David Shaw

Evidence shows that people doing biomedical research with non-human animals suffer psychological consequences. A culture of care in animal research demands ensuring the well-being of personnel and research animals, and proposals for ethical oversight, social support, and external interventions to address the psychological burden on personnel are growing. With biomedical research being a public good, and the people involved doing so to advance scientific knowledge for societal health benefits, society bears some responsibility for animal research and could be involved in ways that promote the well-being of research personnel. Society, through citizen involvement initiatives, is increasingly involved in shaping biomedical research more generally, while the animal research community is also committed to greater openness and transparency regarding animal use. These initiatives, in addition to the “citizen responsibility” approach used in criminal justice, can be explored to pursue societal involvement in promoting the culture of care in animal research.

The ambivalence of human-animal-relationships culminates in our eating habits; most people disapprove of factory farming, but most animal products that are consumed come from factory farming. While psychology and sociology offer several theoretical explanations for this phenomenon our study presents an experimental approach: an attempt to challenge people’s attitude by confronting them with the animals’ perspective of the consumption process. We confronted our participants with a fictional scenario that could result in them being turned into an animal. In the scenario, a wicked fairy forces them to choose a ticket. Depending on their choice of ticket they have equal chances of becoming a human being with a certain consumption behaviour (meat eater, organic eater, vegetarian, vegan) or, correspondingly, becoming a certain kind of animal (factory farmed meat animal, organically farmed meat animal, animal for dairy/egg production, free living animal). Our results indicate a strong discrepancy between people’s actual consumption habits (mostly regular meat eaters) and their choices in the experiment (strong preferences for the organic or vegan life style). The data reveal a broad spectrum of explanations for people’s decisions in the experiment. We investigated the influence of four different factors on the participant’s choices in addition to reasons they gave as open-ended answers. Correspondingly, different coping strategies to overcome the tension (cognitive dissonance) between real-life consumption choices and attitudes towards nonhuman animals could be detected. Furthermore, many participants indicated a lack of knowledge concerning living conditions in farming but also concerning capacities and properties of nonhuman animals.

This study explores animal research professionals’ attitudes toward the 3R principles (i.e., 3R: replacement, reduction, and refinement of the use of animals in research) using an experimental ethics approach. A thought experiment involving a superior extraterrestrial alien species conducting research on humans according to 3R was presented to 13 Swiss-based animal research professionals (i.e., researchers using animals, veterinarians, animal welfare officers, 3R coordinators, animal science trainers, and members of animal experimentation commissions) during qualitative semi-structured interviews. Participants were asked to reflect on whether the aliens’ research is justified, as well as on the extent to which 3R is the right framework for it. Thematic analysis was used to analyze the data. Participants revealed a spectrum of attitudes, ranging from ambivalent acceptance to outright rejection of “3R for humans”. Key themes included concerns about legitimacy, consent, and power asymmetry, as well as anthropocentric and speciesist attitudes. These findings support previously identified concerns about the limitations of 3R and show that professionals also recognize these challenges when reflecting on the issue using a role-reversal thought experiment. This underscores the ongoing need to advance ethical frameworks in animal research, expanding beyond 3R to incorporate broader moral considerations. Ultimately, our findings suggest that empirical animal ethics, and in particular thought experiments of this kind, offers a promising route to fostering ethical reflection and reform.

Research on emerging technologies such as AI-driven health interventions, extended reality (XR) systems, biobanks, and genome editing poses novel ethical challenges that traditional ethics governance models struggle to address. This article explores various models of research ethics governance within the European Union (EU) context, starting from traditional one-time research ethics committee (REC) reviews, REC review with post-approval monitoring, as well as alternative models such as ethics self-assessment, and ethics-by-design approaches. Based on literature analysis and a survey of European research ethics experts, the study identifies prevalent models of research ethics oversight, research ethics expert perceptions of their sufficiency, and challenges such as insufficient technical and ethics expertise, lack of specific guidelines, and unclear boundaries of REC responsibilities. Findings also indicate that traditional REC reviews remain dominant but have limitations in effectively managing rapidly evolving technologies. Research ethics experts highlighted the feasibility of continuous oversight mechanisms to better integrate ethical reflection throughout the research lifecycle. The article concludes by recommending a shift towards proportional, risk-based oversight, development of clearer, technology-specific guidelines, enhanced REC training, and improved harmonization across EU ethics governance systems to address current gaps.

