James Wilson

Fair allocation of scarce healthcare resources has been much studied within philosophy and bioethics, but analysis has focused on a narrow range of cases. The Covid-19 pandemic provided significant new challenges, making powerfully visible the extent to which health systems can be fragile, and how scarcities within crucial elements of interlinked care pathways can lead to cascading failures. Health system resilience, while previously a key topic in global health, can now be seen to be a vital concern in high-income countries too. Unfortunately, mainstream philosophical approaches to the ethics of rationing and prioritisation provide little guidance for these new problems of scarcity. Indeed, the cascading failures were arguably exacerbated by earlier attempts to make health systems leaner and more efficient. This paper argues that health systems should move from simple and atomistic approaches to measuring effectiveness to approaches that are holistic both in focusing on performance at the level of the health system as a whole, and also in incorporating a wider range of ethical concerns in thinking about what makes a health system good.

The pandemic significantly raised the stakes for the translation of bioethics insights into policy. The novelty, range and sheer quantity of the ethical problems that needed to be addressed urgently within public policy were unprecedented and required high‐bandwidth two‐way transfer of insights between academic bioethics and policy. Countries such as the United Kingdom, which do not have a National Ethics Committee, faced particular challenges in how to facilitate this. This paper takes as a case study the brief career of the Ethics Advisory Board (EAB) for the NHS Covid‐19 App, which shows both the difficulty and the political complexity of policy‐relevant bioethics in a pandemic and how this was exacerbated by the transience and informality of the structures through which ethics advice was delivered. It analyses how and why, after EAB's demise, the Westminster government increasingly sought to either take its ethics advice in private or to evade ethical scrutiny of its policies altogether. In reflecting on EAB, and these later ethics advice contexts, the article provides a novel framework for analysing ethics advice within democracies, defining four idealised stances: the pure ethicist, the advocate, the ethics arbiter and the critical friend.

Comprehensive Biomedical Research Centre and Centre for Philosophy, Justice and Health, UCL, First Floor, Charles Bell House, 67–73 Riding House Street, London W1W 7EJ, UK. Tel.: +44 (0)20 7679 9417; Fax: +44 (0)20 7679 9426; Email: james-gs.wilson{at}ucl.ac.uk ' + u + '@' + d + ' '//--> . Abstract This paper aims to shed some light on the difficulties we face in constructing a generally acceptable normative framework for thinking about public health. It argues that there are three factors that combine to make theorising about public health difficult, and which when taken together defeat simplistic top-down and bottom-up approaches to the design of public health policies. The first factor is the problem of complex systems, namely that the distribution of health both affects and is affected by the distribution of other goods. The second is the difficulty of defining the goals of public health: we still need to get clear about what we should mean by health in this context, and what the goals of public health should be. The third is that we stand in need of an account of how important health is relative to the importance of other goods that a just society should be trying to secure for its citizens. The paper argues that these problems should lead us to abandon the search for a ‘one-size fits all’ normative framework for thinking about public health. Rather, different approaches will be appropriate at different levels of abstraction. CiteULike Connotea Del.icio.us What's this?

This paper develops an account of rigour in the use of thought experiments in ethics. I argue that there are two separate challenges to be faced. The first is internal validity: is the thought experiment designed in a way that allows its readers to make judgements that are confident and free of bias about the hypothesis or point of principle that it aims to test? The second is external validity: to what extent do ethical judgements that are correct of the world of the thought experiment generalize to a wide variety of other contexts, including ethical decision-making in the actual world? Ensuring external validity is the harder and more important problem of rigour, yet it is one that few philosophers have even noticed, let alone begun to solve.

This paper focuses on the ethical justifiability of patents on Genetically Modified (GM) crops. I argue that there are three distinguishing features of GM crops that make it unethical to grant patents on GM crops, even if we assume that the patent system is in general justified. The first half of the paper critiques David Resnik’s recent arguments in favor of patents on GM crops. Resnik argues that we should take a consequentialist approach to the issue, and that the best way to do so is to apply the Precautionary Principle, and that the Precautionary Principle, in this case, supports patents on GM crops. I argue that his argument in favor of a consequentialist treatment is invalid; his Precautionary Principle in any case appears to be incompatible with consequentialism; and his conception of reasonable precautions is too ill-defined to have any argumentative purchase. In the second half of the paper, I argue against GM crop patents, on three grounds. First, there is insufficient evidence to say whether allowing patents on GM crops will make research go faster than not having patents, whilst there is a good reason to think that, other things being equal, a society that allows patents on GM crops will be less just than one that does not. Second, even assuming that patents on GM crops will increase the pace of GM crop research, there is no social need to do so. Third, patents on GM crops will frequently have ethically unacceptable side effects.

