Donna Dickenson

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more obviously problematic. Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky?

Guidelines on embryo storage prioritise 'respect for the embryo' above the wishes of the women whose labour and tissue have gone into creating the embryo in the first place, effectively making women and the female body disappear. In this article I draw a parallel between this phenomenon relating to embryo storage and other instances of a similar phenomenon that I have called 'the lady vanishes', particularly in stem cell and 'mitochondrial transfer' research. I suggest that a modified property regime could protect women's interests in embryo storage, making a parallel with the Yearworth case, in which it was recognised that men had limited but actionable interests in their stored sperm..

A ‘should’ question normally signals work for an ethicist but this ethicist’s task is complicated by the normative dimension of all the chapters in this volume. Each author was asked to come up with three recommendations from their own subject area – ’should’ statements deriving from the ‘is’ analysis that they present. If those prescriptions cover the relevant topics, what more is there for an ethicist to do? I have had a personal interest in obstetricians’ relationship with ‘older women’ since being classified as an ‘elderly primigravida’ at the superannuated age of 26 years. Apart from that, however, what original contribution can I make? The convenors of the 56th RCOG Study Group gave me plentiful suggestions – perhaps a little too plentiful: How should the RCOG approach its constituencies, medical ethics, regulation and its relationship to government and the rest of the medical profession, i.e. the NHS and the market, vested interests, individuals or consumers, families, the unborn, doctors, drug companies, surrogacy, the unborn, trafficking, global adoption, law, research? I have to admit this was just too much for me. Instead, I want to argue for what may seem a self-evidently simple point. The RCOG describes its mission as ‘setting standards to improve women’s health’ – presumably all women. In the 6 years that I have served on the RCOG Ethics Committee, however, we have almost always been concerned with that minority of the female population who are of reproductive age.

Whilst India has been debating how to regulate 'surrogacy' the UK has undergone a major consultation on increasing the amount of 'expenses'paid to egg 'donors', while France has recently finished debating its entire package of bioethics regulation and the role of its Biomedicine Agency. Although it is often claimed that there is no alternative to the neo-liberal, market-based approach in regulating (or not) reproductive medicine--the ideology prevalent in both India and the UK--advocates of that position ignore the alternative model offered by France's tighter regulation, as well as its overarching concern with protecting the vulnerable and ensuring social justice. Whilst the concepts underpinning the French model of regulation also have their provenance in Western political philosophy and not in the developed world, they embody a very different attitude and suggest that there is indeed an alternative to letting the market decide. However, even in France that alternative is highly contested.

The results of a recent survey of Nigerian women might give pause to opponents of female genital mutilation (FGM). One could well argue that if these Nigerian women themselves favour FGM, then it is ironically paternalistic to oppose it. Should Western feminists actually support FGM if it is what women in the South want? I argue in this commentary that such an argument rests on shaky statistical, psychological, medical, political and philosophical grounds. We should go on opposing female genital mutilation with all our power.

How can intellectuals who oppose the illegitimate war in Iraq come to similar terms with the U.S. neoconservatives, and their unrepentant British collaborators, who have stranded us in it? In the Tempest, Shakespeare’s most political play, comedy though it is meant to be, intellectuals are warned not to consider themselves guiltless. But how can those who marched against the war, or who tried to speak truth to power in other ways, be guilty of its misuses? Surely this is too harsh a view of the role of the public intellectual. What choice did Prospero really have? He was exiled, hapless, stranded. What choice do intellectuals who are against the war have? We, too, are powerless. Aren’t we?

There has been a troublesome anomaly in the UK between cash payment to men for sperm donation and the effective assumption that women will pay to donate eggs. Some commentators, including Donald Evans in this journal, have argued that the anomaly should be resolved by treating women on the same terms as men. But this argument ignores important difficulties about property in the body, particularly in relation to gametes. There are good reasons for thinking that the contract model and payment for gametes are both inappropriate, and that a model based on altruism should be applied to both sexes.

In this article we explore the underpinnings of what we view as a recent "backlash" in English law, a judicial reaction against considering children's and young people's expressions of their own feelings about treatment as their "true" wishes. We use this case law as a springboard to conceptual discussion, rooted in (a) empirical psychological work on child development and (b) three key philosophical ideas: rationality, autonomy and identity. Using these three concepts, we explore different understandings of our central theme, true wishes. These different conceptual interpretations, we argue, help to elucidate important clinical questions in the area of children's informed consent to treatment. For example, how much should a child's own wishes count in making medical decisions? Does it make a difference if the child or young person is undergoing psychiatric treatment?—if in some sense her wishes are abnormal, not "true" expressions of what she really wants? If the child's wishes do not count, why not? If they do matter but count for less, how much less? We conclude by advocating functional tests of a young person's true wishes, applicable on a case-by-case basis, rather than a black-and-white distinction between "incompetent" children and "competent" adults.

What should we do about children and young people who want to be tested for incurable, adult onset, genetic disorders? In particular, what should a general practitioner do if he or she believes the young person is competent to decide, but the regional genetics unit refuses to test anyone under 18? In this article I discuss such a case (drawn from actual practice, but anonymised), and consider the arguments for and against allowing the young person to be tested in terms of good practice, case and statute law, empirical evidence, and ethics.

It is well known that there is a shortage of human ova for in vitro fertilization (IVF) purposes, but little attention has been paid to the way in which the demand for ova in stem-cell technologies is likely to exacerbate that shortfall and create a trade in human eggs. Because the 'Dolly' technology relies on enucleated ova in large quantities, allowing for considerable wastage, there is a serious threat that commercial and research demands for human eggs will grow exponentially from the combination of these two pressures. In the absence of legal regulation in the United Kingdom, and in the context of a globalized trade in human organs, we face a 'Wild West' situation in genetic and biotechnological research that involves human ova.

Should we do whatever science lets us do? This short introduction in the 'All That Matters' series shows how developments in biotechnology, such as genetics, stem cell research and artificial reproduction, arouse both our greatest hopes and our greatest fears. Many people invest the new biotechnology with all the aspirations and faith once accorded to religious salvation. But does everyone benefit equally from scientific progress? This book argues that although we've entered new scientific territory, there is no need to jettison our existing moral sense. By discussing a range of real-life cases, it equips readers to make up their own minds on these important questions. Good science and good ethics needn't be contradictory.