To obtain information about the similarities and differences in regulating different types of medical research in the European Union (EU).
Web searches were performed from September 2009 to January 2011. Notes on pre-determined topics were systematically taken down from the web pages. The analysis relied only on documents and reports available on the web, reflecting the situation at the end of 2010.
In several countries, regulatory legislation applied only to clinical trials on drugs and medical devices, in other states various types of research were also regulated but by laws different from those concerning trials, and in many countries, some research areas were not controlled by legislation at all. In very few countries was all medical research handled similarly from a legal point of view. The number of research ethics committees (RECs) in a single country varied from one to 264. Their areas of responsibility, working principles and length of time to grant research permission varied as well as the rules for obtaining informed consent from vulnerable groups. In 10 EU countries, there was no appeal mechanism after a negative decision by an REC. The RECs were not accountable to any organisation in five EU countries.
There is a need for a fundamental debate regarding whether and which kinds of changes are needed for the further harmonisation of medical research governance in the EU and how cross-country medical research could be facilitated in the future.
One reason for the lack of clarity is controversy over whether and when participants should have access, after the study, to the study intervention. At one extreme is the view that continued access should be ensured when the intervention has benefited the...]]>
Apart from radicalising the support for active euthanasia in certain instances of neonatal diagnoses, is another interesting point that views of children and death are shaped by religion and culture and are especially highly charged with culturally specific symbolism/s. Furthermore, this is augmented in the context of non-Western cultures—further polarising the positivist ethics of Western scientific medicine from the cultures that affect only those who are members of ‘other’ societies.
From this starting point, the authors shift the focus from clinical explanations of the causation and prognosis of the genetic defects and enter a dialogue with cultural narratives. Consequently, their argument is, broadly, a reassessment of medical practice as a contextualisation of a...]]>
To explore the views in non-Western cultures about ending the lives of damaged newborns.
254 university students from India and 150 from Kuwait rated the acceptability of ending the lives of newborns with genetic defects in 54 vignettes consisting of all combinations of four factors: gestational age (term or 7 months); severity of genetic defect (trisomy 21 alone, trisomy 21 with serious morphological abnormalities or trisomy 13 with impending death); the parents’ attitude about prolonging care (unknown, in favour or opposed); and the procedure used (withholding treatment, withdrawing it or injecting a lethal substance).
Four clusters were identified by cluster analysis and subjected to analysis of variance. Cluster I, labelled ‘Never Acceptable’, included 4% of the Indians and 59% of the Kuwaitis. Cluster II, ‘No Firm Opinion’, had little variation in rating from one scenario to the next; it included 38% of the Indians and 18% of the Kuwaitis. In Cluster III, ‘Parents’ Attitude+Severity+Procedure’, all three factors affected the ratings; it was composed of 18% of the Indians and 16% of the Kuwaitis. Cluster IV was called ‘Severity+Parents’ Attitude’ because these had the strongest impact; it was composed of 40% of the Indians and 7% of the Kuwaitis.
In accordance with the teachings of Islam versus Hinduism, Kuwaiti students were more likely to oppose ending a newborn's life under all conditions, Indian students more likely to favour it and to judge its acceptability in light of the different circumstances.
Debates and controversies have shaped the understanding and the practices related to death determined by neurological criterion (DNC). Confusion about DNC in the public domain could undermine this notion. This confusion could further jeopardise confidence in rigorous death determination procedures, and raise questions about the integrity, sustainability, and legitimacy of modern organ donation practices.
We examined the depictions of ‘brain death’ in major American and Canadian print media to gain insights into possible common sources of confusion about DNC and the relationship between expert and lay views on this crucial concept.
We gathered 940 articles, available in electronic databases, published between 2005 and 2009 from high-circulation Canadian and American newspapers containing keywords ‘brain dead’ or ‘brain death’. Articles were systematically examined for content (eg, definitions of brain death and criteria for determination of death) using the NVivo 8 software.
Our results showed problematic aspects in American and Canadian media, with some salient differences. DNC was used colloquially in 39% (N=366) of the articles and its medical meaning infrequently defined (2.7%; N=14 in the USA and 3.6%; N=15 in Canada). The neurological criterion for determination of death was mentioned in less than 10% of the articles, and life support in about 20% of the articles. Organ donation issues related to DNC were raised more often in Canadian articles than in American articles (33.5% vs 21.2%; p<0.0001).
Further discussion is needed to develop innovative strategies to bridge media representations of DNC with experts’ views in connection with organ donation practices.
Currently, The nature and scope of Clinical Ethics Protocols (CEPs) in Madrid (Spain) are not well understood.
