Xavier Symons

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs.

There has been significant debate about whether the moral norms of medical practice arise from some feature or set of features internal to the discipline of medicine. In this article, I analyze Edmund Pellegrino’s conception of the internal morality of medicine, and situate it in the context of Alasdair MacIntyre’s influential account of “practice.” Building upon MacIntyre, Pellegrino argued that medicine is a social practice with its own unique goals—namely, the medical, human, and spiritual good of the patient—and that the moral norms that govern medical practice are derived from these goals. After providing an overview of Pellegrino’s work, I discuss some forceful objections to his theory—specifically, that it is too rigid and incapable of entering into dialogue with contemporary values systems; that it is dependent on an external conception of human flourishing; and that it is incompatible with the rapidly changing nature of modern medicine. In the final section of this article, I consider how theorists working in the Hippocratic tradition might respond to these objections against ethical essentialism by drawing upon MacIntyre’s historico-cultural method as well as what he calls Aristotle’s “metaphysical biology.”

Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we abandon the standard rationalistic conception of the secular realm and see it rather as “a forum for the negotiation of rival reasonings”. Religious reasoning is one among a number of ways of thinking that must vie for acceptance. Medical ethics, says Biggar, is characterised by “spiritual and moral mixture and ambiguity”. We acknowledge this uncertainty by recognising rival viewpoints and agreeing to provisional compromises. In this response, I object to Biggar's characterisation of medical ethics as “morally ambiguous” and “provisional”. I argue that Biggar has failed to provide adequate support for his conception of ethics as a “forum for negotiation and compromise”. I criticise Biggar's attempt to ‘pluralise’ rationality, and assert that if religion is to play a role in secular medicine, it must be ready to defend itself against a universal standard of reason. In the second section of my response, I argue that ‘theistic natural law’ gives us the resources to defend using reason alone ostensibly faith-based positions in healthcare ethics. In doing so, we retain a univocal conception of rationality, while at the same time leaving space for ‘theism’ in healthcare ethics.

Thomas Riisfeldt’s essay1 is a valuable contribution to the literature on palliative sedation, appropriately titrated administration of opioids (ATAOs) and euthanasia. In this response, I will not deal with the author’s empirical claim about the relationship between opioid use, palliative sedation and survival time. Rather, I will briefly critique the author’s discussion of doctrine of double effect (DDE) and its application to palliative sedation and opioid use at the end of life. That is, I will focus on the ethical claims made by the author. Riisfeldt argues that DDE is incompatible with both Kantian deontology and Millian consequentialism. Yet, I will argue that the DDE is coherent and defensible when interpreted from the perspective of the philosophy of Thomas Aquinas, the theorist who first proposed the doctrine. I will also argue that Riisfeldt mischaracterises ATAOs and palliative sedation as procedures that hasten death as a means to relieve pain. While death may indeed be hastened by ATAOs and palliative sedation, it is not at all clear that clinicians intend to hasten death as a means to relieve pain. Indeed, clinical guidelines explicitly prohibit the intentional hastening of death. Riisfeldt provides a brief summary of the DDE. He describes DDE as a ‘strange hybrid of four principles’. He lists the four criteria that must be met for an act with a good and a bad effect to be permissible. These criteria are the ‘intention and means criteria’ and the ‘intrinsic and proportionality criteria’ (p.127). The author uses Kant and Mill as lens through which to highlight a tension between the intrinsic and proportionality criteria of DDE. The author claims that ‘the intrinsic criterion is derived from deontology, the predominant form of which is championed by Kant’, and that ‘the proportionality criterion is derived from consequentialism, the predominant form of …

The doctrine of double effect (DDE) is a principle of crucial importance in law and medicine. In medicine, the principle is generally accepted to apply in cases where the treatment necessary to relieve pain and physical suffering runs the risk of hastening the patient’s death. More controversially, it has also been used as a justification for withdrawal of treatment from living individuals and physician-assisted suicide. In this paper, I will critique the findings of the controversial Victorian Civil and Administrative Tribunal (VCAT) hearing Syme vs the Medical Board of Australia. In that hearing, Dr Rodney Syme, a urologist and euthanasia advocate, was defending his practice of prescribing barbiturates to terminally ill patients. Syme claimed that he prescribed the drugs with the intention of relieving their existential suffering and not to assist in suicide; he argued that the DDE could be applied. Pace VCAT, I argue that this is an illegitimate application of DDE. I argue that a close scrutiny of Syme’s actions reveals that, at the very least, he intended to give patients the option of suicide. He furthermore used what on a traditional definition of DDE would be considered a ‘bad’ means—the prescription of Nembutal—to achieve a ‘good’ end—the relief of suffering. The case demonstrates the crucial importance of analysing an agent’s ‘intention’ and the ‘effects’ of their actions when applying DDE. Ethicists and, indeed, the judiciary need to attend to the ethical complexities of DDE when they assess the applicability of DDE to end of life care. If they fail to do this, the doctrine risks losing its legitimacy as an ethical principle.

Schuklenk and Smalling argue that it is practically impossible for civic institutions to meet the conditions necessary to ensure that conscientious objection does not conflict with the core principles of liberal democracies. In this response, I propose an alternative definition of conscience to that offered by Schuklenk and Smalling. I discuss what I call the ‘traditional’ notion of conscience, and contrast this with the existentialist conception of conscience (which I take to be a close cousin of the view targeted by Schuklenk and Smalling). I argue that the traditional notion, grounded in an objective moral order, avoids the criticisms advanced by Schuklenk and Smalling; the existentialist conception, in contrast, does not. I conclude by discussing the benefits and risks of a ‘restricted view’ of respect for conscience.

Several bioethicists have recently discussed the complexity of defining human death, and considered in particular how our definition of death affects our understanding of the ethics of vital organ procurement. In this brief paper, we challenge the mainstream medical definition of human death—namely, that death is equivalent to total brain failure—and argue with Nair-Collins and Miller that integrated biological functions can continue even after total brain failure has occurred. We discuss the implications of Nair-Collins and Miller’s argument and suggest that it may be necessary to look for alternative biological markers that reliably indicate the death of a human being. We reject the suggestion that we should abandon the dead-donor criteria for organ donation. Rather than weaken the ethical standards for vital organ procurement, it may be necessary to make them more demanding. The aim of this paper is not to justify the dead donor rule. Rather, we aim to explore the perspective of those who agree with critiques of the whole brain and cardiopulmonary definitions of death but yet disagree with the proposal that we should abandon the dead-donor rule. We will consider what those who want to retain the dead-donor rule must argue in light of Nair-Collins and Miller’s critique.

In this article we critically evaluate an argument against state‐sanctioned euthanasia made by David Velleman in his 1992 paper ‘Against the right to die’. In that article, Velleman argues that legalizing euthanasia is morally problematic as it will deprive eligible patients of the opportunity of staying ‘alive by default’. That is to say, those patients who are rendered eligible for euthanasia as a result of legislative reform will face the burden of having to justify their continued existence to their epistemic peers if they are to be perceived as ‘reasonable’. We discuss potential criticisms that could be made of the argument, and consider how a defender of the view might respond. Velleman’s argument is particularly interesting as it is a consequentialist argument against state‐sanctioned euthanasia, challenging the many consequentialist arguments that have been made in favour of legalizing the procedure. We conclude by suggesting that further research on the question of unfair burdens is important to adequately evaluating the potential harms of legalizing euthanasia for patients at the end of life.