Alberto Giubilini

The treatment-enhancement distinction is often used to delineate acceptable and unacceptable medical interventions. It is likely that future assistive and augmenting technologies will also soon develop to a level that they might be considered to provide users, in particular those with disabilities, with abilities that go beyond natural human limits, and become in effect an enhancing technology. In this paper, we describe how this process might take place, and discuss the moral implications of such developments. We argue that such developments are morally acceptable and indeed desirable.

We discuss the relationship between expertise, expert authority, and trust in the case of vaccine research and policy, with a particular focus on COVID-19 vaccines. We argue that expert authority is not merely an epistemic notion, but entails being trusted by the relevant public and is valuable if it is accompanied by expert trustworthiness. Trustworthiness requires, among other things, being transparent, acknowledging uncertainty and expert disagreement (e.g., around vaccines’ effectiveness and safety), being willing to revise views in response to new evidence, and being clear about the values that underpin expert recommendations. We explore how failure to acknowledge expert disagreement and uncertainty can undermine trust in vaccination and public health experts, using expert recommendations around COVID-19 vaccines as a case study.

To the extent that antibiotic resistance (ABR) is accelerated by antibiotic consumption and that it represents a serious public health emergency, it is imperative to drastically reduce antibiotic consumption, particularly in high‐income countries. I present the problem of ABR as an instance of the collective action problem known as ‘tragedy of the commons’. I propose that there is a strong ethical justification for taxing certain uses of antibiotics, namely when antibiotics are required to treat minor and self‐limiting infections, such as respiratory tract infections, in otherwise healthy individuals. Taxation would allow a reduction in consumption (given certain behavioural economics assumptions) and/or ensure that individuals internalize or compensate for their contribution to the erosion of the common good of antibiotic effectiveness. I suggest that revenue from the tax could be used to fund conservation and innovation strategies. Taxation might be a coercive policy, especially for certain individuals, but the ethical case for coercive policies is very strong when the good to be preserved is important enough and when they force individuals to do something they have a moral obligation to do anyway. I argue that, in the case of mild and self‐limiting infections, individuals have a moral duty of easy rescue and a moral duty of fairness to make their contribution to the preservation of the common good of antibiotic effectiveness by foregoing antibiotics. I also suggest that taxing antibiotics in such cases is an all things considered ethically justified policy even if it would introduce inequalities in access to healthcare.

We provide ethical criteria to establish when vaccine mandates for healthcare workers are ethically justifiable. The relevant criteria are the utility of the vaccine for healthcare workers, the utility for patients (both in terms of prevention of transmission of infection and reduction in staff shortage), and the existence of less restrictive alternatives that can achieve comparable benefits. Healthcare workers have professional obligations to promote the interests of patients that entail exposure to greater risks or infringement of autonomy than ordinary members of the public. Thus, we argue that when vaccine mandates are justified on the basis of these criteria, they are not unfairly discriminatory and the level of coercion they involve is ethically acceptable—and indeed comparable to that already accepted in healthcare employment contracts. Such mandates might be justified even when general population mandates are not. Our conclusion is that, given current evidence, those ethical criteria justify mandates for influenza vaccination, but not COVID-19 vaccination, for healthcare workers. We extend our arguments to other vaccines.

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage or at the development stage. The Catholic Church’s position is that, if there are alternatives, Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies.

Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This ‘conditional’ policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers’ established professional, legal and ethical obligations to their patients and to society at large.

Cameron et al ’s1 ethical considerations about the ‘Dualism of Values’ in pandemic response emphasise the need to strike a fair balance between the interests of the less vulnerable to COVID-19 and the interests of the more vulnerable. Those considerations are at the basis of ethical defences of focused protection strategies.2 One example is the proposal put forward in the Great Barrington Declaration. It presented focused protection strategies as more ethical alternatives to lockdowns which would prevent lockdowns’ ‘irreparable damage, with the underprivileged disproportionately harmed’.3 Here we want to suggest that a version of Cameron et al ’s analysis can be applied to the case of vaccines to support a focused protection vaccination strategy. At this stage, we should limit vaccination to the vulnerable and not target children in COVID-19 vaccination strategies. We argue that, given the current state of knowledge about COVID-19, immunity and vaccines, it would be wrong to pose the costs and risks of vaccines on children for three reasons. First, they are unlikely to benefit from COVID-19 vaccination …

