Arianne Shahvisi

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.

The demand for informed consent in clinical medicine is usually justified on the basis that it promotes patient autonomy. In this article I argue that the most effective way to promote autonomy is to improve patient understanding in order to reduce the epistemic disparity between patient and medical professional. Informed consent therefore derives its moral value from its capacity to reduce inequalities of power as they derive from epistemic inequalities. So in order for a patient to have given informed consent, she must understand the treatment. I take this to mean that she has sufficient knowledge of its causal mechanisms and has accepted the explanations in which the treatment is implicated. If this interpretation of informed consent is correct, it is unethical for medical professionals to offer or endorse ‘alternative medicine’ treatments, for which there is no known causal mechanism, for if they do, they may end up widening the epistemic disparity. In this way, informed consent may be understood as an effective way of ruling out particular treatments in order to improve patient autonomy and maintain trust in the medical profession

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.

In this paper, I argue that the conscience clause around abortion provision in England, Scotland and Wales is inadequate for two reasons. First, the patient and doctor are differently situated with respect to social power. Doctors occupy a position of significant moral and epistemic authority with respect to their patients, who are vulnerable and relatively disempowered. Doctors are rightly required to disclose their conscientious objection, but given the positioning of the patient and doctor, the act of doing so exploits the authority of the medical establishment in asserting the legitimacy of a particular moral view. Second, the conscientious objector plays an unusual and self-defeating moral role. Since she must immediately refer the patient on to another doctor who does not hold a conscientious objection, she becomes complicit, via her necessary causal role, in the implementation of the procedure. This means that doctors are not able to prevent abortions, rather, they are required to ensure that they...

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.

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,...

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 most benign rationale for sex selection is deemed to be “family balancing.” On this view, provided the sex distribution of an existing offspring group is “unbalanced,” one may legitimately use reproductive technologies to select the sex of the next child. I present four novel concerns with granting “family balancing” as a justification for sex selection: families or family subsets should not be subject to medicalization; sex selection for “family balancing” entrenches heteronormativity, inflicting harm in at least three specific ways; the logic of affirmative action is appropriated; the moral mandate of reproductive autonomy is misused. I conclude that the harms caused by family balancing are sufficiently substantive to override any claim arising from a supposed right to sex selection as an instantiation of procreative autonomy.

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.

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.

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.

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 …

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.

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.

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 …

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.

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 …

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.