The main objective is to describe the features of ‘guideline/recommendation’ type CEPs that have been or are being developed by existing Clinical Ethics Committees (CECs) in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development.
We collected CEPs produced and in process by CECs accredited in the public hospitals in Madrid, Spain, from 1996 to 2008.
CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment (seven CEPs developed; two in process). If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate ‘ethical problems at the end of life’ category, this CEP subject emerges as the most common (eight developed; four in process). There is a relationship between the age of the CEC and the development of CEPs (the oldest CECs have developed more CEPs). CECs now seem to be more likely to engage in CEP development.
The CECs in Madrid, Spain, have developed a significant number of CEPs (30 in total and 10 in process) and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient.
To determine (1) whether fetal care paediatric (FCP) and maternal–fetal medicine (MFM) specialists harbour differing attitudes about pregnancy termination for congenital fetal conditions, their perceived responsibilities to pregnant women and fetuses, and the fetus as a patient and (2) whether self-perceived primary responsibilities to fetuses and women and views about the fetus as a patient are associated with attitudes about clinical care.
Mail survey of 434 MFM and FCP specialists (response rates 60.9% and 54.2%, respectively).
MFMs were more likely than FCPs to disagree with these statements (all p values<0.005): (1) ‘the presence of a fetal abnormality is not an appropriate reason for a couple to consider pregnancy termination’ (MFM : FCP—78.4% vs 63.5%); (2) ‘the effects that a child born with disabilities might have on marital and family relationships is not an appropriate reason for a couple to consider pregnancy termination’ (MFM : FCP—80.5% vs 70.2%); and (3) ‘the cost of healthcare for the future child is not an appropriate reason for a couple to consider pregnancy termination’ (MFM : FCP—73.5% vs 55.9%). 65% MFMs versus 47% FCPs disagreed that their professional responsibility is to focus primarily on fetal well-being (p<0.01). Specialists did not differ regarding the fetus as a separate patient. Responses about self-perceived responsibility to focus on fetal well-being were associated with clinical practice attitudes.
Independent of demographic and sociopolitical characteristics, FCPs and MFMs possess divergent ethical sensitivities regarding pregnancy termination, pregnant women and fetuses, which may influence clinical care.
Research supports the efficacy of both a remedial consent procedure (corrected feedback (CF)) and a motivational consent procedure (incentives) for improving recall of informed consent to research. Although these strategies were statistically superior to standard consent, effects were modest and not clinically significant. This study examines a combined incentivised consent and CF procedure that simplifies the cognitive task and increases motivation to learn consent information.
We randomly assigned 104 individuals consenting to an unrelated host study to a consent as usual (CAU) condition (n=52) or an incentivised CF (ICF) condition (n=52). All participants were told they would be quizzed on their consent recall following their baseline assessment and at 4 monthly follow-ups. ICF participants were also informed that they would earn $5 for each correct answer and receive CF as needed.
Quiz scores in the two conditions did not differ at the first administration (p=0.39, d=0.2); however, ICF scores were significantly higher at each subsequent administration (second: p=0.003, Cohen's d=0.6; third: p<0.0001, d=1.4; fourth: p<0.0001, d=1.6; fifth: p<0.0001, d=1.8).
The ICF procedure increased consent recall from 72% to 83%, compared with the CAU condition in which recall decreased from 69% to 59%. This supports the statistical and clinical utility of a combined remedial and motivational consent procedure for enhancing recall of study information and human research protections.
Routine prenatal screening for Down syndrome challenges professional non-directiveness and patient autonomy in daily clinical practices. This paper aims to describe how professionals negotiate their role when a pregnant woman asks them to become involved in the decision-making process implied by screening.
Forty-one semi-structured interviews were conducted with gynaecologists–obstetricians (n=26) and midwives (n=15) in a large Swiss city.
Three professional profiles were constructed along a continuum that defines the relative distance or proximity towards patients’ demands for professional involvement in the decision-making process. The first profile insists on enforcing patient responsibility, wherein the healthcare provider avoids any form of professional participation. A second profile defends the idea of a shared decision making between patients and professionals. The third highlights the intervening factors that justify professionals’ involvement in decisions.
These results illustrate various applications of the principle of autonomy and highlight the complexity of the doctor–patient relationship amidst medical decisions today.
There is little evidence of junior trainee perspectives in the design and implementation of medical ethics and law (MEL) curriculum in UK medical schools.
To determine the ethical issues the foundation year 1 (FY1) doctors (first year after graduation) encountered during clinical practice and the skills and knowledge of MEL, which were useful in informing MEL curriculum development.