Antimicrobial resistance is one of the greatest public health crises of our time. The natural biological process that causes microbes to become resistant to antimicrobial drugs presents a complex social challenge requiring more effective and sustainable management of the global antimicrobial commons—the common pool of effective antimicrobials. This special issue of Health Care Analysis explores the potential of two legal approaches—one long-term and one short-term—for managing the antimicrobial commons. The first article explores the lessons for antimicrobial resistance that can be learned from recent climate change agreements, and the second article explores how existing international laws can be adapted to better support global action in the short-term.

An international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change—both are common pool resource challenges that require massive, long-term political commitments—the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current governance structures for AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support.

This paper presents a normative analysis of restrictive measures in response to a pandemic emergency. It applies to the context presented by the Corona virus disease 2019 global outbreak of 2019, as well as to future pandemics. First, a Millian-liberal argument justifies lockdown measures in order to protect liberty under pandemic conditions, consistent with commonly accepted principles of public health ethics. Second, a wider argument contextualizes specific issues that attend acting on the justified lockdown for western liberal democratic states, as modeled on discourse and accounted for by Jürgen Habermas. The authors argue that a range of norms are constructed in societies that, justifiably, need to be curtailed for the pandemic. The state has to take on the unusual role of sole guardian of norms under emergency pandemic conditions. Consistently with both the Millian-liberal justification and elements of Habermasian discourse ethics, they argue that that role can only be justified where it includes strategy for how to return political decisionmaking to the status quo ante. This is because emergency conditions are only justified as a means to protecting prepandemic norms. To this end, the authors propose that an emergency power committee is necessary to guarantee that state action during pandemic is aimed at re-establishing the conditions of legitimacy of government action that ecological factors have temporarily curtailed.

We thank the authors of the five commentaries for their careful and highly constructive consideration of our paper,1 which has enabled us to develop our proposal. Participation in research has traditionally been viewed as altruistic. Over time, payments for inconvenience and lost wages have been allowed, as have small incentives, usually in kind. The problem, particularly with controlled human infection model research or ‘challenge studies’, is that they are unpleasant and time-consuming. Researchers want to offer carrots to incentivise participation. We are proposing that research participation be viewed as a job with the full suite of financial entitlements of fairly remunerated work, including payment for risk and labour law protections. This would be a significant shift from current practice and standards. Ambuehl, Ockenfels and Roth have grasped this basic point and have beautifully elaborated how a fair price could be arrived at using economic theory. They build on our proposal helpfully and suggest ‘ salary for time involvement that is adjusted to account for the amount of discomfort experienced during participation, insurance against ex post adverse outcomes and ex ante compensation for risks that cannot be compensated ex post.’3 This effectively addresses Fernandez Lynch and Largent’s2 concern that compensation for risk is inappropriate for harms which do not eventuate. However, because death cannot be compensated for, there must be payment for risk of death, as Ambuehl, Ockenfels and Roth convincingly argue.3 Indeed, the three-part model suggested by Ambuehl, Ockenfels and Roth makes us realise that job model would be a better title for our model than a payment for risk model. The alternative to a properly remunerated job model is the original altruistic model. However, this …

We argue that we should provide extra payment not only for extra time worked but also for the extra risks healthcare workers (and those working in healthcare settings) incur while caring for COVID‐19 patients—and more generally when caring for patients poses them at significantly higher risks than normal. We argue that the extra payment is warranted regardless of whether healthcare workers have a professional obligation to provide such risky healthcare. Payment for risk would meet four essential ethical requirements. First, assuming healthcare workers do not have a professional obligation to take on themselves the risks, payments in the form of incentives would preserve autonomy in deciding what risks to take on oneself. Second, even assuming that healthcare workers do have a professional obligation to take on themselves the risks, payments for risk would create fair working conditions by avoiding exploitation. Third, payments for risk would make it more likely that public healthcare systems can discharge their institutional responsibility to provide healthcare in circumstances where healthcare workers may otherwise (perhaps legitimately) opt out. Fourth, payments for risk would guarantee an efficient healthcare system in pandemic situations. Finally, we address two likely objections that some might raise against our proposal, particularly with regard to incentives, namely that such payments or incentives can themselves be coercive and that they represent a form of undue inducement.

