Brian D. Earp

Obtaining informed consent in paediatrics is an essential yet ethically complex aspect of clinical practice. Children have varying levels of autonomy and understanding based on their age and developmental maturity, with parents traditionally playing a central role in decision-making. However, there is increasing recognition of children’s evolving capacities and their right to be involved in care decisions, raising questions about facilitating meaningful consent, or at least assent, in complex medical situations. Large language models (LLMs) may offer a partial solution to these challenges. These generative artificial intelligence (AI) systems can provide interactive, age-appropriate explanations of medical procedures, risks and outcomes tailored to each child’s comprehension level. LLMs could be designed to adapt their responses to young patients’ cognitive and emotional needs while supporting parents with clear, accessible medical information. This paper examines the ethical implications of using LLMs in paediatric consent, focusing on balancing autonomy promotion with protecting children’s best interests. We explore how LLMs could be used to empower children to express preferences, mediate family disputes and facilitate informed consent. However, important concerns arise: Can LLMs adequately support developing autonomy? Might they exert undue influence or worsen conflicts between family members and healthcare providers? We conclude that while LLMs could enhance paediatric consent processes with appropriate safeguards and careful integration into clinical practice, their implementation must be approached cautiously. These systems should complement rather than replace the essential human elements of empathy, judgement and trust in paediatric consent.

The development of brain organoids and use of human embryonic neural structures for research each raise distinct ethical considerations that require careful analysis. We propose that rather than attempting to resolve longstanding debates about embryonic moral status, a more productive approach is to examine how different positions on this fundamental question lead to distinct conclusions about appropriate research strategies. For those who ground moral status in species membership or developmental potential, even early-stage embryo research may be ethically impermissible, suggesting focus on carefully bounded organoid development. Conversely, for those who ground moral status in current capacities, embryonic neural tissue studied before the emergence of consciousness may offer significant advantages over organoids while raising fewer novel ethical concerns. Our analysis reveals inadequacies in current policies, particularly the 14-day rule, which appears difficult to justify under either ethical framework. We demonstrate how careful attention to the relationship between ethical premises and research implications can advance both scientific progress and ethical oversight, while suggesting specific policy reforms including capacity-based research guidelines and sophisticated monitoring protocols.

Traditional female genital practices, though long-standing in many cultures, have become the focus of an expansive global campaign against ‘female genital mutilation’ (FGM). In this article, we critically examine the harms produced by the anti-FGM discourse and policies, despite their grounding in human rights and health advocacy. We argue that a ubiquitous ‘standard tale’ obscures the diversity of practices, meanings and experiences among those affected. This discourse, driven by a heavily racialised and ethnocentric framework, has led to unintended but serious consequences: the erosion of trust in healthcare settings, the silencing of dissenting or nuanced community voices, racial profiling and disproportionate legal surveillance of migrant families. Moreover, we highlight a troubling double standard that legitimises comparable genital surgeries in Western contexts while condemning similar procedures in others. We call for more balanced and evidence-based journalism, policy and public discourse—ones that account for cultural complexity and avoid the reductive and stigmatising force of the term ‘mutilation’. A re-evaluation of advocacy strategies is needed to ensure that they do not reproduce the very injustices they aim to challenge.

In this paper, we examine the potential effects of relationships with Large Language Model (LLM)‐based digital doppelgängers (DDs) on users' values, concerns, and interests, that is, on their practical identity. DDs are artificially intelligent conversational agents trained on individuals' data to replicate their speech patterns, mannerisms, and personality traits. We start by showing that practical identity is largely defined by the relationships we find ourselves in or cultivate. Next, we discuss how DDs work and distinguish between task‐specific and relational DDs, arguing that the latter are specifically created to take on the role of relational partners by imitating other people we care about. We then consider how relationships with DDs might shape individuals' practical identities, before concluding with some general thoughts regarding what we should be paying attention to before developing and deploying DDs.

Institutional review boards (IRBs) play a crucial role in ensuring the ethical conduct of human subjects research, but face challenges including inconsistency, delays, and inefficiencies. We propose the development and implementation of application-specific large language models (LLMs) to facilitate IRB review processes. These IRB-specific LLMs would be fine-tuned on IRB-specific literature and institutional datasets, and equipped with retrieval capabilities to access up-to-date, context-relevant information. We outline potential applications, including pre-review screening, preliminary analysis, consistency checking, and decision support. While addressing concerns about accuracy, context sensitivity, and human oversight, we acknowledge remaining challenges such as over-reliance on artificial intelligence and the need for transparency. By enhancing the efficiency and quality of ethical review while maintaining human judgement in critical decisions, IRB-specific LLMs offer a promising tool to improve research oversight. We call for pilot studies to evaluate the feasibility and impact of this approach.