Cunningham and Kavic [1] rightly note that standard accounts of surgical complications—ours included—have focused on postoperative events [2, 3]. As they point out, this postoperative focus leaves open the question of how we should categorize adverse intraoperative events. They argue that we should distinguish between two types of adverse intraoperative events: those that introduce additional risk of postoperative complications and those that do not. On their account, adverse intraoperative events that introduce additional risk of postoperative complications are intraoperative complications, whereas those that do not are simple errors. Cunningham and Kavic say little about why we might want to make this distinction. We take it that the underlying purpose is to focus attention on the importance of diligence in surgical performance. Gawande defines diligence as ‘‘the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles’’ [4, p. 8]. It is clear that diligence in surgery requires us to attend not just to those adverse intraoperative events that lead to postoperative complications but also to adverse intraoperative events that increase the risk of postoperative complications. We wholeheartedly agree about the importance of diligence in surgery, both in the intraoperative and the..

Public health policies which involve active intervention to improve the health of the population are often criticized as paternalistic. This article argues that it is a mistake to frame our discussions of public health policies in terms of paternalism. First, it is deeply problematic to pick out which policies should count as paternalistic; at best, we can talk about paternalistic justifications for policies. Second, two of the elements that make paternalism problematic at an individual level—interference with liberty and lack of individual consent—are endemic to public policy contexts in general and so cannot be used to support the claim that paternalism in particular is wrong. Instead of debating whether a given policy is paternalistic, we should ask whether the infringements of liberty it contains are justifiable, without placing any weight on whether or not those infringements of liberty are paternalistic. Once we do so, it becomes apparent that a wide range of interventionist public health policies are justifiable

Verbal autopsy presents the opportunity to understand the disease burden in many low-income countries where vital registration systems are underdeveloped and most deaths occur in the community. Advances in technology have led to the development of software that can provide probable cause of death information in real time, and research considering the ethical implications of these advances is necessary to inform policy. Our research explores these ethical issues in rural Nepal using a public health ethics framework. We considered the burdens and benefits of VA and giving cause of death information to families of the deceased through qualitative research with VA interviewers, community members, national policy stakeholders and international academics. Burdens can be experienced differently, and it is important to balance the emotional burden of VA with utilization of the data to inform planning and increased access to health services. The training, support and supervision of VA interviewers should be prioritized if VA is taken to scale. Initial and ongoing community engagement is recommended in addition to engaging ethical, legal, health and policy personnel in developing protocols and systems. Integrating rigorous research while cautiously moving forward is recommended to ensure systems and responses to concerns are relevant to contexts.

Research involving human subjects is much more stringently regulated than many other nonresearch activities that appear to be at least as risky. A number of prominent figures now argue that research is overregulated. We argue that the reasons typically offered to justify the present system of research regulation fail to show that research should be subject to more stringent regulation than other equally risky activities. However, there are three often overlooked reasons for thinking that research should be treated as a special case. First, research typically involves the imposition of risk on people who do not benefit from this risk imposition. Second, research depends on public trust. Third, the complexity of the moral decision making required favors ethics committees as a regulative solution for research

This article examines when deceptive withholding of information is ethically acceptable in research. The first half analyses the concept of deception. We argue that there are two types of accounts of deception: normative and non-normative, and argue that non-normative accounts are preferable. The second half of the article argues that the relevant ethical question which ethics committees should focus on is not whether the person from whom the information is withheld will be deceived, but rather on the reasonableness of withholding the information from the person who is deceived. We further argue that the reasonableness of withholding information is dependent on the context. The last section examines how the context of research should shape our judgements about the circumstances in which withholding information from research participants is ethically acceptable. We argue that some important features of research make it more difficult to justify withholding information in the context of research than elsewhere

DeGrazia argues that post-persons have as much justification in believing that they have higher moral status than persons as persons have in believing that they have higher moral status than animals. DeGrazia's claim presupposes that what Buchanan calls the “moral equality assumption” is false. This article argues that DeGrazia has given us no reason to disbelieve the moral equality assumption. Further, even if DeGrazia's arguments about moral status were sound, it is unclear that his first-order normative claims about how we should weigh human against animal interests would follow