The reward infrastructure in science centres on publication, in which journal editors play a key role. Reward distribution hinges on value assessments performed by editors, who draw from plural value systems to judge manuscripts. This conceptual paper examines the numerous biases and other factors that affect editorial decisions. Hybrid and often conflicting value systems contribute to an infrastructure in which editors manage reward through editorial review, commissioned commentaries and reviews and weighing of peer review judgments. Taken together, these systems and processes push the editor into a role resembling censorship. Editors and authors both experience this phenomenon as an unintended side-effect of the reward infrastructure in science. To work towards a more constructive editor-author relationship, we propose a conversation, an exchange between editor and author in which value is collectively assessed as obligatory passage points in the publishing process are traversed. This paper contributes to the discourse on editorial practices by problematising editorial paradigms in a new way and suggesting solutions to entrenched problems.

Artificial intelligence (AI) based clinical decision support systems (CDSS) are becoming ever more widespread in healthcare and could play an important role in diagnostic and treatment processes. For this reason, AI‐based CDSS has an impact on the doctor‐patient relationship, shaping their decisions with its suggestions. We may be on the verge of a paradigm shift, where the doctor‐patient relationship is no longer a dual relationship, but a triad. This paper analyses the role of AI‐based CDSS for shared decision‐making (SDM) to better comprehend its promise and associated ethical issues. Moreover, it investigates how certain AI implementations may instead foster the inappropriate paradigm of paternalism. Understanding how AI relates to doctors and influences doctor‐patient communication is essential to promote more ethical medical practice. Both doctors’ and patients’ autonomy need to be considered in the light of AI.This article is protected by copyright. All rights reserved.

Animals can only be used in research when there is a convincing scientific justification, when the expected benefits of the research outweigh the potential risks in terms of animal suffering and when the scientific objectives cannot be achieved using non-animal alternative methods. Researchers must also apply the 3R principles—replace, reduce and refine—to ensure that animals are used ethically in research. All research involving animals must have been reviewed and approved by an ethics committee prior to commencing the study; the harm–benefit analysis (HBA) is the cornerstone of ethical evaluation, as it will determine if the use of animals is justified. In this paper, we apply the 3R principles (refine, reduce, replace) and HBA used in regulation of animal research to veterinary studies of homeopathy and provide an ethical analysis of such studies. It emerges that proper application of the 3Rs and HBA effectively rules out any homeopathy research in animals.

Background Scientific research projects involving animals are required to undergo ethical evaluation, generally known as harm-benefit analysis (HBA), to ensure that they address important ethical concerns related to animal welfare and the scientific quality of the research to maximize the likelihood of their potential benefits. Research continuously shows the challenges encountered by decision-makers, prompting researchers to review how HBA is conducted and to propose tools to aid decision-making. However, the extent to which such resources are currently available, their jurisdictions of applicability, and how they guide decision-making are not entirely clear. Method Through a Scoping Review methodology, a systematic literature search was conducted in PubMed, Scopus and Web of Science for publications in Europe and North America (USA and Canada) from 1985 to 2023. Title and abstract, full-text, and reference screenings, followed by data charting, respectively, were carried out for retrieved publications using pre-developed and registered review protocol. Results 17 resources that can guide HBA and decision-making were identified. They discussed what should constitute harm to animals and benefits of research, and how these two interests can be balanced to make a decision. Some adopt mathematical calculations, some propose guidelines for committee discussions, while others propose the combination of different approaches to decision-making. Conclusions Decision-making based on deliberation among committee members should be supported over the use of scoring approaches. Additionally, making ethical decisions on a case-by-case basis is preferable to accuracy, which may not be realistically practicable.

In this chapter I consider the narrow and wider benefits of permitting assisted dying in the specific context of organ donation and transplantation. In addition to the commonly used arguments, there are two other neglected reasons for permitting assisted suicide and/or euthanasia: assisted dying enables those who do not wish to remain alive to prolong the lives of those who do, and also allows many more people to fulfill their wish to donate organs after death. In the first part of this chapter I explore the possibility of allowing those who die with assistance to donate their organs and the potential benefits of doing so in countries where some form of assisted dying is legal; in the second part I consider the added force that organ donation considerations bring to the argument in favour of legalizing assisted dying in countries where such practices remain forbidden.

This chapter explores what we actually mean by data donation after death, and what different types of data donation metadata are involved in the process. It then provides an analysis of the ethical ramifications of each of these different types of data, outlines the concepts of data advance directives and data donation guardians as one way of dealing with these issues, and considers alternative governance mechanisms. The degree of control given to the first data donors may need to be high in order to maintain trust, but over time attitudes may evolve towards everyone giving “big consent” to data donation.

