Udo Schüklenk

Some jurisdictions that have decriminalized assisted dying exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients’ access to this service amount to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system.

In few other areas of bioethical inquiry exists as close a connection between bioethical professional advice and policy development as is the case with HIV and AIDS. Historically, the reasons for this have much to do with one of the groups initially affected most severely by HIV and AIDS, namely well-educated middle-class gay men in developed countries. This particular group of people, highly sophisticated and used to political activism in its pursuit of civil rights-related objectives, engaged the medical profession as well as regulatory agencies such as the US Food and Drug Administration, and legislators (more so in the USA than in other countries) in a number of bioethically interesting policy areas. Many of the controversies of the times were framed as civil rights and/or ethical disputes. The initial areas of concern and inquiry focused on: informed consent to HIV testing and trial participation, the confidentiality of HIV test results, access to trials as a means of access to experimental drugs, the length of time it took to get an experimental drug to the market approval stage, and end-of-life decision-making. This line-up of issues explains why AIDS has become such an interesting topic for bioethicists. Bioethicists concerned about the traditional breadand- butter themes of medical ethics themes of the doctor - patient relationship (e.g., Daniels, 1991; Boyd, 1992), as well as bioethicists more concerned about policy and regulatory issues in the drug research and approval process (e.g., Edgar & Rothman, 1990; Salisbury & Schechter, 1990), found research topics worthy of vigorous pursuit. No surprise, then, that HIV/AIDS led to a probably unprecedented number of books and articles in professional journals (Manuel et al., 1990). HIV/AIDS has become a permanent fixture in all major mainstream bioethics textbooks (e.g., Kuhse & Singer, 1998; Arras & Steinbock, 1999). Reference series in medicine, ethics and law provide for dedicated volumes on AIDS.1 Even specialist bioethics textbooks, for instance those directed at dentistry students, carry chapters on HIV/AIDS (Ozar & Sokol, 2002). 128 Udo Schuklenk AIDS, designated by the medical profession a pandemic lives up to its classification. It did not stop at the borders of developed countries. As one would expect of a primarily sexually transmitted illness in the age of globalisation, it spread rapidly across the globe. Indeed, in many countries it has become one of the main causes of death, as in sub- Saharan Africa (Shisana & Simbayi, 2002). Dramatic increases in the number of AIDS cases are predicted for many Eastern European countries as well as for the two most populous nations on earth, India and China. Some of the HIV/AIDS-related bioethical and policy issues of concern to developed countries remain the same for developing countries. However, in ethically important ways they are dwarfed by concerns over drug prices, intellectual property rights, and affordable access to essential AIDS drugs for the impoverished masses of infected people in such countries. Of increasing importance have become ethical issues pertaining to the ever-growing research industry associated with clinical trials undertaken in developing countries. Indeed, major funding initiatives both in the USA and UK have brought clinical research in developing countries into focus. Some have questioned whether this attention is appropriate, considering other bioethical problems of arguably greater importance to developing countries (Chadwick & Schuklenk, 2003). Standards of clinical care in a study, and after a trial has concluded, as well as community benefits and access to the trial regime after the trial’s conclusion remain contentious issues. It is worth noting that more often than not it was an AIDS-related trial or policy decision that led to a great deal of bioethical analysis, yet the issues discussed almost always have ramifications far beyond AIDS. For instance, decisions about the question of what (if any) standards of care failures in preventive trials (of HIV vaccines or microbicides) ought to receive have important implications for non-AIDS prevention trials

Research into the genetic component of some complex behaviors often causes controversy, depending on the social meaning and significance of the behavior under study. Research into sexual orientation—simplistically referred to as “gay gene” research—is an example of research that provokes intense controversy. This research is worrisome for many reasons, including the fact that it has been used to harm lesbians and gay men. Many homosexual people have been forced to undergo “treatments” to change their sexual orientation. Others chose to undergo them to escape discrimination and social disapprobation. But there are other reasons to worry about such research. The very motivation for seeking an “origin” of homosexuality reveals homophobia. Moreover, such research may lead to prenatal tests that claim to predict for homosexuality. For homosexual people who live in countries with no legal protections these dangers are particularly serious.

The ethical challenge is squarely focused on the question of what is owed to participants of vaccine trials who happen to become infected during the course of the trial. Not surprisingly, given the prominence of HIV/AIDS in many parts of the developing world, HIV vaccine trials have become the focal point of this debate. It is worth noting from the outset, however, that the same arguments that apply to HIV vaccines would apply to any number of microbicide trials aimed at protecting women against a large variety of sexually transmitted illnesses.1 One of the controversial questions in this debate has been the issue of whether or not an infection acquired by vaccine trial participants during the course of the trial can reasonably be considered a trial related injury that ought to be subject to compensation (in the form of access to good quality AIDS treatments, including antiretrovirals).

It is argued by Lie et al in the current issue of the Journal of Medical Ethics that an international consensus opinion has formed on the issue of standards of care in clinical trials undertaken in developing countries. This opinion, so they argue, rejects the Declaration of Helsinki’s traditional view on this matter. They propose furthermore that the Declaration of Helsinki has lost its moral authority in the controversy in research ethics. Although the latter conclusion is supported by this author, it will be demonstrated in this paper that there is not such a thing as an international consensus opinion, and that the authorities used by Lie et al as evidence in support of their claim should not be relied upon as authorities or final arbiters in this debate. Furthermore, it will be shown that arguments advanced substantively to show that lower standards of care are ethically acceptable in the developing world, conflate scientific with economic reasons, and ultimately fail to bolster the case they are designed to support

The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada’s assisted dying law. The question of whether changes to a country’s assisted dying legislation lead to descents down slippery slopes has also come to the fore—as it does any time a jurisdiction changes its laws. We explore these two questions through the lens of Canada’s experience both to inform Canada’s ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada’s Medical Assistance in Dying law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada’s new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada’s journey supports slippery slope arguments against permitting assisted dying. All data relevant to the study are included in the article.