The National Research Ethics Service gave ethical approval. Eighteen one-to-one interviews were conducted in each school with FY1 doctors.
Interviews were recorded and transcribed verbatim; a thematic analysis was undertaken with the transcriptions and saturation of themes was achieved.
Themes closely overlapped between the two study sites. (1) Knowing my place as an FY1 (this theme consisted of four subthemes: challenging the hierarchy, being honest when the team is titrating the truth, taking consent for unfamiliar procedures and personal safety vs competing considerations); (2) Do not attempt resuscitation)/end-of-life pathway and its implications; (3) ‘You have to be there’ (contextualising ethics and law teaching through cases or role plays to allow students to explore future work situations); and (4) advanced interpersonal skills competency for ethical clinical practice.
The data provide a snapshot of the real challenges faced by MEL FY1 doctors in early clinical practice: they may feel ill-prepared and sometimes unsupported by senior members of the team. The key themes suggest areas for development of undergraduate and postgraduate MEL curricula. We will work to develop our own curriculum accordingly. We intend to further investigate the applicability of our findings to UK medical ethics and law curriculum.
In his challenging paper,
In reply, we would like to insist that if our freedom is freedom in...]]>
The American Academy of Pediatrics (AAP) Task Force on Circumcision published its policy statement and technical report on newborn circumcision in September 2012.
Although Saghai primarily focuses on distinguishing nudges from other forms of influence, ‘Salvaging the Concept of Nudge’ offers a definition of nudges that could blunt much of the moral criticism of nudging and clarify debates about specific policies.
According to Saghai, ‘A nudges B when A makes it more likely that B will , primarily by triggering B's shallow cognitive processes, while A's influence preserves B's choice-set and is substantially non-controlling (i.e., preserves B's freedom of choice)’. Because the second condition—the substantial non-control condition—is supposed to ensure that nudges preserve freedom in a robust sense, this condition warrants careful attention.
According to Saghai, A's influence is substantially non-controlling ‘when...]]>
Policy makers are understandably interested—for both political and moral reasons—in following Thaler and Sunstein's recommendation to use ‘choice architecture’ (as in Cafeteria), or other ‘nudges’, to promote desirable behaviour in ways that are allegedly compatible with personal freedom. How important is definitional salvaging? If a ‘substantially controlling’ influence were more efficacious in promoting healthy behaviours, we...]]>
Salvaging the Concept of Nudge
In this Commentary, I want to explore some of the difficulties that remain in getting a clear understanding of the ideas used to clarify the idea of freedom of choice, in particular, the idea that some influences are easily resistible and some are not. In particular, I am interested in the use of various deceptive modes such as lying, failure to disclose and misleading utterances. I believe that there is an important ambiguity in thinking about...]]>
In ‘Salvaging the Concept of Nudge’ Yashar Saghai performs an important clarificatory task which certainly advances our philosophical and ethical understanding of nudges in public policy, and in healthcare ethics in particular.
A central difficulty with ethical discussions of nudging is that insufficient care is taken to distinguish two morally important features of nudges. The first, which Saghai very properly concentrates upon, is the mechanism of nudging. Nudges rely on psychological properties of human decision-makers as the way in which their intended effects are brought about. Much of the ethical concern with nudges focuses on just this. Whatever the motive of the nudger, or the objective of the nudge, or the ex ante or ex post ratification of the nudge by the nudge, operating through influence, impulse or non-rational features of...]]>
What is it to be influenced in a SNC-ing way? For Saghai, a subject is SNC-ed if she could easily resist the influence, meaning that she can effortlessly (i) become aware of the pressure exerted and (ii) ‘inhibit the triggered propensity’ if she wanted to.
In The Ethics of Nudge,2 I discuss subliminal images sliced into films to increase, say, the consumption of Coke. Suppose that we could also use this technology to encourage healthier eating habits. I argue that subliminal images are not nudges because they do not satisfy ‘token interference transparency’, that is, it is not...]]>
Ingmar Persson challenges
The focus of my argument was the possible improvement of moral standing brought by the radical enhancement of human cognitive and affective capacities. This would give stronger moral entitlements to benefits and stronger moral protections against harms. My opposition to varieties of enhancement that have this effect is grounded in significant harms for unenhanced humans that predictably result from a loss in relative moral standing. Significant benefits for the radically enhanced...]]>
Wertheimer argues that my Choice-Set Preservation Condition is objectionable because it wrongly implies that any reduction of the choice-set is incompatible with the preservation of freedom of choice.
I agree with Wertheimer's substantive claim, although I do not think it is incompatible with my view. As Joel Feinberg argued, freedom of choice is undermined when fecund options are eliminated.