The rise of self-driving cars raises numerous ethical conundrums, none has attracted so much public attention as the question of how to programme AVs in crash scenarios. How does a car respond when difficult, life-and-death choices are to be made? The most popular approach to answering this question is to employ trolley problems (trolleyology). Trolleyology, employed within the context of AVs, pits one human life against another on the basis of their distinctive characteristics: old vs young, single vs group membership, innocent vs guilty, etc. Doing so attempts to create value hierarchies for human particularity. This article argues for the failure of this approach by considering the distinctive manner in which trolley problems are employed within crash scenarios involving AVs. The article argues for the evaluative error of establishing human value on human particularity through a process of abstract individualisation. Properly speaking, individual humans are valued not on the basis of their particularities, but on the basis of their innate unsubstitutability.

Many business graduates regard management consultancy firms as a desirable, even utopian, career destination. Hythloday's description of the island of Utopia identifies several characteristics that resonate with aspects of the management consulting industry. They include its separation from the rest of humanity, the Utopians' attitude to acquiring knowledge, their commitment to their way of life, their attitude to work, the governance structure of their state, and their attitude to wealth. These characteristics may be compared and contrasted with management consultancy firms' elite identities, their knowledge intensity, their use of standardized methods, their cultural commitment to intensive work, the autonomy that they allow their members in their practice, and their commitment to achieving ambitious financial targets. This article uses Thomas More's _Utopia_ (1516) as an analytical framework for understanding the utopian visions of management consulting that some business graduates form, and for exploring how alternative, perhaps better, visions might be imagined.

Oncologists frequently have to break bad news to patients. Although they are not normally the ones who tell patients that they have cancer, they are the ones who have to tell patients that treatment is not working, and they are almost always the ones who have to tell them that they are going to die and that nothing more can be done to cure them. Perhaps the most difficult cases are those where further treatment is almost certainly futile, but there remains an extremely slim chance of yet more aggressive treatment having a near-miraculous effect. In such situations, it can be difficult for the oncologist to decide how to explain things to the patient, and how much to tell them. It can also be very difficult to achieve the correct balance between respecting the patient's autonomy and not exposing them to harm. This paper examines an example of one such case and makes three suggestions. First, that respecting autonomy cannot be achieved by maximizing information sharing only to deny patients the chance to make decisions based on that information; second, that the simplistic application of the principles of non-maleficence and respect for autonomy can lead to erroneous conclusions about the most ethical course of action; and third, that there is an extra reason, in addition to respecting patients' autonomy, for attempting near-futile last-ditch interventions: when treating rare conditions, useful evidence can be generated that will benefit future patients.

Rodger et al have interestingly argued that xenotransplantation should, if possible, entail the use of genetic pain disenhancement to prevent otherwise unavoidable pain in ‘donor’ animals.1 Their argument relies on the empirical assumption that xenotransplantation offers a realistic solution to organ shortage, and that, due to the recent clinical developments and the lack of human donors, it will thus continue for the foreseeable future. We argue below that other options should be prioritised over xenotransplantation, and that so-called ‘non-sentientist’ harms are undervalued in discussions on disenhancement. We do not challenge the empirical claim made by the authors. That is, xenotransplantation research might continue for the foreseeable future since organ demand is increasing. However, we disagree with the priority given to xenotransplantation over other solutions that are more morally desirable. We argue that, if we comply with the 3R principles (Replacement, Reduction, and Refinement of the use of animals in research) and follow a minimal welfarist reasoning (to which the authors seem to adhere), then (1) the principle of replacement demands the use of non-animal alternatives if possible and (2) there are alternative solutions that lead to morally better consequences. Schematically, there are four ways to …

Pro-life and pro-choice advocates battle for rational dominance in abortion debates. Yet, public polling (and general legal opinion) demonstrates the public’s preference for the middle ground: that abortions are acceptable in certain circumstances and during early pregnancy. Implicit in this, are two contradictory intuitions: (1) that we were all early fetuses, and (2) abortion kills no one. To hold these positions together, Harman and Räsänen have argued for the Actual Future Principle (AFP) which distinguishes between fetuses that will develop into persons and those that will never develop into persons. However intellectually ingenious their solutions are, they fail to account for a third intuition: that the death of a wanted fetus – e.g. through termination or miscarriage – is of moral significance. Not only is this practically important, but it is also supported by public opinion. The authors of this paper argue that relational ontology can modify the AFP to better account for all three intuitions. Furthermore, it further emphasizes the pivotal role of the pregnant person who relates to their own fetus in either personal or impersonal ways. Addressing the fundamental challenges of relational ontology, the authors defend the position that human personal identity is ultimately relational.

