Trevor Stammers

There can be little doubt, at least in the Western world, that autonomy is the ruling principle in contemporary bioethics. In spite of its ‘triumph’ however, the dominance of the utilitarian concept of autonomy is being increasingly questioned. In this paper, I explore the nature of autonomy, how it came to displace the Hippocratic tradition in medicine and how different concepts of autonomy have evolved. I argue that the reduction of autonomy to ‘the exercise of personal choice’ in medicine has led to a ‘tyranny of autonomy’ which can be inimical to ethical medical practice rather than conducive to it. I take the case of Kerrie Wooltorton as an illustration of how misplaced adherence to respect for patient autonomy can lead to tragic consequences. An analysis of autonomy based on the work of Rachel Haliburton is described and applied to the role of autonomy in a recent bioethical debate — that arising from Savulescu's proposal that conscientious objection by health-care professionals should not be permit..

The demand for organs prompted the first use of elective ventilation in the UK in the 1990s. Recently the shortfall in supply of organs has once again prompted calls for elective ventilation to be instituted even in patients who are not brain dead. This paper proposes that the term ‘elective’ ventilation is a misnomer and the term non-therapeutic ventilation (NTV) should be used instead. It is further argued that the practice of NTV in cases of severe stroke is unethical and has the potential of causing a variety of harms to the patient, their relatives, the healthcare professionals working in transplant teams and this may result in a backlash of reductions in the number of organ donations.

We report on two areas in which UK law and ethics seem out of step with each other. 2013 saw the passing of the Human Transplantation (Wales) Bill, which will introduce an opt-out system of organ donation in Wales from 2015. In the first section, we discuss the convoluted evolution of the Bill and some potential problems that we consider may prevent it from achieving its intended goal of increasing the number of organs transplanted. The prospect of being able to enhance human cognition through cognitive-enhancing drugs ("smart drugs") also presents a nexus of questions associated with future ambitions, hopes, and concerns as a society. How these drugs might affect the future of work and employment is beginning to generate wide public engagement in the UK and forms the focus of the second section.

Among the many potential benefits arising from the rapidly advancing field of nanomedicine is the possibility of a whole new range of nanovaccines in which novel delivery mechanisms utilizing nanoparticles could make obsolete the use of needles for administering any vaccine. However, as the massive resources of the worldwide pharmaceutical industry are deployed to develop nanovaccines, urgent questions arise as to which diseases should be targeted and which populations will benefit most. This paper explores how such targeting of nanovaccines might be decided in an ethically optimal way and considers some of the practical considerations and potential problems of implementing such a global nanovaccine policy. There seems little doubt that nanomedical research could develop vaccines against most major global infectious diseases. Throughout the history of medicine, however, it is well recognized that insufficient attention and resources have been given to public health and preventive medicine and the environmental causes of ill-health remain under-researched. We urge that national governments and regional authorities of wealthier countries incentivise their powerful pharmaceutical corporations to develop nanovaccines within a global and long term perspective and not just to focus on the diseases of the developed world.