Arianne Shahvisi

Between October 2023 and January 2025, the Israeli military's sustained attacks on Gaza resulted in an estimated 186,000 deaths and the systematic destruction of healthcare infrastructure. Despite the professed commitment to human dignity, justice, and the minimization of suffering within bioethics, major institutions and scholars in the field have largely remained silent or selectively engaged with the crisis. This paper argues that the Gaza genocide exposes a deeper crisis within bioethics: its growing detachment from urgent, real‐world ethical challenges. Such detachment erodes public trust and raises fundamental questions about the discipline's relevance and credibility. The article interrogates the possible reasons and motivations for the silence and disengagement in the face of genocide in Gaza, and examines the institutional and disciplinary responsibilities that bioethics bears in response to health‐destroying state violence. Framing the inaction as a moral failure with far‐reaching implications, the article proposes alternative routes of ethical engagement and outlines steps toward a more inclusive and responsive bioethics. It calls for the urgent reorientation of the field toward a justice‐driven, politically conscious practice capable of confronting today's most pressing ethical issues.

Medical ethics is often regarded as the most practical branch of philosophy, grounded as it is in the everyday realities of clinical care and health policy. Yet from its inception, it has been replete with analyses of speculative technologies and hypothetical scenarios, from ectogenesis, xenotransplantation and human enhancement to kidnappings to save ailing violinists.1 These works ask: what would be the right thing to do if this unreal(istic) situation existed? For example, in the current issue, Chin et al argue for the strict regulation of preimplantation genetic testing for polygenic traits (PGT-P) in Singapore.2 PGT-P is an experimental form of embryo screening in in vitro fertilisation (IVF) whose predictive power is currently limited and uncertain, but the authors’ analysis is ‘based on the assumption that the efficacy of this new technology platform has already been validated’. There are two common justifications for speculative inquiry in medical ethics. First, it encourages ethical preparedness for innovations that may one day be available or even commonplace. In this issue, Rudra et al. explore whether large language models (LLMs) could be used to simulate empathy, thereby taking on aspects of the emotional labour clinicians often lack time to provide and easing the informed consent process.3 We have seen a flurry of work on LLMs in these pages over the last few years4–8 and some of these technologies are now used within the UK’s National Health Service.9 Second, it is argued that speculative work has value as an intellectual exercise that can generate new tools or pathways for analysis or can test our intuitions in ways that shed light on real-world moral problems. For example, in a 2023 paper, Räsänen explores the implications that the speculative technology of ectogenesis might have for abortion law and in doing so challenges us …

In recent years, the removal of monuments which glorify historical figures associated with racism and colonialism has become one of the most visible and contested forms of decolonisation. Yet many have objected that there is educational value in leaving such monuments standing. In this paper, I argue that public monuments can be understood as speech acts which communicate messages to those who live among them. Some of those speech acts derogate particular social groups, contributing to their marginalisation in much the way that slurs do. Comparing derogating monuments to slurs is also productive in suggesting morally appropriate responses to their harms. I explore the limits of the use-mention distinction in relation to the harmfulness of slurs and apply this to show that attempting to recontextualise harmful monuments in situ—by, for example, changing the text on an accompanying plaque in order to retain the monument for its educational value—will not solve the problem in most cases. I conclude that the removal of slurring monuments, or their relocation to museum exhibitions dedicated to presenting a more critical view of history, is a more robust and reliable way of protecting against harm, and that this consideration outweighs any purported educational value in leaving monuments in place.

As recently appointed co-editors-in-chief of the Journal of Medical Ethics, our goal is to serve the community of authors, reviewers and readers by ensuring that the work we publish is timely, rigorous and distinctive. In this editorial, we want to share a few notes about how we are approaching editorial decisions, so that our rationale is clear, and to call attention to some simplification of the journal’s article types and what we’re hoping for from work in each of these categories. First, some important background. We are currently managing a full pipeline, with accepted articles scheduled for publication many months in advance. In fact, we have inherited enough excellent material from our predecessor, John McMillan, to fill almost a year of print issues without needing to accept a single new article. However, this means there is a lag between the acceptance of a paper and its assignment to a print issue of the journal. Another lag that some authors have commented on is the delay between submission of a paper (or its revision) and an editorial decision following peer review. This, in turn, is related to concerns about reviewer fatigue within our community. We describe our responses to these issues in the following subsections. ### Concerns about slow assignment of online-first articles to a print issue Given our prodigious queue of inherited manuscripts, we are exploring the possibility of publishing a number of online-only special issues consisting of thematically grouped papers from among those that have already been accepted, which we would then heavily promote and advertise. This should both raise the profile and visibility of these papers and allow authors to have their work receive its final citation information sooner than would otherwise be possible. For example, we may publish e-issues focused on AI ethics, reproductive ethics, environmental ethics and so on, making the material easier to find while also …

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.