In the book Valuing Health, Daniel Hausman sets out a normative framework for assessing social policy, which he calls restricted consequentialism. For the restricted consequentialist, government policy-making not only is, but ought to be, largely siloed in individual government departments. Each department has its own goal linked to a fundamental public value, which it should pursue in a maximizing way. I argue that, first, Hausman’s argument appears to be internally inconsistent: his case for thinking that health policy should default to a form of maximization is plausible only if a much narrower vision of the goals of policy is adopted than Hausman thinks appropriate in the case of education. Secondly, it turns out that none of Hausman’s analysis helps us with the crucial question of how maximization should be constrained by other values—a question that even on Hausman’s account looks to be crucial, and that will be even more important if adopt a broader perspective on the purposes of health policy than Hausman allows.

Drugs are much more expensive whilst they are subject to patent protection than once patents expire: patented drugs make up only 20% of NHS drugs prescriptions, but consume 80% of the total NHS drugs bill. This article argues that, given the relatively uncontroversial assumption that we should save the greater number in cases where all are equally deserving and we cannot save both groups, it is more difficult than is usually thought to justify why publicly funded healthcare systems should pay for patented treatments. The claim to medical treatment of those who will be sick with a given condition once the patent runs out is just as strong as those who are sick with it now, but we will be able to treat more people with the same unit of resource in the future. Hence, when resource constraints entail that both cannot be funded, publicly funded healthcare systems ought to wait until patents expire before approving drugs for general use in the publicly funded system

The idea that there is something ethically corrupt or ethically corrupting about Nietzsche’s work is an anathema to Nietzsche scholars today. Although there are some serious moral philosophers, such as Philippa Foot, Jonathan Glover and Martha Nussbaum who write about Nietzsche whilst finding his position ethically deplorable, most Nietzsche scholars tend to focus rather more heavily on his positive aspects. This means that negative ethical assessments of Nietzsche now tend to be relatively few and far between, and given that they tend to be composed by people who know the texts less well than the dedicated Nietzsche scholars, these criticisms can usually be swatted away quite easily. There are two halves to this paper. The first half sets up the problem for the Nietzsche interpreter: the moral equality of human beings is the basic idea through which we (now) think about morality; and Nietzsche’s views on the nature of human ethical life commit him to opposing the moral equality of human beings. The second half of the paper examines Nietzsche’s critique of moral egalitarianism in more detail. Nietzsche’s critique, I suggest, is composed of two parts: a negative and a positive. The negative part (the slave morality thesis) argues that (a) we should make a distinction between moralities of affirmation and moralities of denial; and (b) all moralities which have the equality of human beings as their fundamental value are moralities of denial. The positive part, which, following Nietzsche, I shall call the pathos of distance thesis claims that human greatness requires a feeling of great height from which the great person looks down in lofty contempt on others. I shall argue that it is false to claim that all moralities which have the equality of human beings as their fundamental value are moralities of denial, and that the pathos of distance thesis is either false or question begging or both. Hence there is no reason, even being as generous to Nietzsche as we can be, to think his critique should force us to give up moral egalitarianism. However, even if not all egalitarian moralities are moralities of denial, it is certainly true that some are, which leaves us with a very difficult question: how do we ensure that our belief in the moral equality of human beings forms part of a morality of affirmation rather than one of denial?

In this chapter we argue that the four principles of medical ethics -- beneficence, non-maleficence, respect for autonomy and justice (Beauchamp & Childress, 2001; Gillon, 1985), a new Family Interest Principle (introduced below) and a consideration of ‘capacity’ provide a reasoned practice guide for work with mothers experiencing health problems, focussing here on mental health when a parent is a patient. Our concern is the relationship of the clinician with a parent and through the parent their child. Ethics of service provision or services planning (e.g. Culyer, 2001; McLachlan, 2005; see also Newbigging and Paul, chapter xxx), or the provision of other services (e.g. education, child protection) although intensely relevant to this area are not addressed in this chapter nor will we deal with the complex aspects of medical ethics relating to the treatment of children (Baines, 2008). We use the term ‘parent’ to refer to any adult person who fulfils a substantive parental role with a child. Defining what counts as a family will in certain circumstances be contentious. There are diverse patterns of family arrangements that may be influenced by cultural, political economic and temporal factors. For the purposes of our discussion, we define a family in terms of its role in childrearing, as a group of at least one adult and at least one child, living together in long term relationships on an ongoing basis with vested interest in the well being of each of the family members.