This article describes how a small but vocal group of biomedical scientists propagates the views that either HIV is not the cause of AIDS, or that it does not exist at all. When these views were rejected by mainstream science, this group took its views and arguments into the public domain, actively campaigning via newspapers, radio, and television to make its views known to the lay public. I describe some of the harmful consequences of the group's activities, and ask two distinct ethical questions: what moral obligations do scientists who hold such minority views have with regard to a scientifically untrained lay audience, and what moral obligations do mainstream newspapers and government politicians have when it comes to such views. The latter question will be asked because the 'dissidents' succeeded for a number of years in convincing the South African government of the soundness of their views. The consequences of their stance affected millions of HIV infected South Africans severely.

This paper discusses a number of critical ethical problems that arise in interactions between queer patients and health care professionals attending them. Using real-world examples, we discuss the very practical problems queer patients often face in the clinic. Health care professionals face conflicts in societies that criminalise same sex relationships. We also analyse the question of what ought to be done to confront health care professionals who propagate falsehoods about homosexuality in the public domain. These health care professionals are more often than not motivated by strong religious convictions that conflict with mainstream medical opinion on homosexuality. We argue that they ought to be held accountable for their conduct by their professional statutory bodies, given that they abuse their professional standing to propagate sectarian views not representative of their profession. Lastly, we propose that medical schools have special responsibilities in training future health care professionals that will enable them to respond professionally to queer patients seeking health care

This article by one of the Editors of Bioethics, published in the 25th anniversary issue of the journal, describes some of the revolutionary changes academic publishing has undergone during the last decades. Many humanities journals went from typically small print-runs, counting by the hundreds, to on-line availability in thousands of university libraries worldwide. Article up-take by our subscribers can be measured efficiently. The implications of this and other changes to academic publishing are discussed. Important ethical challenges need to be addressed in areas such as the enforcement of plagiarism-related policies, the so-called ‘impact factor’ and its impact on academic integrity, and the question of whether on-line only publishing can currently guarantee the integrity of academic publishing histories

Conscience-based refusals by health care professionals to provide care to eligible patients are problematic, given the monopoly such professionals hold on the provision of such services. This article reviews standard ethical arguments in support of conscientious refuser accommodation and finds them wanting. It discusses proposed compromise solutions involving efforts aimed at testing the genuineness and reasonability of refusals and rejects those solutions too. A number of jurisdictions have introduced policies requiring conscientious refusers to provide effective referrals. These policies have turned out to be unworkable. They subject patients to a health care delivery lottery, which is incompatible with the fundamental values of medical professionalism. This paper sheds light on transnational efforts aimed at undermining progress made in reproductive health by means of conscientious refusal accommodation claims. The view that the accommodation of conscientious refusers is indefensible on consequentialist ethical grounds, as well as on grounds related to medical professionalism itself, is defended.

The hysteria and misconceptions about AIDS which are fostered and held by the popular press have been accepted uncritically by many bioethicists, who have not bothered to explore popular empirical claims in sufficient depth. As a result, and because ethicists attempt tosell moral problems in a manner not much different from the way the popular press attempt tosell newspapers, artificial dilemmas have been produced in professional journals. We concentrate on just one popular misconception about AIDS-that the hetersexual incidence of the syndrome is widespread-and showhow bioethicists' unreflective acceptance of this myth has led them to make conceptual and practical errors

This article analyses, from a bioethics journal editor's perspective, the threats to academic freedom and freedom of expression that academic bioethicists and academic bioethics journals are subjected to by political activists applying pressure from outside of the academy. I defend bioethicists’ academic freedom to reach and defend conclusions many find offensive and ‘wrong’. However, I also support the view that academics arguing controversial matters such as, for instance, the moral legitimacy of infanticide should take clear responsibility for the views they defend and should not try to hide behind analytical philosophers’ rationales such as wanting to test an argument for the sake of testing an argument. This article proposes that bioethics journals establish higher-quality requirements and more stringent mechanisms of peer review than usual for iconoclastic articles

Religious considerations and language do not typically belong in the professional advice rendered by a doctor to a patient. Among the rationales mounted by Greenblum and Hubbard in support of that conclusion is that religious considerations and language are incompatible with the role of doctors as public officials.1 Much as I agree with their conclusion, I take issue with this particular aspect of their analysis. It seems based on a mischaracterisation of what societal role doctors fulfil, qua doctors. What obliges doctors to communicate by means of content that is expressed in public reason-based language is not that they are public officials. Doctors as doctors are not necessarily public officials. Rather, doctors have such obligations, because they are professionals. Unlike public officials doctors are part of a profession that is to a significant extent self-governing. This holds true for all professions. The …

The proper role, if any, for religion-based arguments is a live and sometimes heated issue within the field of bioethics. The issue attracts heat primarily because bioethical analyses influence the outcomes of controversial court cases and help shape legislation in sensitive biopolicy areas. A problem for religious bioethicists who seek to influence biopolicy is that there is now widespread academic and public acceptance, at least within liberal democracies, that the state should not base its policies on any particular religion’s metaphysical claims or esoteric moral system. In response, bioethicists motivated by religious concerns have adopted two identifiable strategies. Sometimes they rely on slippery-slope arguments that, sometimes at least, have empirically testable premises. A more questionable response is the manipulation and misuse of secular-sounding moral language, such as references to “human dignity,” and the plights of groups of people labeled “vulnerable.”