Medicine is an innately temporal exercise. Illness and injury shorten a person’s time or worsen it, and the role of medicine is to resist and counter threats to the quality and quantity of our time. By some measures, it is extraordinarily successful in this aim. Life expectancy has doubled in the last two centuries, largely due to medical advances and improved access to healthcare and the determinants of health (eg, nutrition, sanitation, housing and education). Even so, life expectancies between nations differ by decades: Japanese people can expect to live to 85, while Nigerians have average lifespans of just 55 years. 1 One key driver of this disparity is the gap in infant mortality: 60 babies die before their first birthday for every 1000 births in Nigeria, compared with two in Japan. 2 There are similar disparities in the quality of time. Disease burden is standardly measured...

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 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.

The editors of the _Journal of Medical Ethics_ support the call of the UK Health Alliance on Climate for urgent action to ensure that the current Conference of the Parties to the United Nations Framework Convention on Climate Change ‘finally delivers climate justice for Africa and vulnerable countries’. 1 As they note ‘Africa has suffered disproportionately although it has done little to cause the crisis’. The burden of climate change has thus far fallen disproportionately on Global South countries. The monsoon in Pakistan this year killed over 1100 people and the public health implications of the flooding might affect the health of over 5 million people. 2 The South Asian monsoon impacts the lives of a billion people and the flooding associated with wet seasons is likely to occur eight times more frequently in future years than at present. 3 For many pacific islands such as Kiribati,...

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 …

One of the most important motifs within (medical) ethics is scarcity: where essential (health) resources are scarce, urgent ethical questions arise. Over the last decade, at least 250 papers addressing the allocation of scarce health resources have been published in the Journal of Medical Ethics alone.1 In the typical set-up, the authors introduce a situation of scarcity and then review and adjudicate the available or recommended courses of action, sometimes through the lens of a pet normative ethical theory. It is much less common for (medical) ethicists to focus their enquiries on the origins of scarcity. Why aren’t there sufficient health resources to go around? Who caused the scarcity, and how should they be held responsible? These questions are also firmly within the remit of the discipline. Discussions of scarcity tend to circumvent these difficult questions by focussing on exceptional cases in Global North settings, where scarcity is relatively rare, and is sometimes defensible or insoluble. For example: it would be wasteful for a hospital to overstock expensive, bulky, energetically intensive, specialist equipment whose supply would only be challenged under the most extreme and unforeseen circumstances (eg, a pandemic), and there may never be sufficient usable donor organs to meet the demand for transplants. Much less attention is given to under-resourced settings, generally in the Global South, where scarcity is common, and is often both indefensible and soluble. The literature appears to favour what is ‘unusual’ and ‘interesting’ in some contexts, rather than what is commonplace, and by that fact more worrying, in others. This division of attention entrenches the idea that scarcity is a fixed feature of certain places and lives. Why do medical ethicists so often fight shy of these meta-questions? They are, of course, harder and messier. More work and greater care are needed to contextualise …

Among the most harrowing visuals of Britain’s ongoing ‘cost of living crisis’ are the security tags that began to appear on cheese, butter, chicken, sweets and infant formula milk in 2022. A week’s worth of formula milk—the sole or main food of the vast majority of infants for the first 6 months of life—now costs between £9.39 and £15.95.1 Low-income households are entitled to a ‘Healthy Start’ welfare payment, intended to avert malnutrition among the poorest children, but the weekly allowance is just £8.50.2 There are reports of parents watering down formula, skipping or limiting feeds and initiating early weaning, all of which jeopardise the health of infants, with potentially lifelong consequences.3 No determinant of health is more critical than food. A 2019 study found that diet is the most significant risk factor for non-communicable disease, and that one in five deaths globally could be prevented by improving nutrition.4 Globally, 1 in 10 people cannot meet their daily energy needs,1 and the proportion of undernourished people is rising.5 In more than 50 countries, most of them in Africa, over a quarter of children are stunted or wasted due to undernourishment, with long-term effects on their cognitive and physical development. These are not problems of absolute scarcity; enough food is produced globally to feed ten billion people.6 In the UK, there is, at any given moment, sufficient food on supermarket shelves to meet the calorie and nutrient needs of the population. Yet the equivalent of nearly 200 million meals a year are discarded,7 while almost a quarter …