This article introduces a symposium on Daniel Hausman’s Valuing Health: Well-Being, Suffering and Freedom. The symposium contains papers by Elselijn Kingma, Adam Oliver, Anna Alexandrova, Erik Nord, Alex Voorhoeve and James Wilson, with replies by Daniel Hausman. In Valuing Health, Hausman argues that, despite apparently measuring health, projects such as the Global Burden of Disease Study in fact measure judgments about the value of health. Once this has been clarified, the key question is how the value of health should be measured. Hausman argues that existing instruments measure the private value of health, that is, health’s ‘contribution to whatever the individual cares about or should care about’, whereas what should be measured for resource allocation purposes is the public value of health, that is, the value health should be accorded from the perspective of the liberal state. Hausman argues that the public value of health should be measured by the extent to which suffering and activity limitations are relieved. Each commentator engages with a different aspect of Hausman’s argument.

The WHO Commission on the Social Determinants of Health revealed that there is a 28-year disparity between the life expectancy in the poorest postcode and the richest postcode of Glasgow (CSDH, 2008). There are two sets of questions that it is important to ask about health inequalities like these: first, epidemiological questions about the mechanisms that cause inequalities in health and the measures that are effective in reducing them. Second, normative questions about which inequalities in health are wrong and why they are wrong. The papers in this symposium result from the inaugural conference of UCL's Centre for Philosophy, Justice and Health (CPJH) and focus on the relationship between these epidemiological and normative questions.

Health systems that provide for universal patient access through a scheme of prepayments—whether through taxes, social insurance, or a combination of the two—need to make decisions on the scope of coverage that they secure. Such decisions are inherently controversial, implying, as they do, that some patients will receive less than comprehensive health care, or less than complete protection from the financial consequences of ill-heath, even when there is a clinically effective therapy to which they might have access.Controversial decisions of this sort call for a public justification for covering or not covering a given treatment. Priority-setting agencies play a key role in providing such a justification. A recent...

Research involving human subjects is much more stringently regulated than many other nonresearch activities that appear to be at least as risky. A number of prominent figures now argue that research is overregulated. We argue that the reasons typically offered to justify the present system of research regulation fail to show that research should be subject to more stringent regulation than other equally risky activities. However, there are three often overlooked reasons for thinking that research should be treated as a special case. First, research typically involves the imposition of risk on people who do not benefit from this risk imposition. Second, research depends on public trust. Third, the complexity of the moral decision making required favors ethics committees as a regulative solution for research.

This paper examines the ethical issues that arise when healthcare providers act as gatekeepers to research involving vulnerable populations. Traumatised refugees serve as an example of this subset of research participants. Highlighting the particular vulnerabilities of this group, we argue that specific ethical considerations are required that go beyond the conventional research approaches. While gatekeeping responds to some of those vulnerabilities, it risks wronging through unwarranted paternalism. Instead, we will propose that a relational ethics of justice and care serves as a more appropriate framework for responding to the challenges of research involving traumatised refugees. Specifically, such a framework allows us to reflect more deeply on the role of the gatekeeper. In conclusion, we recommend that clinicians and researchers collaborate with survivors’ advisory groups in the development of specific research ethical guidelines.

As health policy-makers around the world seek to make progress towards universal health coverage, they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states’ efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points of tension stem largely from inadequate interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play.

In this article we aim to assess the ethical desirability of self-test diagnostic kits for influenza, focusing in particular on the potential benefits and challenges posed by a new, mobile phone-based tool currently being developed by i-sense, an interdisciplinary research collaboration based at University College London and funded by the Engineering and Physical Sciences Research Council. Our study adopts an empirical ethics approach, supplementing an initial review into the ethical considerations posed by such technologies with qualitative data from three focus groups. Overall, we map a range of possible considerations both for and against the use of such technologies, synthesizing evidence from a range of secondary literature, as well as identifying several new considerations previously overlooked. We argue that no single consideration marks these technologies as either entirely permissible or impermissible but rather tools which have the potential to incur certain costs and benefits, and that context is important in determining these. In the latter stages of the article, we explain how developers of such technologies might seek to mitigate such costs and reflect on the possible limitations of the empirical ethics method brought out during the study. Not applicable.