In his ‘Moral Enhancement, Freedom, and What We (Should) Value in Moral Behaviour’, Many scholars doubt what I assert: that there is nothing inherently wrong with MB. Some doubt this on the basis of a conviction that there is something inherently wrong with biomedical enhancement technologies in general. Chief among their objections are the charges that (1) biomedical enhancement is unnatural, (2) use of biomedical enhancements evinces an insufficient appreciation for human "giftedness", and (3) biomedical enhancements pose a threat to personal identity. Elsewhere I have attempted to neutralize these objections. Here I will address a set of concerns that are directed at MB in particular and appeal to the nature and value of human freedom.
Let me make clear at once that I do...]]>
Thomas Szasz, the radical critic of state-supported psychiatry, and root and branch sceptic about mental illness, died in September 2012. Based on the obituary
Certainly, some have seen him as a notable figure from the past. There is a sense in which, as far as Szasz's critique of psychiatry goes, it did not really change at all in its essence from the time it was first explicitly expressed in his writings of the 1960s right up to his last publications and talks in the 2010s. He started his 1960 paper The Myth of Mental Illness
John O'Neill, a molecular biologist in Frank Herbert's 1982 novel ‘The White Plague’,
When the definitive history of armed conflict is written, the chapter on biological weapons will make for a long and disagreeable read. Now, happily, disavowed by most nations under the 1972 Biological Weapons Convention, the presumption is that any future deployment would be at the hands of rogue states, criminal gangs or perhaps terrorist organisations, to whom they could appeal because of their apparent ease of preparation and dissemination coupled with their sinister reputation and potential for causing mass casualties.
But Herbert's villain is different. He is a trained scientist possessing expert skills and with access to...]]>
Ethical decision making in intensive care is a demanding task. The need to proceed to ethical decision is considered to be a stress factor that may lead to burnout. The aim of this study is to explore the ethical problems that may increase burnout levels among physicians and nurses working in Portuguese intensive care units (ICUs). A quantitative, multicentre, correlational study was conducted among 300 professionals.
The most crucial ethical decisions made by professionals working in ICU were related to communication, withholding or withdrawing treatments and terminal sedation. A positive relation was found between ethical decision making and burnout in nurses, namely, between burnout and the need to withdraw treatments (p=0.032), to withhold treatments (p=0.002) and to proceed to terminal sedation (p=0.005). This did not apply to physicians. Emotional exhaustion was the burnout subdimension most affected by the ethical decision. The nurses' lack of involvement in ethical decision making was identified as a risk factor. Nevertheless, in comparison with nurses (6%), it was the physicians (34%) who more keenly felt the need to proceed to ethical decisions in ICU.
Ethical problems were reported at different levels by physicians and nurses. The type of ethical decisions made by nurses working in Portuguese ICUs had an impact on burnout levels. This did not apply to physicians. This study highlights the need for education in the field of ethics in ICUs and the need to foster inter-disciplinary discussion so as to encourage ethical team deliberation in order to prevent burnout.
The aim of this study was to examine if it is plausible to interpret the appearance of shame in a Swedish healthcare setting as a reaction to having one's honour wronged.
Using a questionnaire, we studied answers from a sample of long-term sick-listed patients who had experienced negative encounters (n=1628) and of these 64% also felt wronged. We used feeling wronged to examine emotional reactions such as feeling ashamed and made the assumption that feeling shame could be associated with having one's honour wronged. In statistical analyses relative risks (RRs) were computed, adjusting for age, sex, disease-labelling, educational levels, as well as their 95% CI.
Approximately half of those who had been wronged stated that they also felt shame and of those who felt shame, 93% (CI 91 to 95) felt that they had been wronged. The RR was 4.5 (CI 3.0 to 6.8) for shame when wronged. This can be compared with the other emotional reactions where the RRs were between 1.1 (CI 0.9 to 1.3)–1.4 (CI 1.2 to 1.7). We found no association between country of birth and feeling shame after having experienced negative encounters.
We found that the RR of feeling shame when wronged was significantly higher compared with other feelings. Along with theoretical considerations, and the specific types of negative encounters associated with shame, the results indicate that our research hypothesis might be plausible. We think that the results deserve to be used as point of departure for future research.
In his thoughtful defence of very modest moral enhancement, David DeGrazia
In order to make this case, I review the three main models of healthcare service delivery by focusing my analysis along three axes: the goal of the care model; the predominant understanding of autonomy implicit in the model; and, the main actors in the care relationship. By examining how the various concepts translate from one model to the next, I discuss what I identify to be one of the main conceptual obstacles to less problematic transitioning, the notion of autonomy and the corresponding view of the patient as an isolated agent.