The fair distribution of health resources is critical to health justice. But distributing healthcare equitably requires careful attention to the existing distribution of other resources, and the economic system which produces these inequalities. Health is strongly determined by socioeconomic factors, such as the effects of racism on the health of communities of colour, as well as the broader market-oriented healthcare and pharmaceutical systems that put the pursuit of profit above the alleviation of suffering. Two papers in this issue confront health injustices at different scales, and make far-reaching recommendations for more just healthcare allocation policies. Orphan drugs are those that pharmaceutical companies are unwilling to develop unless they are offered financial incentives to do so. When a target patient group is very small, or very poor, producing drugs is unprofitable. If patients are to benefit from these drugs in a marketised pharmaceutical regime, governments must step in to provide incentives for research and development. Yet government spending ought to prioritise value for money, and is generally guided by a utilitarian framework. In the case of neglected tropical diseases, there is no moral conflict: large numbers of people would benefit greatly from these treatments. However, there are practical limitations: the governments of affected populations are often unable to fund incentives for research and development, and solidarity from elsewhere is limited.1 2 In the case of rare diseases, Global North governments usually can afford to incentivise the development of treatments to serve their populations, but given the small numbers of beneficiaries, doing so seems a questionable use of resources. Many Global North governments make an exception to the general utilitarian heuristic to accommodate the moral intuition that the claims of a person with a rare …

In this paper I explore a method for refusing uptake when explanations are morally and epistemically troubling. Gaile Pohlhaus Jr has shown that imploring marginalised people to “understand” marginalising practices amounts to a request that they legitimise their own marginalisation. In this paper, I expand upon this analysis with the aim of describing a method for withholding understanding. First, I analyse understanding through its association with explanation. Drawing on pragmatic theories, I describe explanations as speech acts whose success depends on the explainee granting the explainer uptake by revising their background assumptions. Those background assumptions sometimes reference troubling generalisations, and in those cases, the explanation must be blocked. Accordingly, I formalise a form of explanatory resistance in which the explainee feigns misunderstanding to corner the explainer into exposing the problematic assumptions upon which their explanation depends. Second, I situate wrongful requests for understanding within the epistemic injustice schema as “explanatory injustices,” emphasising the fact that marginalised groups are also specifically marginalised within the explanation economy. I conclude that we should be more cognisant of the way in which explanations track power, and be prepared to undertake resistance in order to expose moral and epistemic shortcomings in how we explain.

Many healthcare goods, such as surgical instruments, textiles and gloves, are manufactured in unregulated factories and sweatshops where, amongst other labour rights violations, workers are subject to considerable occupational health risks. In this paper we undertake an ethical analysis of the supply of sweatshop-produced surgical goods to healthcare providers, with a specific focus on the National Health Service of the United Kingdom. We contend that while labour abuses and occupational health deficiencies are morally unacceptable in the production of any commodity, an additional wrong is incurred when the health of certain populations is secured in ways that endanger the health and well-being of people working and living elsewhere. While some measures have been taken to better regulate the supply chain to healthcare providers in the UK, further action is needed to ensure that surgical goods are sourced from suppliers who protect the labour and occupational health rights of their workers.

In this paper, I argue that men should take primary responsibility for protecting against pregnancy. Male long-acting reversible contraceptives are currently in development, and, once approved, should be used as the standard method for avoiding pregnancy. Since women assume the risk of pregnancy when they engage in penis-in-vagina sex, men should do their utmost to ensure that their ejaculations are responsible, otherwise women shoulder a double burden of pregnancy risk plus contraceptive responsibility. Changing the expectations regarding responsibility for contraception would render penis-in-vagina sex more equitable, and could lead to a shift in the discourse around abortion access. I describe the sex asymmetries of contraceptive responsibility and of pregnancy-related risk, and offer arguments in favour of men taking primary responsibility for contraception. My arguments centre on: (1) analogies between contraception and vaccination, and unwanted pregnancy and disease; (2) a veil-of-ignorance approach, in which I contend that if a person were not told their sex, they would find a society in which men were expected to acquire and use effective contraceptives the fairest arrangement for everyone.

The aim of this paper is to debunk the assertion that miraculous “conspiracies” between fundamental particles are required to bring about the projectibility of special science generalisations. Albert and Loewer have proposed a theory of lawhood which supplements the Best System of fundamental laws with a statistical postulate over the initial conditions of the universe, thereby rendering special science generalisations highly probable, and dispelling the conspiracy. However, concerns have been raised about its ability to confer typicality upon special science generalisations in the way that is required. In this paper I defend their account against these charges, arguing that they derive from a misunderstanding of the typicality claim. I suggest a way out of the impasse via a naturalised approach which focusses on the genealogy of subsystems and encourages conceptual demonstrations of typicality for special science generalisations. I argue for an account of special science laws that acknowledges the way in which the special sciences reduce to the fundamental physics, thereby dissolving the conspiracy, yet respects the methodological and explanatory autonomy of special science generalisations.