Aim To examine the challenges and opportunities presented by generative artificial intelligence in healthcare education and explore how it can be used ethically to enhance rather than compromise future healthcare workforce competence. Background Generative artificial intelligence is fundamentally changing healthcare education, yet many universities and healthcare educators have failed to keep pace with its rapid development. Design A discussion paper. Methods Discussion and analysis of the challenges and opportunities presented by students' increasing use of generative artificial intelligence in healthcare education, with particular focus on assessment approaches, critical thinking development and artificial intelligence literacy. Results Students' widespread use of generative artificial intelligence threatens assessment integrity and may inhibit critical thinking, problem-solving skills and knowledge acquisition. Without adequate artificial intelligence literacy there is a risk of eroding future healthcare workforce competence and compromising patient safety and professional integrity. Conclusion While generative artificial intelligence presents significant challenges to healthcare education, it offers great promise if used carefully with awareness of its limitations. The development of artificial intelligence literacy is crucial for maintaining professional standards and ensuring patient safety and mitigating its potentially negative impact on the formation of critical thinking skills.

In a recent paper,1 we proposed a Personalised Patient Preference Predictor (P4), building on earlier work by Rid and Wendler.2 The P4 is a hypothetical computer program that would, in the context of surrogate decision-making (eg, following a substituted judgement standard), use generative artificial intelligence (AI) models to infer a patient’s underlying values and preferences and, on that basis, predict which treatment option they would choose in the current situation. Such AI models, we suggested, could be ‘fine-tuned’ on various pre-existing data or materials produced by, or otherwise pertaining to (eg, including information about), the patient considered as a unique individual.1 3 Annoni has offered a thoughtful critique of this proposal, challenging what he (implicitly) characterises as assumptions underlying our work.4 In his critique, in addition to advancing the negative claim that the P4 would not, as we had suggested,1 allow surrogate decision-makers to more effectively show respect for formerly competent patients, Annoni makes the positive claim that the P4 could help surrogates better honour the patient’s unique identity. We appreciate Annoni’s contribution to this important ethical conversation and welcome the opportunity to clarify our position. We agree with Annoni that the P4 serves ethical purposes beyond showing respect for autonomy, and that this may include honouring their identity.5 We also agree, contrary to what Annoni implies about our position, that respect for autonomy is not simply reducible to mere preference satisfaction. However, we do not agree with Annoni’s claim that the P4 does not, or could not, promote the value of autonomy at all. We argue that Annoni’s view of respect for autonomy is too narrow, insofar as it seems to require occurrent explicit consent, which is impossible for incapacitated patients. We advocate for a spectrum approach to autonomy: When direct choice or …

In this paper, we suggest that personalized LLMs trained on information written by or otherwise pertaining to an individual could serve as artificial moral advisors (AMAs) that account for the dynamic nature of personal morality. These LLM-based AMAs would harness users’ past and present data to infer and make explicit their sometimes-shifting values and preferences, thereby fostering self-knowledge. Further, these systems may also assist in processes of self-creation, by helping users reflect on the kind of person they want to be and the actions and goals necessary for so becoming. The feasibility of LLMs providing such personalized moral insights remains uncertain pending further technical development. Nevertheless, we argue that this approach addresses limitations in existing AMA proposals reliant on either predetermined values or introspective self-knowledge.

There is an ongoing debate about the ethics of research on lifespan extension: roughly, using medical technologies to extend biological human lives beyond the current “natural” limit of about 120 years. At the same time, there is an exploding interest in the use of artificial intelligence (AI) to create “digital twins” of persons, for example by fine-tuning large language models on data specific to particular individuals. In this paper, we consider whether digital twins (or digital doppelgängers, as we refer to them) could be a path toward a kind of life extension—or more precisely, a kind of person extension—that does not rely on biological continuity. We discuss relevant accounts of consciousness and personal identity and argue that digital doppelgängers may at least help us achieve some of the aims or ostensible goods of person-span extension, even if they may not count as literal extensions of our personhood on dominant philosophical accounts. We also consider relational accounts of personhood and discuss how digital doppelgängers may be able to extend personhood in a relational sense, or at least secure some of the goods associated with relevant relationships. We conclude by suggesting that a research program to investigate such issues is relevant to ongoing debates about the ethics of extending the human lifespan.