Nanotechnology, which involves manipulation of matter on a ‘nano’ scale, is considered to be a key enabling technology. Medical applications of nanotechnology are expected to significantly improve disease diagnostic and therapeutic modalities and subsequently reduce health care costs. However, there is no consensus on the definition of nanotechnology or nanomedicine, and this stems from the underlying debate on defining ‘nano’. This paper aims to present the diversity in the definition of nanomedicine and its impact on the translation of basic science research in nanotechnology into clinical applications. We present the insights obtained from exploratory qualitative interviews with 46 stakeholders involved in translational nanomedicine from Europe and North America. The definition of nanomedicine has implications for many aspects of translational research including: fund allocation, patents, drug regulatory review processes and approvals, ethical review processes, clinical trials and public acceptance. Given the interdisciplinary nature of the field and common interest in developing effective clinical applications, it is important to have honest and transparent communication about nanomedicine, its benefits and potential harm. A clear and consistent definition of nanomedicine would significantly facilitate trust among various stakeholders including the general public while minimizing the risk of miscommunication and undue fear of nanotechnology and nanomedicine.

The convergence of human and artificial intelligence is currently receiving considerable scholarly attention. Much debate about the resulting _Hybrid Minds_ focuses on the integration of artificial intelligence into the human brain through intelligent brain-computer interfaces as they enter clinical use. In this contribution we discuss a complementary development: the integration of a functional in vitro network of human neurons into an _in silico_ computing environment. To do so, we draw on a recent experiment reporting the creation of silico-biological intelligence as a case study (Kagan et al., 2022b ). In this experiment, multielectrode arrays were plated with stem cell-derived human neurons, creating a system which the authors call _DishBrain_. By embedding the system into a virtual game-world, neural clusters were able to receive electrical input signals from the game-world and to respond appropriately with output signals from pre-assigned motor regions. Using this design, the authors demonstrate how the _DishBrain_ self-organises and successfully learns to play the computer game ‘Pong’, exhibiting ‘sentient’ and intelligent behaviour in its virtual environment. The creation of such hybrid, silico-biological intelligence raises numerous ethical challenges. Following the neuroscientific framework embraced by the authors themselves, we discuss the arising ethical challenges in the context of Karl Friston’s Free Energy Principle, focusing on the risk of creating synthetic phenomenology. Following the _DishBrain’s_ creator’s neuroscientific assumptions, we highlight how DishBrain’s design may risk bringing about artificial suffering and argue for a congruently cautious approach to such synthetic biological intelligence.

The aim of this paper is to analyze the attitudes and reactions of researchers towards an authorship claim made by a researcher in a position of authority who has not made any scientific contribution to a manuscript or helped to write it. This paper draws on semi-structured interviews conducted with 33 researchers at three seniority levels working in biomedicine and the life sciences in Switzerland. This manuscript focuses on the analysis of participants’ responses when presented with a vignette describing an authorship assignment dilemma within a research group. The analysis indicates that researchers use a variety of explanations and arguments to justify inclusion of what guidelines would describe as honorary or guest authorship. Fuzzy parameters such as “substantial contribution” lead to varied interpretation and consequently convenient application of authorship guidelines in practice. Factors such as the culture of the research group, the values and practice shaped by the research leaders, the hierarchy and relative positions of power within research institutions, and the importance given to publications as the currency for academic success and growth tend to have a strong influence on authorship practice. Unjustified authorship assignment practices can be reduced to some extent by creating empowering research cultures where each researcher irrespective of his/her career stage feels empowered to confidently raise concerns without fearing adverse impact on their professional lives. However, individual researchers and research institutions currently have limited influence on established methods for evaluating academic success, which is primarily based on the number of high impact publications.

Researchers often refer to “research integrity”, “scientific integrity”, “research misconduct”, “scientific misconduct” and “research ethics”. However, they may use some of these terms interchangeably despite conceptual distinctions. The aim of this paper is to clarify what is signified by several key terms related to research integrity, and to suggest clearer conceptual delineation between them. To accomplish this task, it provides a conceptual analysis based upon definitions and general usage of these phrases and categorization of integrity-breaching behaviours in literature and guidelines, including clarification of the different domains and agents involved. In the first part of the analysis, following some initial clarifications, I explore the distinction between internal and external rules of integrity. In the second part, I explore the distinction between integrity and lack of misconduct, before suggesting a recategorisation of different types of integrity breach. I conclude that greater clarity is needed in the debate on research integrity. Distinguishing between scientific and research integrity, reassessing the relative gravity of different misbehaviours in light of this distinction, and recognising all intentional breaches of integrity as misconduct may help to improve guidelines and education.