Conflict of interests in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner’s financial interest conflicts with patients’ interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of “interests” cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners’ moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs.

We humans can enhance some of our mental and physical abilities above the normal upper limits for our species with the use of particular drug therapies and medical procedures. We will be able to enhance many more of our abilities in more ways in the near future. Some commentators have welcomed the prospect of wide use of human enhancement technologies, while others have viewed it with alarm, and have made clear that they find human enhancement morally objectionable. The Ethics of Human Enhancement examines whether the reactions can be supported by articulated philosophical reasoning, or perhaps explained in terms of psychological influences on moral reasoning. An international team of ethicists refresh the debate with new ideas and arguments, making connections with scientific research and with related issues in moral philosophy.

In this review article we describe the current scope, methods, and contents of medical ethics education in medical schools in Western English speaking countries (mainly the United Kingdom, the United States, and Australia). We assess the strengths and weaknesses of current medical ethics curricula, and students’ levels of satisfaction with different teaching approaches and their reported difficulties in learning medical ethics concepts and applying them in clinical practice. We identify three main challenges for medical ethics education: counteracting the bad effects of the “hidden curriculum,” teaching students how to apply ethical knowledge and critical thinking to real cases in clinical practice, and shaping future doctors’ right character through ethics education. We suggest ways in which these challenges could be addressed. On the basis of this analysis, we propose practical guidelines for designing, implementing, teaching, and assessing a medical ethics program within a four-year medical course.

Although the COVID-19 pandemic is a serious public health and economic emergency, and although effective vaccines are the best weapon we have against it, there are groups and individuals who oppose certain kinds of vaccines because of personal moral or religious reasons. The most widely discussed case has been that of certain religious groups that oppose research on COVID-19 vaccines that use cell lines linked to abortions and that object to receiving those vaccine because of their moral opposition to abortion. However, moral opposition to COVID-19 vaccine research can be based on other considerations, both secular and religious. We argue that religious or personal moral objections to vaccine research are unethical and irresponsible, and in an important sense often irrational. They are unethical because of the risk of causing serious harm to other people for no valid reason; irresponsible because they run counter to individual and collective responsibilities to contribute to important public health goals; and in the case of certain kinds of religious opposition, they might be irrational because they are internally inconsistent. All in all, our argument translates into the rather uncontroversial claim that we should prioritize people’s lives over religious freedom in vaccine research and vaccination roll out.

Antimicrobial resistance (AMR) is an urgent threat to global public health and development. Mitigating this threat requires substantial short-term action on key AMR priorities. While international legal agreements are the strongest mechanism for ensuring collaboration among countries, negotiating new international agreements can be a slow process. In the second article in this special issue, we consider whether harnessing existing international legal agreements offers an opportunity to increase collective action on AMR goals in the short-term. We highlight ten AMR priorities and several strategies for achieving these goals using existing “legal hooks” that draw on elements of international environmental, trade and health laws governing related matters that could be used as they exist or revised to include AMR. We also consider the institutional mandates of international authorities to highlight areas where additional steps could be taken on AMR without constitutional changes. Overall, we identify 37 possible mechanisms to strengthen AMR governance using the International Health Regulations, the Agreement on the Application of Sanitary and Phytosanitary Measures, the Agreement on Trade-Related Aspects of Intellectual Property Rights, the Agreement on Technical Barriers to Trade, the International Convention on the Harmonized Commodity Description and Coding System, and the Basel, Rotterdam, and Stockholm conventions. Although we identify many shorter-term opportunities for addressing AMR using existing legal hooks, none of these options are capable of comprehensively addressing all global governance challenges related to AMR, such that they should be pursued simultaneously with longer-term approaches including a dedicated international legal agreement on AMR.