Participation in research is supposed to be voluntary and informed. Yet it is difficult to ensure people are adequately informed about the potential uses of their biological materials when they donate samples for future research. We propose a novel consent framework which we call “demonstrated consent” that leverages blockchain technology and generative AI to address this problem. In a demonstrated consent model, each donated sample is associated with a unique non-fungible token (NFT) on a blockchain, which records in its metadata information about the planned and past uses of the sample in research, and is updated with each use of the sample. This information is accessible to a large language model (LLM) customized to present this information in an understandable and interactive manner. Thus, our model uses blockchain and generative AI technologies to track, make available, and explain information regarding planned and past uses of donated samples.

The pursuit of artificial consciousness requires conceptual clarity to navigate its theoretical and empirical challenges. This paper introduces a composite, multilevel, and multidimensional model of consciousness as a heuristic framework to guide research in this field. Consciousness is treated as a complex phenomenon, with distinct constituents and dimensions that can be operationalized for study and for evaluating their replication. We argue that this model provides a balanced approach to artificial consciousness research by avoiding binary thinking (e.g., conscious vs. non-conscious) and offering a structured basis for testable hypotheses. To illustrate its utility, we focus on "awareness" as a case study, demonstrating how specific dimensions of consciousness can be pragmatically analyzed and targeted for potential artificial instantiation. By breaking down the conceptual intricacies of consciousness and aligning them with practical research goals, this paper lays the groundwork for a robust strategy to advance the scientific and technical understanding of artificial consciousness.

The opening lines of the first issue of the Journal of Medical Ethics —an unsigned April 1975 editoriali—capture the uselessness of editorial policy statements: > The reputation of a newly founded journal must be established by the style, quality and range of the material it offers. Perhaps then editorial policy statements achieve very little, for, either the reader can appreciate the usefulness of the journal’s contents without editorial encouragement, or he discovers for himself their irrelevance to his interests.1 As incoming editors, succeeding John McMillan who ably led the journal for more than half a decade, we appreciate this insight. Whatever we might say about our plans for the journal as it hurtles past its 50th birthday, the proof of the pudding will be in the tasting—or the reading—not in editorial promises. Nevertheless, we will say a few words about our mindset and aspirations as we jointly assume the editor-in-chief role of this venerable journal. First, something ‘old.’ We are as committed as ever to the founding promise of the journal to ‘provide a forum for the reasoned discussion of moral issues arising from the provision of medical care’ (emphasis ours) while—just as crucially—holding ‘no brief for one particular professional, political or religious viewpoint.’1 In other words, we will not be favouring articles that are politically convenient—for any one side of a morally charged debate—and nor will we allow prejudice for, or against, positions associated with certain professional or religious (or for that matter, non-religious) viewpoints to sway our decisions about what to publish. We are, instead, concerned first and foremost with the strength of the reasons, argument and evidence marshalled in favour of a given view, based on premises that can be reasonably shared (or at least seriously entertained) among a wide set of interlocutors.2 …

Medical ethics is not known for being a fast-paced discipline; many of the principles we draw on are 2000 years old. And yet, during John McMillan’s 7 -year tenure as editor of the Journal of Medical Ethics ( JME ), the journal has changed a great deal and has in turn changed the discipline. The issues discussed and the ethical concepts in play have broadened while the purpose itself has been refined to publish excellent medical ethics articles that are both philosophically sound and of practical use to clinicians, patients and policy makers. Under his leadership, the journal remained committed to the idea that bioethics is not merely an academic exercise but a normative enterprise—concerned, at its core, with how we ought to respond to the ethical challenges that arise in medicine, science and public life. John’s vision of good bioethics is rooted in a belief that philosophical clarity and real-world relevance should not be seen as competing aims but as mutually reinforcing. As he argued in a 2018 editorial, good medical ethics is defined not just by its analytic sharpness or theoretical sophistication but by how well it is framed, how transparent it is about its normative commitments and how seriously it takes engagement with diverse perspectives.1 For John, good medical ethics needs to be open to input from law, social science and clinical experience but without losing sight of the responsibility to make reasoned ethical judgments. Good medical ethics needs to take a normative stand. In this spirit, John has encouraged work that grapples with moral complexity without retreating into abstraction and that draws on a wide range of disciplinary tools while maintaining a clear normative focus. He has also been attentive to how bioethical arguments are presented—not only in terms of structure and clarity but also in terms of …

