest that allocating funds to such a pursuit can affront human dignity by diverting resources away from those existing people who lack sufficient health to enable them to exercise basic rights and liberties. This version of the argument posits cloning as an affront to human dignity in particular circumstances, rather than claiming the technology as intrinsically inconsistent with human dignity. (shrink)

The idea that an individual has a ‘right not to know’ genetic information about himself or herself is entrenched in both the policy sphere and the genetic counselling ethos. In this paper, I interrogate this idea of a ‘right not to know’, questioning particularly its status as a right. I identify the conception of rights that seems to underlie the posited ‘right not to know’ as a conception of rights in which they are prioritised non-outweighable interests. Turning to a series (...) of hypothetical situations in which the ‘right not to know’ is invoked, I argue that the ‘right not to know’ is not a right consistent with such a conception. The ‘right not to know’ can only exist in a framework of rights in which they lack significant moral weight. Thus, considering the gravity of rights in popular understanding, I suggest caution in the continuing use of the phrase ‘right not to know’ in the context of genetic testing. This investigation suggests that structuring the debate around genetic ignorance in terms of the ‘right not to know’ is not conducive to moving forward ethical thinking in this area. (shrink)

In contrast to Di Nucci’s characterisation, my argument is not a technoapocalyptic one. The view I put forward is that systems like IBM’s Watson for Oncology create both risks and opportunities from the perspective of shared decision-making. In this response, I address the issues that Di Nucci raises and highlight the importance of bioethicists engaging critically with these developing technologies.

In their account of the value of parental permission, Navin and Wasserman see families as “collective agents” who “form identities” and have interests as a “family unit” that sometimes justify subo...

Ethical concerns about therapeutic misconception have been raised since the early 1980s. This concept was originally described as research participants' assumptions that decisions relating to research interventions are made on the basis of their individual therapeutic needs. The term has since been used to refer to a range of ‘misunderstandings’ that research participants may have. In this paper, we describe a new concept—therapeutic appropriation. Therapeutic appropriation occurs when patients, or clinicians, actively reframe research participation as an opportunity to enhance patients' (...) clinical care, while simultaneously acknowledging the generalised research aims. To illustrate the concept of therapeutic appropriation, we draw on data from an interview study which we conducted to investigate the experiences of patients and general practitioners involved in clinical trials in primary care. We argue that therapeutic appropriation has two key elements: comprehension that the research project is not necessarily aiming to benefit participants and the deliberate use of incidental features of the research for personal therapeutic benefit of various kinds. We conclude that therapeutic appropriation is a useful concept that refines understanding of potential ethical problems in clinical research, and points to strategies to address them. (shrink)

The Human Fertilisation and Embryology Authority’s recent restrictive recommendations on sex selection have highlighted the need for consideration of the plausibility of ethical arguments against sex selection. In this paper, the author suggests a parental virtues approach to some questions of reproductive ethics as a superior alternative to an exclusively harm focused approach such as the procreative liberty framework. The author formulates a virtue ethics argument against sex selection based on the idea that acceptance is a character trait of the (...) good parent. It is concluded that, because the argument presented posits a wrong in the sex selecting agent’s action that is not a harm, the argument could not function as a justification of the HFEA’s restrictive position in light of their explicit commitment to procreative liberty; it does, however, suggest that ethical approaches focused exclusively on harm fail to capture all the relevant moral considerations and thus that we should look beyond such approaches. (shrink)

Clinical ethics records offer bioethics researchers a rich source of cases that clinicians have identified as ethically complex. In this paper, we suggest that clinical ethics records can be used to point to types of cases that lack attention in the current bioethics literature, identifying new areas in need of more detailed bioethical work. We conducted an analysis of the clinical ethics records of one paediatric hospital in Australia, focusing specifically on conflicts between parents and health professionals about a child’s (...) medical treatment. We identified, analysed, and compared cases of this type from the clinical ethics records with cases of this type discussed in bioethics journals. While the cases from journals tended to describe situations involving imminent risk to the child’s life, a significant proportion of the clinical ethics records cases involved different stakes for the child involved. These included distress, poorer functional outcome, poorer psychosocial outcome, or increased risk of surgical complications. Our analysis suggests that one type of case that warrants more detailed ethics research is parental refusal of recommended treatment, where the refusal does not endanger the child’s life but rather some other aspect of the child’s well-being. (shrink)

