David M. Shaw

It is well known that prisoners’ human rights are often violated. In this chapter we examine whether guidelines can be effective in preventing such violations and in helping physicians resolve the significant conflicts of interest that they often face in trying to protect prisoners’ rights. We begin by explaining the role of clinical and ethical guidelines outside prisons, in the context of healthcare for non-incarcerated prisoners, and then the specific role of such guidelines within prisons, where the main concerns are ensuring respect for the principle of equivalence of care, and for a prisoner patient’s autonomy in health care decisions. After reviewing and analysing various national and international guidelines, we review the literature and assess whether the good practices set out in these guidelines actually translate into changes in professional behaviour and consequent benefits for prisoners. It emerges that physicians both outside and within prisons tend to be insufficiently familiar with the relevant guidelines, and that they too infrequently use the guidance to make decisions, preferring instead to use personal codes of conduct. Guidelines designed specifically for the prison context are important to ensure equivalence of care and should be better known by health care personnel and other professional groups working in prison. Further guidelines should be developed that describe challenging situations and provide concrete guidance as to how to deal with them.

Several bioethical topics received a great deal of news coverage here in Scotland in 2009. Three important issues with transatlantic connections are the swine flu outbreak, which was handled very differently in Scotland, England and America; the US debate over healthcare reform, which drew the British NHS into the controversy; and the release to Libya of the Lockerbie bomber, which at first glance might not seem particularly bioethical, but which actually hinged on the very public discussion of the prisoner’s medical records. On a national level, there have been attempts in both Scotland and England to change the law on assisted suicide, where success looks more likely than ever. This paper will discuss each of these issues, and hopefully raise awareness of how these issues were dealt with in the UK and its component countries.

It is highly probable that you have fallen victim to a spoiler at some point in your life. Perhaps you heard what the twist was in The Sixth Sensei before you saw it, or perhaps you have come across one of the now near-ubiquitous references in the media to Keyzer Soze, and thus had much of your enjoyment of The Usual Suspectsii ruined. Put simply, a spoiler is a piece of information that spoils your enjoyment of a film, usually by revealing a key plot detail. This paper argues that those working in the media and the public at large have an ethical obligation to avoid communicating spoilers if at all possible. Although this might seem like an unimportant moral issue (or not a moral issue at all) it transpires {SPOILER ALERT} that spoilers, particularly of the media variety, can have a significant cumulative antiutilitarian effect. This paper will feature less examples than is typical of a philosophical work, because the author wishes to avoid any spoilers.

This paper analyses the current organ donor card system in Switzerland and identifies five problems that may be partially responsible for the country’s low deceased organ donation rates. There are two minor issues concerning the process of obtaining a donor card: the Swisstransplant website understates the prospective benefits of donation, and the ease with which donor cards can be obtained raises questions regarding whether any consent to donation provided is truly informed. Furthermore, there are two major practical problems that might affect those who carry an organ donor card: the lack of a central donor registry increases the likelihood that donors’ wishes will be “lost”, and there is a high probability that family members will veto organ donation. The fact that these two practical problems are not mentioned to potential donors by Swisstransplant constitutes the fifth problem. Donation rates would probably improve if more accurate information about the benefits of donation was provided to potential donors, a central donor registry was created, and families were not permitted to veto donation from those on the registry.

The GDC’s recent third edition (interim) of The First Five Years places renewed emphasis on the place of professionalism in the undergraduate dental curriculum. This paper provides a brief analysis of the concepts of ethics, professionalism and fitness to practice, and an examination of the GDC’s First Five Years and Standards for Dental Professionals guidance, as well as providing an insight into the innovative ethics strand of the BDS course at the University of Glasgow. It emerges that GDC guidance is flawed inasmuch as it advocates a virtue-based approach to ethics and professionalism, and fails to distinguish clearly between these two concepts.

Nanotechnology, which involves manipulation of matter on a ‘nano’ scale, is considered to be a key enabling technology. Medical applications of nanotechnology are expected to significantly improve disease diagnostic and therapeutic modalities and subsequently reduce health care costs. However, there is no consensus on the definition of nanotechnology or nanomedicine, and this stems from the underlying debate on defining ‘nano’. This paper aims to present the diversity in the definition of nanomedicine and its impact on the translation of basic science research in nanotechnology into clinical applications. We present the insights obtained from exploratory qualitative interviews with 46 stakeholders involved in translational nanomedicine from Europe and North America. The definition of nanomedicine has implications for many aspects of translational research including: fund allocation, patents, drug regulatory review processes and approvals, ethical review processes, clinical trials and public acceptance. Given the interdisciplinary nature of the field and common interest in developing effective clinical applications, it is important to have honest and transparent communication about nanomedicine, its benefits and potential harm. A clear and consistent definition of nanomedicine would significantly facilitate trust among various stakeholders including the general public while minimizing the risk of miscommunication and undue fear of nanotechnology and nanomedicine.