]]>I read Robert Card's recent paper entitled ‘Is there no alternative? Conscientious objection by medical students’ with great interest.
Several issues, many of which have been described by Padela and del Pozo,
Altruism is arguably the quintessential moral trait, involving willingness to benefit others and unwillingness to harm them. In this study, I explored how altruism and other personality variables relate to acceptance of euthanasia. In addition, I investigated the role of culture in attitudes to subcategorical distinctions of euthanasia.
190 Iranian students completed the Attitude Towards Euthanasia scale, the HEXACO Personality Inventory-Revised, and an interest in religion measure.
Higher scores on altruism, Honesty–Humility, Agreeableness, Conscientiousness and religiousness were associated with viewing euthanasia as unacceptable. As expected, altruism explained unique variance in euthanasia attitude beyond gender, religiosity and broad personality factors.
Cultural and individual differences should be taken into consideration in moral psychology research and end-of-life decision-making.
Thanks to Dominic Wilkinson, a formidable clinician-philosopher, for his considered response, and especially for highlighting my work's translatability outside of an (explicitly) theological context. In part, because bioethics’ pioneers were theologians, the discipline misses something important when theology is not an integral part of the conversation. I do not have the space to do an in-depth response,
Wilkinson spends significant time critiquing my claim that the Social Quality of Life Model (sQOL) is consistent with a healthcare provider acting in the best interest of her patient. And though he notes that my general argument goes through without this claim, the idea that clinicians should always act in the (individualistically considered) best interests of their patients is so commonly held that this topic...]]>
In the first part of this paper I will outline and critique Camosy's central argument, which he calls the ‘social quality of life (sQOL)’ model. Although there are some conceptual problems with the way the argument is presented, even those who do not share Camosy's Catholic background have good reason to accept his key point that resources should be considered in intensive care treatment decisions for all patients. In the second part of the paper, I explore the ways in which we might identify which infants are too expensive to treat. I argue that both traditional personal ‘quality of life’ and Camosy's ‘sQOL’ should factor into these decisions, and I outline two practical proposals.
]]>The consequences of poor access and quality of healthcare services in developing countries are widely recognised by international agencies such as WHO.
Adolescents have had very limited access to research on biomedical prevention interventions despite high rates of HIV acquisition. One concern is that adolescents are a vulnerable population, and trials carry a possibility of harm, requiring investigators to take additional precautions. Of particular concern is preventive misconception, or the overestimation of personal protection that is afforded by enrolment in a prevention intervention trial.
As part of a larger study of preventive misconception in adolescent HIV vaccine trials, we interviewed 33 male and female 16–19-year-olds who have sex with men. Participants underwent a simulated HIV vaccine trial consent process, and then completed a semistructured interview about their understanding and opinions related to enrolment in a HIV vaccine trial. A grounded theory analysis looked for shared concepts, and focused on the content and process of adolescent participants’ understanding of HIV vaccination and the components of preventive misconception, including experiment, placebo and randomisation.
Across interviews, adolescents demonstrated active processing of information, in which they questioned the interviewer, verbally worked out their answers based upon information provided, and corrected themselves. We observed a wide variety of understanding of research concepts. While most understood experiment and placebo, fewer understood randomisation. All understood the need for safer sex even if they did not understand the more basic concepts.
Education about basic concepts related to clinical trials, time to absorb materials and assessment of understanding may be necessary in future biomedical prevention trials.
The science of moral bioenhancement is in its infancy. Laboratory studies of human morality usually employ highly simplified models aimed at measuring just one facet of a cognitive process that is relevant for morality. These studies have certainly deepened our understanding of the nature of moral behaviour, but it is important to avoid overstating the conclusions of any single study. De Grazia cites several purported examples of ‘non-traditional means of moral enhancement’, including one of my own studies. According to De Grazia, we showed that ‘selective serotonin...]]>
DeGrazia presents MB as a form of enhancement directed at moral capacities. There are, in the philosophical literature, two broad approaches to defining human enhancement. Simplifying somewhat, one account identifies enhancement with improvement. DeGrazia joins other advocates of MB in preferring this type of account, defining a human enhancement as ‘any deliberate intervention that aims to improve an existing capacity, select for a desired capacity, or create a new capacity in a human being.’
An alternative approach relativises enhancement to human norms.
If the question is whether promoting a ‘medical brain-drain’ from poor to rich countries is morally acceptable, then it is not only the actions of the persons soliciting relocation and those considering relocation that need to be...]]>
To document the legal guardian-related barriers to consent procurement, and their stated reasons for non-participation in a paediatric critical care research study.