Young children with cancer are treated with interventions that can have a high risk of compromising their reproductive potential. ‘Fertility preservation’ for children who have not yet reached puberty involves surgically removing and cryopreserving reproductive tissue prior to treatment in the expectation that strategies for the use of this tissue will be developed in the future. Fertility preservation for prepubertal children is ethically complex because the techniques largely lack proven efficacy for this age group. There is professional difference of opinion (...) about whether it is ethical to offer such ‘experimental’ procedures. The question addressed in this paper is: when, if ever, is it ethically justifiable to offer fertility preservation surgery to prepubertal children? We present the ethical concerns about prepubertal fertility preservation, drawing both on existing literature and our experience discussing this issue with clinicians in clinical ethics case consultations. We argue that offering the procedure is ethically justifiable in certain circumstances. For many children, the balance of benefits and burdens is such that the procedure is ethically permissible but not ethically required; when the procedure is medically safe, it is the parents’ decision to make, with appropriate information and guidance from the treating clinicians. We suggest that clinical ethics support processes are necessary to assist clinicians to engage with the ethical complexity of prepubertal fertility preservation and describe the framework that has been integrated into the pathway of care for patients and families attending the Royal Children’s Hospital in Melbourne, Australia. (shrink)

This paper argues that the professional situation of junior doctors is unique in ethically important ways and thus that ethics work focusing on junior doctors specifically is necessary. Unlike the medical student or the more senior doctor, the doctor in his or her early postgraduate years is simultaneously a responsible health professional, a subjugate learner and a human resource. These multiple roles generate the set of ethical issues faced by junior doctors, a set that has some overlaps with that faced (...) by medical students and with that faced by more experienced doctors but is far from completely continuous with either. Further, the multiple roles that junior doctors play affect their options for negotiating the ethical challenges that they face. Their position determines not only the content of the set of ethical issues that they encounter, but also the kinds of actions they can take in the face of these challenges. Thus considering junior doctors only in combination with medical students or more senior doctors fails on two fronts. Firstly, only a very incomplete set of the ethical issues faced by junior doctors will be addressed, and, secondly, the constraints associated with the specific professional situation of junior doctors will not be adequately considered, limiting the practical applicability for these agents of any such analyses. (shrink)

Since the publication of Black Skin,White Masks, questions of blackness have invoked the problem as being related to time and temporality. Afropessimism has placed this temporal problem at the core of its endeavor. This paper takes that intuition as a means to interrogate and deepen Frank B. Wilderson III’s claim that black time is without narrative capacity or coordinates. Black time is thus one in which the movement of time is uncontestable. Moving through Patterson’s concept of natal alienation and then (...) Heidegger and Derrida on Death and givenness, Wilderson’s argument can be substantiated. Specifically, if we understand black time as being nonauthentic rather than contained within Heidegger’s authenticity/inauthenticity constellation, and essentially bound up with an interminable and unsettled life debt that racial slavery entailed, there is a means to unfold Wilderson’s claim and approach the notion that what blackness gives is time. (shrink)

The articles in this issue explore a number of difficult choices in medical care and research. They investigate ethical complexity in a range of decisions faced by policymakers and clinicians, and offer new evidence or normative approaches for navigating this complexity. In this issue’s feature article, Ford and colleagues engage with an ethical challenge faced by policymakers in relation to health research: should free text data contained in medical records be shared for research purposes?1 While some types of data from (...) electronic medical records are used widely in health research, privacy concerns have limited the use of free text data specifically. Ford and colleagues highlight the richness of the clinical information in free text and its centrality to some areas of healthcare such as mental health and primary care. In their view, while text analytic technology is developing rapidly, ‘policy makers routinely judge that the risk of re-identifying patients from text data is too high for these data uses’. Their citizens’ jury study in the UK found that participants were largely in favour of medical free text data being shared outside the NHS for research using an opt-out model: ‘the majority of jurors believed the benefits of sharing data for research outweighed the privacy risks’. In their commentary on this research, Largent and Morain raise some important issues about policymakers’ use of empirical findings …. (shrink)