Advance directives (ADs), which are also sometimes referred to as ‘living wills’, are statements made by a person that indicate what treatment she should not be given in the event that she is not competent to consent or refuse at the future moment in question. As such, ADs provide a way for patients to make decisions in advance about what treatments they do not want to receive, without doctors having to find proxy decision-makers or having recourse to the doctrine of necessity. While patients can request particular treatments in an AD, only refusals are binding. This paper will examine whether ADs safeguard the autonomy and best interests of the incompetent patient, and whether legislating for the use of ADs is justified, using the specific context of the legal situation in the United Kingdom to illustrate the debate. The issue of whether the law should permit ADs is itself dependent on the issue of whether ADs are ethically justified; thus we must answer a normative question in order to answer the legislative one. It emerges that ADs suffer from two major problems, one related to autonomy and one to consent. First, ADs’ emphasis on precedent autonomy effectively sentences some people who want to live to death. Second, many ADs might not meet the standard criteria for informed refusal of treatment, because they fail on the crucial criterion of sufficient information. Ultimately, it transpires that ADs are typically only appropriate for patients who temporarily lose physical or mental capacity

In the last year there has been a great deal of public debate about homeopathy. The House of Commons Select Committee on Science and Technology concluded in November that there is no evidence base for homeopathy, and agreed with some academic commentators that homeopathy should not be funded by the NHS.i ii While homeopathic doctors and hospitals are quite commonplace, some might be surprised to learn that there are also many homeopathic dentists practicing in the UK. This paper examines some of the claims made by homeopathic organisations regarding dentistry, and suggests that they may not be entirely ethical.

Kihlbom has recently argued that a system of seeking negatively informed consent might be preferable in some cases to the ubiquitous informed consent model. Although this theory is perhaps not powerful enough to supplant informed consent in most settings, it lends strength to Evans’ and Hungin’s proposal that it can be ethical to prescribe placebos rather than "active" drugs. This paper presents an argument for using negatively informed consent for the specific purpose of authorising the use of placebos in clinical contexts.

The annual UK potential donor audit captures families’ reasons for not consenting to donation of their deceased family members’ organs . Given that many families’ refusals and vetoes are based on false beliefs, cognitive bias and misunderstanding, it is incumbent upon doctors, nurses and transplant coordinators to invest sufficient time to facilitate informed consent or authorization. While such families are distressed, organ donation rates could be substantially improved if they were made aware of any mistaken beliefs, using recently suggested criteria for the ethical use of persuasion . This article examines some of the reasons for refusal of donation and suggests ways to help families make better decisions. It emerges that the use of persuasion is ethically essential in order to prevent families making decisions that they may come to regret.

Homeopathic medicine is based on the two principles that “like cures like” and that the potency of substances increases in proportion to their dilution. In November 2009 the UK Parliament’s Science and Technology Committee heard evidence on homeopathy, with several witnesses arguing that homeopathic practice is “unethical, unreliable, and pointless”. Although this increasing scepticism about the merits of homeopathy is to be welcomed, the unethical effects of funding homeopathy on the NHS are even further-reaching than has been acknowledged.

Despite the heavy emphasis on consent in the ethical code of the General Dental Council (GDC), it is often overlooked that communication difficulties between patient and dentist can cause problems in maintaining genuine consent during interventions. Inconsistencies in the GDC's Standards for dental professionals and Principles of patient consent guidelines are examined in this article, and it is concluded that more emphasis must be placed on continuous consent as an ongoing process essential to maintaining patients' dignity in dentistry.

Cryonic suspension is a relatively new technology that offers those who can afford it the chance to be 'frozen' for future revival when they reach the ends of their lives. This paper will examine the ethical status of this technology and whether its use can be justified. Among the arguments against using this technology are: it is 'against nature', and would change the very concept of death; no friends or family of the 'freezee' will be left alive when he is revived; the considerable expense involved for the freezee and the future society that will revive him; the environmental cost of maintaining suspension; those who wish to use cryonics might not live life to the full because they would economize in order to afford suspension; and cryonics could lead to premature euthanasia in order to maximize chances of success. Furthermore, science might not advance enough to ever permit revival, and reanimation might not take place due to socio-political or catastrophic reasons. Arguments advanced by proponents of cryonics include: the potential benefit to society; the ability to cheat death for at least a few more years; the prospect of immortality if revival is successful; and all the associated benefits that delaying or avoiding dying would bring. It emerges that it might be imprudent not to use the technology, given the relatively minor expense involved and the potential payoff. An adapted and more persuasive version of Pascal's Wager is presented and offered as a conclusive argument in favour of utilizing cryonic suspension.

The publish-or-perish paradigm is a prevailing facet of science. We apply game theory to show that, under rather weak assumptions, this publication scenario takes the form of a prisoner’s dilemma, which constitutes a substantial obstacle to beneficial delayed publication of more complete results. One way of avoiding this obstacle while allowing researchers to establish priority of discoveries would be an updated “pli cacheté”, a sealed envelope concept from the 1700s. We describe institutional rules that could additionally favour high-quality work and publications and provide examples of such policies that are already in place. Our analysis should be extended to other publication scenarios and the role of other stakeholders such as scientific journals or sponsors.