Neglected tropical diseases are defined operationally as diseases that prevail in “tropical” regions and are under‐researched, under‐funded, and under‐treated compared with their disease burden. By analysing the adjectives “tropical” and “neglected,” I expose and interrogate the discourses within which the term “neglected tropical disease” derives its meaning. First, I argue that the term “tropical” conjures the notion of “tropicality,” a form of Othering which erroneously explains the disease‐prevalence of “tropical” regions by reference to environmental determinism, rather than colonialism and neocolonialism. Second, I examine the way in which this Othering enables the abjection of tropical regions and their peoples, leading to neglect. I recommend that the term “neglected tropical diseases” be more carefully contextualised within health scholarship, education, and policy.

During the “age of austerity” the UK government has progressively limited free health services for “overseas visitors” on the grounds of fairness and frugality. This is despite the fact that the cost of the additional bureaucracy required by the new system and the public health consequences are expected to exceed the sums saved. In this article I explore the interaction between the discourses of austerity and xenophobia as they relate to migrants’ access to healthcare. By examining the available data and adjudicating various moral arguments, I cast doubt on the claim that the current charging regulations are cost-effective and fair. I instead contend that if the UK is concerned with running a health service that is economically-sustainable and morally-defensible, it is critical that migrants are welcomed, both as staff and as patients. I conclude by arguing that xenophobia has precipitated changes to the health service which do not qualify as “austerity” in the way that is claimed, but rather deliberately produce a “hostile environment” for migrants, despite this very likely generating economic losses.

Pregnancy care is chargeable for migrants who do not have indefinite leave to remain in the UK. Women who are not ‘ordinarily resident’, including prospective asylum applicants, some refused asylum-seekers, unidentified victims of trafficking and undocumented people are required to pay substantial charges in order to access antenatal, intrapartum and postnatal services as well as abortion care within the National Health Service. In this paper, we consider the ethical issues generated by the exclusion of pregnancy care from the raft of services which are free to all. We argue that charging for pregnancy care amounts to sex discrimination, since without pregnancy care, sex may pose a barrier to good health. We also argue that charging for pregnancy care violates bodily autonomy, entrenches the sex asymmetry of sexual responsibility, centres the male body and produces health risks for women and neonates. We explore some of the ideological motivations for making maternity care chargeable, and suggest that its exclusion responds to xenophobic populism. We recommend that pregnancy care always be free regardless of citizenship or residence status, and briefly explore how these arguments bear on the broader moral case against chargeable healthcare for migrants.

Women are over-represented within alternative medicine, both as consumers and as service providers. In this paper, I show that the appeal of alternative medicine to women relates to the neglect of women’s health needs within scientific medicine. This is concerning because alternative medicine is severely limited in its therapeutic effects; therefore, those who choose alternative therapies are liable to experience inadequate healthcare. I argue that while many patients seek greater autonomy in alternative medicine, the absence of an evidence base and plausible mechanisms of action leaves patients unable to realize meaningful autonomy. This seems morally troubling, especially given that the neglect of women’s needs within scientific medicine seems to contribute to preferences for alternative medicine. I conclude that the liberatory credentials of alternative medicine should be questioned and make recommendations to render scientific medicine better able to meet the needs of typical alternative medicine consumers.

The U.K.'s National Health Service (NHS) is critically reliant on staff from overseas, which means that a sizeable number of U.K. healthcare professionals have received their training at the cost of other states, whose populations are urgently in need of healthcare professionals. At the same time, while healthcare is widely seen as a primary good, many migrants are unable to access the NHS without charge, and anti‐immigration political trends are likely to further reduce that access. Both of these topics have received close attention in the global health ethics literature. In this article, I make the novel move of suggesting that these two seemingly disparate issues should be folded into the same moral narrative. The ‘brain drain’ upon which the NHS and its users depend derives from the same gradient of wealth, security, and opportunity that produces migrants who require the NHS. I endorse moral cosmopolitanism as a lens for understanding patients' right to healthcare regardless of nationality or immigration status. I argue that the NHS in its current formulation effectively enacts a partial cosmopolitanism in its reliance on medical workers from abroad, but could more meaningfully instantiate that cosmopolitanism were it to offer the same healthcare to migrants as it does to citizens.

A UK doctor was recently acquitted of charges of reinstating a variety of female genital mutilation after delivering a child. In this paper, I contend that this incident reflects a broader confusion concerning the ethico-legal status of non-therapeutic genital surgeries for children and adults, which are not derivable from tenets of medical ethics, but rather violate them. I argue that medical professionals have an obligation to announce and address this confusion in order to motivate legislative reform, since the inconsistency of the current law entrenches the underlying sexism and ethnocentrism upon which its sense depends. Without convincing arguments for condoning male circumcision and female cosmetic genital surgery and for treating adult women of colour as lacking the capacity to consent, the current legislation stands in need of urgent revision.