The integration of artificial intelligence (AI), particularly large language models (LLMs) like OpenAI’s ChatGPT, into clinical research could significantly enhance the informed consent process. This paper critically examines the ethical implications of employing LLMs to facilitate consent in clinical research. LLMs could offer considerable benefits, such as improving participant understanding and engagement, broadening participants’ access to the relevant information for informed consent and increasing the efficiency of consent procedures. However, these theoretical advantages are accompanied by ethical risks, including the potential for misinformation, coercion and challenges in accountability. Given the complex nature of consent in clinical research, which involves both written documentation (in the form of participant information sheets and informed consent forms) and in-person conversations with a researcher, the use of LLMs raises significant concerns about the adequacy of existing regulatory frameworks. Institutional Review Boards (IRBs) will need to consider substantial reforms to accommodate the integration of LLM-based consent processes. We explore five potential models for LLM implementation, ranging from supplementary roles to complete replacements of current consent processes, and offer recommendations for researchers and IRBs to navigate the ethical landscape. Thus, we aim to provide practical recommendations to facilitate the ethical introduction of LLM-based consent in research settings by considering factors such as participant understanding, information accuracy, human oversight and types of LLM applications in clinical research consent.

Children are treated differently to adults in liberal societies with respect to their right to bodily integrity. A commonly given justification for treating them differently is that they supposedly lack the sort of autonomy that is normally attributed to neurotypical adults. As such children fall through the cracks when it comes to protecting their bodily integrity: they are viewed as less than fully autonomous persons in philosophical, medical, and legal settings. With this editorial, we analyse current treatments of the concept of the child's right to bodily integrity and how this relates to their (developing or future) autonomy on various conceptions.

The American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and other largely US-based medical organizations have argued that at least some forms of non-therapeutic child genital cutting, including routine penile circumcision, are ethically permissible even when performed on non-consenting minors. In support of this view, these organizations have at times appealed to potential health benefits that may follow from removing sexually sensitive, non-diseased tissue from the genitals of such minors. We argue that these appeals to “health benefits” as a way of justifying medically unnecessary child genital cutting practices may have unintended consequences. For example, it may create a “loophole” through which certain forms of female genital cutting—or female genital “mutilation” as it is defined by the World Health Organization—could potentially be legitimized. Moreover, by comparing current dominant Western attitudes toward female genital “mutilation” and so-called intersex genital “normalization” surgeries (i.e. surgeries on children with certain differences of sex development), we show that the concept of health invoked in each case is inconsistent and culturally biased. It is time for Western healthcare organizations—including the American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and World Health Organization—to adopt a more consistent concept of health and a unified ethical stance when it comes to child genital cutting practices.

Background Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity (“T1 preference”) should trump a contrary preference expressed after significant cognitive decline (“T2 preference”). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants’ judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one’s future self) versus third-person (deciding for a friend or stranger) perspective. Methods A vignette-based survey was conducted (N = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design. Results Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their “true selves,” which correlated with increased deference to their T2 preferences. Conclusions These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decision-maker’s true self.

Jennifer Hawkins (2024) offers two cases that challenge traditional accounts of decision-making capacity, according to which respect for a medical decision turns on an individual’s cognitive capacities at the time the decision is made (Hawkins 2024; Appelbaum and Grisso 1988). In each of her described cases (involving anorexia nervosa and grief, respectively), a patient makes a decision that—although instrumentally rational at the time—does not reflect the patient’s longer-term values due to being in a particular psychological state. Importantly, this state does not impair the patient’s cognition, but rather predisposes them to make a decision that conflicts with their own broader values, beliefs, or desires.

Sacrificial dilemmas such as the trolley problem play an important role in experimental philosophy (x-phi). But it is increasingly argued that, since we are not likely to encounter runaway trolleys in our daily life, the usefulness of such thought experiments for understanding moral judgments in more ecologically valid contexts may be limited. However, similar sacrificial dilemmas are experienced in real life by animal research decision makers. As part of their job, they must make decisions about the suffering, and often the death, of many non-human animals. For this reason, a context-specific investigation of so-called “3R dilemmas” (i.e., dilemmas where there is a conflict between the principles of replacement, reduction, and refinement of the use of animals in research) is essential to improve the situation of both non-human animals and human stakeholders. An approach well suited for such investigation is experimental philosophical bioethics (“bioxphi”), which draws on methods similar to x-phi to probe more realistic, practical scenarios with an eye to informing normative debates and ethical policy. In this article, we argue for a need to investigate 3R dilemmas among professional decision-makers using the tools of bioxphi. In a first step, we define 3R dilemmas and discuss previous investigations of professionals’ attitudes in such cases. In a second step, we show how bioxphi is a promising method to investigate the whys and hows of professional decision-making in 3R dilemmas. In a last step, we provide a bioxphi template for 3R dilemmas, give recommendations on its use, explore the normative relevance of data collected by such means, and discuss important limitations.