In this paper, we explore the ethics of restricting visitation to hospitals during an infectious disease outbreak. We aim to answer three questions: What are the features of an ethically justified hospital visitor restriction policy? Should policies include scope for case‐by‐case exemptions? How should decisions about exemptions be made? Based on a critical interpretive review of the existing ethical literature on visitor restrictions, we argue that an ethically justified hospital visitor restriction policy has the following features: proportionality, comprehensiveness, harm mitigation, (...) exemptions for specific patient populations, visitation decisions made separately from a patient's treating clinicians, transparency, and consistency in application. We also argue that an ethical policy ought to include scope for case‐by‐case exemptions for individual patients. We propose a process for ethical decision‐making that provides a shared language and structure to decrease the risks and burdens of decision‐making when clinicians or managers are considering requests for exemptions. (shrink)

Consequentialist theories that directly assess multiple focal points face an important objection: that one right option may conflict with another. Robert Adams raises an instance of this objection regarding the possibility that the right act conflicts with the right motives. Whereas only partial responses have previously been given, assuming particular views of the relation between motives and acts, an exhaustive treatment is in order. Either motives psychologically determine acts, or they do not – and I defend direct consequentialism on each (...) assumption. Crucially, if motives determine acts, this may be compatible with the ability to act otherwise, but there remains a defense for consequentialism even on these assumptions. What clears consequentialism of conflict is not necessarily that the apparently right act is unavailable, but rather that its outcome is suboptimal once we account for necessary motives. Even if the agent remains free to perform the act, the act costs too much. (shrink)

The articles in this issue direct our attention to the role of concepts in medical ethics. The issue includes research that defines a concept,1 research that applies concepts to illuminate the moral aspects of various elements of medicine,2 3 and research investigating the appropriate set of concepts to teach medical students.4 In their in-depth exploration of the concept of disease in this issue, Powell and Scarffe argue that our understanding of a concept should be ‘tailored to the role that the (...) concept plays in the institutional settings in which it is deployed’.1 Their methodology takes seriously the institutional context in which a concept operates. This approach to thinking about concepts is potentially applicable very broadly in medical ethics. What is the institutional role that a concept plays? What is the work that we need the concept to do? The feature article by Powell and Scarffe proposes a new definition of a foundational concept in medicine, that of disease. On their view, ‘a biomedical state is a disease only if it implicates a biological dysfunction that is, or would be, properly disvalued’.1 They describe their definition as involving both a moral criterion (of being ‘properly disvalued’) and a biological criterion (of biological dysfunction). A number of commentators engage with Powell and Scarffe’s proposal. Tekin focuses on the moral criterion, through the example of grief and depression. …. (shrink)

The once deeply held conviction that all necessary truths are known a priori is now widely, although by no means universally agreed to have been subjected to penetrating, if not devastating criticism. Scott Soames, for example, on behalf of Saul Kripke, and indirectly of Hilary Putnam, argues that in respect of natural kinds, the introduction of basic essentialist assumptions grounded in our pre-theoretical habits of thinking and speaking – for example, that atomic or molecular structure provides the underlying essence of (...) a substance – allows a sentence like "water = H 2 0," in which the identity sign is flanked by rigid designators to express a metaphysically necessary truth. Yet doubts and puzzlement remain over the status of a posteriori necessities, including those relating to an individual's origin. This paper considers some prominent criticisms that have been made of the Kripke–Putnam approach by A. J. Ayer and Frank Ebersole among others and reveals in what respects they are valid, where they are misplaced, and, perhaps more importantly, why the most valuable aspect of this approach can be seen to reflect aspects of our scientific procedures that do indeed point towards an application for a distinction that roughly mirrors that between epistemic and metaphysical possibility, yet one that is grounded instead in the nature of our actual practices. (shrink)

This paper argues that doctors' ethical challenges can be usefully conceptualised as role virtue conflicts. The hospital environment requires doctors to be simultaneously good doctors, good team members, good learners and good employees. I articulate a possible set of role virtues for each of these four roles, as a basis for a virtue ethics approach to analysing doctors' ethical challenges. Using one junior doctor's story, I argue that understanding doctors' ethical challenges as role virtue conflicts enables recognition of important moral (...) considerations that are overlooked by other approaches to ethical analysis. (shrink)