We analyzed stable patients’ views regarding synthetic biology in general, the medical application of synthetic biology, and their potential participation in trials of synthetic biology in particular. The aim of the study was to find out whether patients’ views and preferences change after receiving more detailed information about synthetic biology and its clinical applications. The qualitative study was carried out with a purposive sample of 36 stable patients, who suffered from diabetes or gout. Interviews were transcribed verbatim, translated and fully anonymized. Thematic analysis was applied in order to examine stable patients’ attitudes towards synthetic biology, its medical application, and their participation in trials. When patients were asked about synthetic biology in general, most of them were anxious that something uncontrollable could be created. After a concrete example of possible future treatment options, patients started to see synthetic biology in a more positive way. Our study constitutes an important first empirical insight into stable patients’ views on synthetic biology and into the kind of fears triggered by the term “synthetic biology.” Our results show that clear and concrete information can change patients’ initial negative feelings towards synthetic biology. Information should thus be transmitted with great accuracy and transparency in order to reduce irrational fears of patients and to minimize the risk that researchers present facts too positively for the purposes of persuading patients to participate in clinical trials. Potential participants need to be adequately informed in order to be able to autonomously decide whether to participate in human subject research involving synthetic biology.

It is well known that prisoners’ human rights are often violated. In this chapter we examine whether guidelines can be effective in preventing such violations and in helping physicians resolve the significant conflicts of interest that they often face in trying to protect prisoners’ rights. We begin by explaining the role of clinical and ethical guidelines outside prisons, in the context of healthcare for non-incarcerated prisoners, and then the specific role of such guidelines within prisons, where the main concerns are ensuring respect for the principle of equivalence of care, and for a prisoner patient’s autonomy in health care decisions. After reviewing and analysing various national and international guidelines, we review the literature and assess whether the good practices set out in these guidelines actually translate into changes in professional behaviour and consequent benefits for prisoners. It emerges that physicians both outside and within prisons tend to be insufficiently familiar with the relevant guidelines, and that they too infrequently use the guidance to make decisions, preferring instead to use personal codes of conduct. Guidelines designed specifically for the prison context are important to ensure equivalence of care and should be better known by health care personnel and other professional groups working in prison. Further guidelines should be developed that describe challenging situations and provide concrete guidance as to how to deal with them.

Emergence of novel genome engineering technologies such as clustered regularly interspaced short palindromic repeat has refocused attention on unresolved ethical complications of synthetic biology. Biosecurity concerns, deontological issues and human right aspects of genome editing have been the subject of in-depth debate; however, a lack of transparent regulatory guidelines, outdated governance codes, inefficient time-consuming clinical trial pathways and frequent misunderstanding of the scientific potential of cutting-edge technologies have created substantial obstacles to translational research in this area. While a precautionary principle should be applied at all stages of genome engineering research, the stigma of germline editing, synthesis of new life forms and unrealistic presentation of current technologies should not arrest the transition of new therapeutic, diagnostic or preventive tools from research to clinic. We provide a brief review on the present regulation of CRISPR and discuss the translational aspect of genome engineering research and patient autonomy with respect to the “right to try” potential novel non-germline gene therapies.

In this article we summarise some previously described proposals for ethical governance of autonomous vehicles, critique them, and offer an alternative solution. Rather than programming cars to react to crash situations in the same way as humans, having humans program pre-set responses for a wide range of different potential scenarios, or applying particular ethical theories, we suggest that decisions should be made jointly between humans and cars. Given that humans lack the requisite processing capacity, and computers lack the necessary ethical capacity, the medical paradigm of advance care planning can be retooled for this new context. Advance car-crash planning provides a way to combine humans’ ethical preferences with the advanced data processing capacities of computers to enable shared decision making in collision situations.