In the present chapter, we seek to better understand how lay people reason about the “true self” of a person with advancing dementia. We are also interested in how such reasoning bears on laypeople’s views about the validity or invalidity of an advance directive (AD) regarding that person’s treatment. Toward that end, we will report the results of two empirical studies we undertook to gain insights into this relationship: namely, between judgments about the true self and whether to follow an AD. We find that many participants judge that a hypothetical person with dementia, stipulated to be non-autonomous with respect to her healthcare decision-making, is nevertheless still her “true self” and that her current apparent preference (to be treated) should be honored despite conflicting with the autonomous preference (not to be treated) previously recorded in her AD. We discuss potential normative implications of our findings, drawing on arguments from the emerging literature on experimental philosophical bioethics, also known experimental bioethics or “bioxphi.”

Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamental part of safe and ethical clinical practice. Currently, it is routine for a significant part of the consent process to be delegated to members of the clinical team not performing the procedure (eg, junior doctors). However, it is common for consent-taking delegates to lack sufficient time and clinical knowledge to adequately promote patient autonomy and informed decision-making. Such problems might be addressed in a number of ways. One possible solution to this clinical dilemma is through the use of conversational artificial intelligence using large language models (LLMs). There is considerable interest in the potential benefits of such models in medicine. For delegated procedural consent, LLM could improve patients’ access to the relevant procedural information and therefore enhance informed decision-making.In this paper, we first outline a hypothetical example of delegation of consent to LLMs prior to surgery. We then discuss existing clinical guidelines for consent delegation and some of the ways in which current practice may fail to meet the ethical purposes of informed consent. We outline and discuss the ethical implications of delegating consent to LLMs in medicine concluding that at least in certain clinical situations, the benefits of LLMs potentially far outweigh those of current practices.

Responding to recent concerns about the reliability of the published literature in psychology and other disciplines, we formed the X-Phi Replicability Project to estimate the reproducibility of experimental philosophy. Drawing on a representative sample of 40 x-phi studies published between 2003 and 2015, we enlisted 20 research teams across 8 countries to conduct a high-quality replication of each study in order to compare the results to the original published findings. We found that x-phi studies – as represented in our sample – successfully replicated about 70% of the time. We discuss possible reasons for this relatively high replication rate in the field of experimental philosophy and offer suggestions for best research practices going forward.

ABSTRACT:Psychedelics, including psilocybin, and other consciousness-altering compounds such as 3,4-methylenedioxymethamphetamine (MDMA), currently are being scientifically investigated for their potential therapeutic uses, with a primary focus on measurable outcomes: for example, alleviation of symptoms or increases in self-reported well-being. Accordingly, much recent discussion about the possible value of these substances has turned on estimates of the magnitude and duration of persisting positive effects in comparison to harms. However, many have described the value of a psychedelic experience with little or no reference to such therapeutic benefits, instead seeming to find the experience valuable in its own right. How can we make sense of such testimony? Could a psychedelic experience be valuable even if there were no persisting beneficial effects? If so, how? Using the concept of psychological richness, combined with insights from the philosophy of aesthetics and the enhancement literature, this essay explores potential sources of value in the acute subjective experience, apart from the value derived from persisting beneficial effects.

Socially responsible publishers, such as the BMJ Publishing Group, have demonstrated a commitment to health equity and working towards rectifying the structural racism that exists both in healthcare and in medical publishing.1 The commitment of academic publishers to collecting information relevant to promoting equity and diversity is important and commendable where it leads to that result.2 However, collecting sensitive demographic data is not a morally neutral activity. Rather, it carries with it both known and potential risks. Among these are issues around privacy or data misuse, as well as more basic concerns about how, when or why people should be categorised in certain ways and/or prompted to conceive of themselves or their identities in certain terms.3 If such data are to be collected, therefore, their effectiveness in achieving the stated ends must have a sufficiently compelling evidence base so as to justify the various risks involved. And where possible, these risks must also be identified and minimised. As Varcoe et al 4 argue, > While most leaders and healthcare workers and some patients [in their study] envisioned potential benefits associated with having ethnicity data, these benefits were seen as largely contingent upon action being taken to [actually] ameliorate inequities. Overwhelmingly, however, leaders from ethno-cultural communities and patients of diverse identities anticipated potential harm arising both from having ethnicity data and the process of collection. The analysis illustrates that in today’s sociopolitical context, collecting ethnicity data in clinical contexts may engender considerable harm, particularly for racialized, vulnerable patients. (p1569) Varcoe et al refer to ‘ethnicity’ data, which as they note is an ambiguous concept, potentially encompassing such diverse notions as ancestry, language, religion or culture. It is also a term that is in some contexts—for example, the USA—often used interchangeably with a different, more highly charged term: ‘race’. Data …