A multicentre, prospective, cohort study.
Legal guardians of children who participated in a multicentre study on adrenal insufficiency in paediatric critical illness. Data were collected on all consent encounters in the main study.
Screening data, reasons for consent not being obtained, paediatric risk of mortality (illness severity) scores and age were collected on all 1707 patients eligible for participation in the Adrenal Insufficiency Study.
The main barriers to approaching legal guardians for consent were lack of availability of the legal guardians (321/1707) and language barriers (84/1707). Legal guardians of 917 patients were approached with an overall consent rate of 42% (range 14–56% across the seven sites). 81% of the 528 legal guardians who declined consent provided an unsolicited reason for refusal. The three most commonly stated reasons were: being overwhelmed (117/429), not wanting anything else done to their child (63/429) and not wanting an additional medication (53/429). In addition, 14.2% cited research-related concerns as the reason for their non-participation.
Barriers to consent procurement in a non-therapeutic paediatric critical care study appear to occur at many levels with lack of availability of legal guardians, and legal guardians feeling overwhelmed, being the most commonly recorded reasons. Further research into the impact of these findings on the validity and generalisability of the results of such studies is necessary prior to the development and study of future consent models.
I agree with Dr Eyal that the ‘trust-promotion argument for informed consent’ fails to account for common sense intuitions about informed consent.
While it is in no way necessary for these individuals to trust health professionals, much less medical...]]>
My argument is based on hedonistic utilitarianism.
The thrust of the argument is as follows. In many cases, we should allow people to refuse treatment for the simple reason that...]]>
In exceptional situations not covered by legal provisions, doctors may want to waive confidentiality against the wishes of the patient. Swiss law calls for an authority to rule on such cases. In the Canton of Geneva this authority is the Commission for Professional Confidentiality. This paper concerns 41 cases managed by this commission.
The study shows that the majority of these requests to the Commission concern the reporting of patients who are not incompetent but need the protection of a legal guardianship. In rare cases, there is another interest higher than confidentiality: public order or functioning of justice. The Commission found that the measure requested was justified in the majority of cases brought before it.
This study focuses on exceptional cases but it throws into relief the conflict between the principle of autonomy on the one hand and the need for patient protection and social justice on the other.
]]>Hidalgo offers a novel and interesting defence of the active recruitment of health workers by organisations based in the developed world.
The debate about the effects of the migration of healthcare professionals began in earnest in the 1970s. During this decade a number of researchers argued that migration flows from the developing to the developed world were detrimental to poorer countries and suggested that policies ought to be put in place to both retard the flow of migration and compensate countries for the negative effects of any ongoing migration.
1. Social trust, especially trust in caretakers and medical institutions, is necessary so that, for example, people seek medical advice, comply with it, and participate in medical research.
2. Therefore, it is usually wrong to jeopardise that trust.
3. Coercion, deception, manipulation and other violations of standard informed consent requirements seriously jeopardise that trust.
4. Thus, standard informed consent requirements are justified.
This article describes the initial promise of this argument, then identifies challenges to it. As I show, the value of trust fails to account for some commonsense intuitions about informed consent. We should revise the argument, commonsense morality, or both.
]]>Payment of research participants helps to increase recruitment for research studies, but can pose ethical dilemmas. Research ethics committees (RECs) have a centrally important role in guiding this practice, but standardisation of the ethical approval process in Ireland is lacking.
Our aim was to examine REC policies, experiences and concerns with respect to the payment of participants in research projects in Ireland.
Postal survey of all RECs in Ireland.
Response rate was 62.5% (n=50). 80% of RECs reported not to have any established policy on the payment of research subjects while 20% had refused ethics approval to studies because the investigators proposed to pay research participants. The most commonly cited concerns were the potential for inducement and undermining of voluntary consent.
There is considerable variability among RECs on the payment of research participants and a lack of clear consensus guidelines on the subject. The development of standardised guidelines on the payment of research subjects may enhance recruitment of research participants.
Hidalgo Hidalgo gives an insufficient account of the relevant harms that are inflicted when healthcare workers emigrate. Relatedly, he does not take account of the underlying causes of migration and what might assist in remedying the situation. He thus fails to catalogue a wide range of losses that are born when health workers emigrate from developing countries and fails to appreciate how his recommendations undermine some of the constructive initiatives that might assist poor, developing countries. Hidalgo misrepresents the situation in developing countries, incorrectly describing government funding of tertiary education as some kind of gift, rather than an...]]>
Hidalgo's paper is a clear and powerful contribution to a topic of ongoing concern.