Over the last decade, several European countries and the Council of Europe itself have strongly supported the use of advance directives as a means of protecting patients’ autonomy, and adopted specific norms to regulate this matter. However, it remains unclear under which conditions those regulations should apply to people who are placed in correctional settings. The issue is becoming more significant due to the increasing numbers of inmates of old age or at risk of suffering from mental disorders, all of whom might benefit from using advance directives. At the same time, the closed nature of prisons and the disparate power relationships that characterise them mean that great caution must be exercised to prevent care being withdrawn or withheld from inmates who actually want to receive it. This paper explores the issue of prisoners’ advance directives in the European context, starting with the position enshrined in international and European law that prisoners retain all their human rights, except the right to liberty, and are therefore entitled to self-determination regarding health care decisions.

It is widely accepted in clinical ethics that removing a patient from a ventilator at the patient’s request is ethically permissible. This constitutes voluntary passive euthanasia. However, voluntary active euthanasia, such as giving a patient a lethal overdose with the intention of ending that patient’s life, is ethically proscribed, as is assisted suicide, such as providing a patient with lethal pills or a lethal infusion. Proponents of voluntary active euthanasia and assisted suicide have argued that the distinction between killing and letting die is flawed and that there is no real difference between actively ending someone’s life and "merely" allowing them to die. This paper shows that, although this view is correct, there is even less of a distinction than is commonly acknowledged in the literature. It does so by suggesting a new perspective that more accurately reflects the moral features of end-of-life situations: if a patient is mentally competent and wants to die, his body itself constitutes unwarranted life support unfairly prolonging his or her mental life.

A new Swiss law requires that any research involving humans must aim to answer "a relevant research question". This paper explains the relevance of the relevance criterion in research, analyses the Swiss and British guidelines on relevance, and proposes a framework for researchers and REC members that enables a clearer conception of the role of relevance in research. We conclude that research must be either scientifically or societally beneficial in order to qualify as relevant, and RECs therefore cannot avoid reviewing the scientific aspects of proposed studies. Normally only scientifically relevant studies can be of benefit to society, but research of low scientific relevance can nonetheless be relevant to society if it forms part of the education of new doctors and scientists.

Doctors at four German hospitals have been suspended from their posts following internal investigations which alleged that they had been manipulating the organ transplant allocation system in order to help their patients get donor livers more quickly. It is alleged that doctors exaggerated the severity of their patients’ conditions so that they would be accorded higher priority for receiving organs, but there may also have been manipulation of medical records, deception of patients and potential harm to patients both within Germany and across the EU. There has been significant public reaction to these events. The reported events require analysis as there may be several lessons for the UK context; doing so requires analyzing the alleged events in terms of the issues raised in a hypothetical manner.

It is clearly unethical for the NHS to tell people that they will die sooner unless they pay for private treatment, and then to tell them that if they pay for private treatment they will have to pay the NHS for its insufficient service. This is all the more true if people in other parts of the country are receiving all the drugs they need for the same condition on the NHS. Patients who discover that the NHS care that they have paid for will not keep them alive should be able to supplement their care privately if they can afford it, without the added burden and insult of being told their independently inadequate NHS care will cease unless they pay for it too. Mired in self-contradiction as it is, the NHS’ "anti-two-tier" policy must change.

The Ebola epidemic in Western Africa has highlighted issues related to weak health systems, the politics of drug and vaccine development and the need for transparent and ethical criteria for use of scarce local and global resources during public health emergency. In this paper we explore two key themes. First, we argue that independent of any use of experimental drugs or vaccine interventions, simultaneous implementation of proven public health principles, community engagement and culturally sensitive communication are critical as these measures represent the most cost-effective and fair utilization of available resources. Second, we attempt to clarify the ethical issues related to use of scarce experimental drugs or vaccines and explore in detail the most critical ethical question related to Ebola drug or vaccine distribution in the current outbreak: who among those infected or at risk should be prioritized to receive any new experimental drugs or vaccines? We conclude that healthcare workers should be prioritised for these experimental interventions, for a variety of reasons

Cryoethics is a new theme within bioethics (see bioethics) concerned with the ethics of cryonic storage. Cryonics, which is also erroneously referred to as “cryogenic” technology, offers people the option of having their bodies or brain-stems preserved at very low temperatures after death in order to be revived at some point in the future when technology is sufficiently advanced to enable reanimation, and possibly immortality. The main issues in cryoethics center around whether it is ethical to use this technology, and whether it is prudent to do so. While there are several prudential and ethical arguments against cryonic storage, there is only one argument in favor, but it is quite powerful: the possibility of cheating death for a few years, or even forever if technology advances enough in the time before revival (Shaw 2009).