In this article the predominant, purely theoretical perspectives on animal ethics are questioned and two important sources for empirical data in the context of animal ethics are discussed: methods of the social and methods of the natural sciences. Including these methods can lead to an empirical animal ethics approach that is far more adapted to the needs of humans and nonhuman animals and more appropriate in different circumstances than a purely theoretical concept solely premised on rational arguments. However, the potential tension between lay people’s moral judgements and ethical theory must be handled with care. The thorough analysis of qualitative data can lead to a deep insight into e.g. ethical problems with the application of laws and guidelines, practicality issues with ethical theories, personal ambivalence, and cognitive biases. The interaction between animal ethics theory and empirical findings can lead to both a more context-sensitive and applicable ethical theory and a less arbitrary folk moral system. Findings from the natural sciences can also contribute valuable information to animal ethics theory—the more we know about the properties and preferences of nonhuman animals the better we can respect them. Here, however, it is vital not to justify invasive procedures for the sake of “ethical progress”. It might be ethically required to forego some scientific findings about nonhuman animals if it is not clear how much a procedure would harm them. Only with robust empirical methods will light ultimately be shed on the nature of our moral relationship with animals

The ability to exchange samples and data is crucial for the rapidly growth of biobanking. However, sharing is based on the assumption that the donor has given consent to a given use of her or his sample. Biobanking stakeholders, therefore, must choose 1 of 3 options: obtain general consent enabling multiple future uses before taking a sample from the donor, try to obtain consent again before sharing a previously obtained sample, or look for a legally endorsed way to share a sample without the donor's consent. In this study, we present the results of 36 semistructured qualitative interviews with Swiss biobanking stakeholders regarding these options and the role of ethics committees in the process of authorizing sharing. Our results show that despite a lack of legal or guideline-based barriers to general consent, some stakeholders and ethics committees have reservations about this method of consent. In most cases, however, a general consent form is already in use. Many interviewees describe processes involving the ethics committees as time-consuming and cumbersome and their requirements as too demanding for donors/patients. Greater awareness of donors' opinions and preferences and the content of guidelines and recommendations could therefore be helpful for a better justified perspective of biobanking stakeholders and ethical committee members, equally. Finally, it may be necessary to differentiate between procedures governing future samples, where general consent is clearly desirable, and the use of old yet still relevant samples, where the option of using them without consent can be highly beneficial for research.

Switzerland has very detailed laws regulating the use of animals in agriculture, entertainment and science. There are also many Swiss laws governing the genetic modification of animals, protecting human embryos, and criminalising the creation of human/animal chimeras or hybrids. Despite all these regulations, the creation of an animal embryo that will develop a human organ using induced pluripotent stem cells and the subsequent birth of the resulting chimera would actually be permitted by current legislation. While this might appear to be an unhappy accident due to insufficient scientific foresight, I argue here that this loophole should not be closed, as the creation of human organs inside animals will probably be possible within 10 years, and Swiss laws would currently enable the use of this process to save human lives through this allogenic or autologous organ source.

The importance of medical confidentiality is obvious to anyone who has ever been a patient, and protecting private information about patients is one of the key responsibilities of healthcare professionals. However, maintaining the confidentiality of patients who are incarcerated in prisons poses several ethical challenges. In this chapter we explain the importance of confidentiality in general, and the dilemmas that sometimes face doctors with regard to it, before describing some of the specific difficulties faced by prison doctors. Although healthcare professionals working in prisons have the same duty to respect confidentiality as those working in the wider community, the conflicts of interest caused by their dual loyalty to prisoners and to prison authorities can make it very difficult to strike the right balance between respecting confidentiality and protecting prisoners and third parties. We illustrate some of the dilemmas facing prison doctors with a series of case discussions before providing suggestions for resolving these difficult situations. Ideally, a combination of great ethical and legal sensitivity on the part of healthcare professionals and general respect for prisoners’ rights on the part of other prison staff enables most issues to be resolved without the need to compromise patients’ confidentiality.

MacDougall has argued that Rawls’s liberal social theory suggests that parents who hold certain religious convictions can legitimately refuse blood transfusion on their children’s behalf. This paper argues that this is wrong for at least five reasons. First, MacDougall neglects the possibility that true freedom of conscience entails the right to choose one’s own religion rather than have it dictated by one’s parents. Second, he conveniently ignores the fact that children in such situations are much more likely to die than to survive without blood. Third, he relies on an ambiguous understanding of what is "rational" and treats children as mere extensions of their parents. Fourth, he neglects the fact that those in the original position would seek to protect themselves from persecution and enslavement and thus would not allow groups of children to be killed because of their parents’ beliefs. Finally, Rawls makes it clear that we should choose for children as we would choose for ourselves in the original position, with no particular conception of the good (such as that held by Jehovah’s Witnesses)