As I read Paula Casal's excellent paper, ‘Sexual Dimorphism and Human Enhancement,’
Second, I confess that as I read Casal's article a strong feeling of shame washed over me in virtue...]]>
Two studies reported in the Journal of Medical Ethics add to the growing body of qualitative evidence relating to the use of sedatives at the end of life.
Most of the Dutch respondents in the paper by Reitjens et al
This is an excellent article, probably the best there is in defence of prohibiting the sale of organs, and it deserves a much fuller discussion of detail than there is space for here.
Whenever the subject of organ selling is discussed, it is useful to keep in mind the natural history of the debate. Prohibition was instituted by most governments and professional bodies just about as quickly as possible after it was discovered that payment for kidneys was going on, and was a direct response to feelings of moral outrage. It all happened without time for debate. It was only later,...]]>
Both commentators doubt whether numerically expressing each contributor's relative contribution is feasible. I admit that an important precondition for this task is the possibility of an informed, democratic debate among equals about the relative contribution of each contributor to the article. Mechanisms should be established to protect vulnerable researchers in the academic field in the same way as safeguards exist today to protect vulnerable research participants.
Theoretically, however, I think that the fair allocation of authorship credit is possible, and much of this task is already being performed routinely when contributors determine the order of their names in the byline, being well aware of the widespread assumption that this order mostly mirrors the order of their relative contributions. All they would have to do as an additional task is to express this order in numbers. If they cannot reach a consensus, they could always choose not to express their relative contribution in numbers, in which case the presumption would be that they contributed equally. My proposal could, at best, make the system fairer and, at worst, not reduce the options that evaluators already have.
]]>The Viewpoint article expressed the feelings of unease often encountered at the display of human corpses in museums, whether relating to prehistoric or recent times. The reasons frequently stem from what is seen as a lack of respect for the remains of another human being. In this instance, the underlying concerns are that the corpses are displayed naked, along with lack of consent from anyone with an interest in them. While these are legitimate queries, ethical interests extend further afield to include whether the corpses are identifiable, are prehistoric or recent, and the existence of living descendants. Additional interests include the uses to which corpses are put, namely, research, teaching and/or public displays.
In recent years, it has become commonplace to hear of human remains that had been held for many years by universities or museums being repatriated to indigenous people groups in America, Australia and New Zealand for subsequent reburial.
As the author notes, publication records are critical to decisions on hiring, promotion, tenure, salaries and allocation of research resources. At each of these points, what matters most is the quality of the candidate's work, which cannot be adequately assessed by quick counts of articles, even when the counts are weighted by numbers of citations or impact factors. Some institutions and departments perform careful reviews; others don't. Committees that review many grant proposals routinely and resignedly rely on inadequate proxy measures such as...]]>
Studies describing physicians’ experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation.
Qualitative face-to-face interviews were held in 2007–2008 with 36 physicians (18 from the Netherlands, 18 from the USA), including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses.
In both countries, the use of sedation was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives.
The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making.
The corpse of a high-ranking male official was unearthed in the 1975, and important archaeologic discoveries were claimed. The exact year of his funeral was 167 BC. Autopsy revealed that the man had peptic ulcer disease. His naked body exposing genitalia and post-dissection stitches, with the dissected-out intestines and brain lying alongside, is now exhibited in a formalin-impregnated viewing glass tank in a museum (
Meanwhile a 2000-year-old clothed female corpse is on display in another museum. In 1971, workers in China digging an air-raid shelter near the city of Changsha uncovered an enormous Han Dynasty-era tomb containing ‘the most perfectly preserved corpse ever found’. The tomb belonged to the wife of the Marquis of Han who died between 178 and 145 BC at around 50 years of age (http://listverse.com/2009/12/24/top-10-famous-mummified-bodies/). When autopsied, remains of her last meal were found in her stomach, and type A blood still...]]>
I will focus here on the analysis leading up to his conclusions, and with whether it helps us understand why prostitution is so commonly harmful and what it would take to mitigate those harms.
One striking aspect of his argument is the particular way in which he characterises the common view about the harmfulness of prostitution. Consider the following two possible versions of the claim that prostitution is harmful: The intrinsic claim: The exchange of sex for money is intrinsically harmful to the seller. The contingent claim: Prostitutes are currently likely to experience significant harm.
The intrinsic claim is a conceptual one about an inherent link between selling sex and being harmed; this...]]>
The first main problem is that the authors, in calling for a revolution in the way that withdrawal of treatment cases are dealt with, fail to recognise that their desired revolutionary utopia is the ordinary workaday world of the law courts.
The English law in relation to the administration of treatment to children, and the withdrawal of treatment from them, is straightforward: the only lawful treatment is that which is in the child's best interests. The Children Act 1989 (Section 1(1)(a)) puts it slightly differently, but synonymously: the welfare of the child is the paramount consideration. Yes, the views of those holding parental responsibility are sought, but those views do not determine where the child's best interests lie. This is often misunderstood. One hears people talk about a parental veto on proposed treatment or a withdrawal of treatment. There...]]>
Some commentators argue that conception signals the onset of human personhood and that moral responsibilities toward zygotic or embryonic persons begin at this point, not the least of which is to protect them from exposure to death. Critics of the conception threshold of personhood ask how it can be morally consistent to object to the embryo loss that occurs in fertility medicine and research but not object to the significant embryo loss that occurs through conception in vivo. Using that apparent inconsistency as a starting point, they argue that if that embryo loss is tolerable as a way of conceiving children, it should be tolerable in fertility medicine and human embryonic research. Double-effect reasoning shows, by contrast, that conception in vivo is justified even if it involves the death of persons because the motives for wanting children are not inherently objectionable, because the embryo loss that occurs in unassisted conception is not the means by which successful conception occurs, and because the effect of having children is proportionate to the loss involved. A similar outcome holds true for in vitro fertilisation in fertility medicine but not for in vitro fertilisation for research involving human embryos.
]]>Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this ‘paradigm case’ was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation.
]]>This paper contends that the conventional ethical and legal ways of analysing the wrong involved in the misuse of human body parts are inadequate, and should be replaced with an analysis based on human dignity. It examines the various ways in which dignity has been understood, outlines many of the criticisms made of those ways (agreeing with many of the criticisms), and proposes a new way of seeing dignity which is exegetically consonant with the way in which dignity has been historically understood, and yet avoids the pitfalls which have led to dignity being dismissed by many as hopelessly amorphous or incurably theological. The account of dignity proposed is broadly Aristotelian. It defines dignity in terms of human thriving, and presupposes that it is possible, at least in principle, to determine empirically what makes humans thrive. It contends that humans are quintessentially relational animals, and that it is not possible (and certainly not ethically desirable) to define humans as atomistic entities. One important corollary of this is that when using dignity/thriving as a criterion for determining the ethical acceptability of a proposed action or inaction, one should ask not merely how the dignity interests of the patient (for instance) would be affected, but how the dignity interests of all stakeholders would be affected. The business of ethics is then the business of auditing all those interests, and determining the course of action which would maximise the amount of thriving in the world.
]]>Review boards responsible for vetting the ethical conduct of research have been criticised for their costliness, unreliability and inappropriate standards when evaluating some non-medical research, but the basic value of mandatory ethical review has not been questioned. When the standards that review boards use to evaluate research proposals are applied to review board practices, it is clear that review boards do not respect researchers or each other, lack merit and integrity, are not just and are not beneficent. The few benefits of mandatory ethical review come at a much greater, but mainly hidden, social cost. It is time that responsibility for the ethical conduct of research is clearly transferred to researchers, except possibly in that small proportion of cases where prospective research participants may be so intrinsically vulnerable that their well-being may need to be overseen.
]]>This paper responds to an invitation by the editors to consider whether the intellectual property (IP) regime suggests an appropriate model for protecting interests in detached human body parts. It begins by outlining the extent of existing IP protection for body parts in Europe, and the relevant strengths and weaknesses of the patent system in that regard. It then considers two further species of IP right of less obvious relevance. The first are the statutory rights of ownership conferred by domestic UK law in respect of employee inventions, and the second are the economic and moral rights recognised by European and international law in respect of authorial works. In the argument made, both of these species of IP right may suggest more appropriate models of sui generis protection for detached human body parts than patent rights because of their capacity better to accommodate the relevant public and private interests in respect of the same.
]]>In ‘Imposing Options on People in Poverty: the Harm of a Live Donor Organ Market', Simon Rippon argues that some options in the market do in fact harm. According to Rippon, if we focus on possible negative consequences of increasing an agent's options, one can develop an argument against...]]>
The argument he believes unsound, which I shall use his terminology to refer to as the Laissez-Choisir or LC argument, has three premises. The one be believes false says, "If we take away what some regard as their best option, we thereby make them worse off, at least from their own perspective".
Applied to the case of a market for organs, this says that if we take away what the potential organ seller regards as his best option, that is, there being a market for his organs, we make him worse off as judged by him. The reason Rippon thinks this argument is...]]>