Lucie White

How could the initial, drastic decisions to implement “lockdowns” to control the spread of COVID-19 infections be justifiable, when they were made on the basis of such uncertain evidence? We defend the imposition of lockdowns in some countries by first, and focusing on the UK, looking at the evidence that undergirded the decision, second, arguing that this provided us with sufficient grounds to restrict liberty given the circumstances, and third, defending the use of poorly-empirically-constrained epidemiological models as tools that can legitimately guide public policy.

Models not only represent but may also influence their targets in important ways. While models’ abilities to influence outcomes has been studied in the context of economic models, often under the label ‘performativity’, we argue that this phenomenon also pertains to epidemiological models, such as those used for forecasting the trajectory of the Covid-19 pandemic. After identifying three ways in which a model by the Covid-19 Response Team at Imperial College London may have influenced scientific advice, policy, and individual responses, we consider the implications of epidemiological models’ performative capacities. We argue, first, that performativity may impair models’ ability to successfully predict the course of an epidemic; but second, that it may provide an additional sense in which these models can be successful, namely by changing the course of an epidemic.

Zu Beginn der Pandemie im Frühjahr 2020, und nach einem weitreichenden Lockdown, ruhten große Erwartungen auf Corona-Warn-Apps, um einen erneuten Lockdown zu verhindern. Diese Erwartungen haben sich nicht erfüllt; stattdessen wurden in Deutschland als Reaktion auf erneute Wellen von COVID-19 weitere Kontaktbeschränkungen verordnet. Wie hätte die digitale Kontaktverfolgung wirksamer gestaltet werden können? Wir argumentieren, dass es ein Spannungsfeld zwischen der Datensparsamkeit und einer wirksamen Bekämpfung der Pandemie besteht. Im Gegensatz zur deutschen Corona-Warn-App wäre eine Variante der App, in der pseudonymisierte Kennungen zentral gespeichert werden, in der Lage gewesen, die Effektivität der Kontaktverfolgung entscheidend zu erhöhen. Schließlich argumentieren wir, dass das Spannungsfeld zwischen Datensparsamkeit und einer wirksamen Pandemiebekämpfung sich jedoch nicht in einen Wertekonflikt übersetzt, weil zentrale Systeme uns trotz ihrer erhöhten Wirksamkeit nicht vor deutlich gravierendere Probleme beim Datenschutz stellen als dezentrale Systeme. Zentrale Möglichkeiten der digitalen Kontaktverfolgung wären daher ethisch gerechtfertigt, um auf weitere Wellen von COVID-19 oder auf zukünftige Epidemien effektiv zu reagieren.

At the beginning of the COVID-19 pandemic, high hopes were placed on digital contact tracing. Digital contact tracing apps can now be downloaded in many countries, but as further waves of COVID-19 tear through much of the northern hemisphere, these apps are playing a less important role in interrupting chains of infection than anticipated. We argue that one of the reasons for this is that most countries have opted for decentralised apps, which cannot provide a means of rapidly informing users of likely infections while avoiding too many false positive reports. Centralised apps, in contrast, have the potential to do this. But policy making was influenced by public debates about the right app configuration, which have tended to focus heavily on privacy, and are driven by the assumption that decentralised apps are “privacy preserving by design”. We show that both types of apps are in fact vulnerable to privacy breaches, and, drawing on principles from safety engineering and risk analysis, compare the risks of centralised and decentralised systems along two dimensions, namely the probability of possible breaches and their severity. We conclude that a centralised app may in fact minimise overall ethical risk, and contend that we must reassess our approach to digital contact tracing, and should, more generally, be cautious about a myopic focus on privacy when conducting ethical assessments of data technologies.

At the beginning of the COVID-19 pandemic, high hopes were put on digital contact tracing, using mobile phone apps to record and immediately notify contacts when a user reports as infected. Such apps can now be downloaded in many countries, but as second waves of COVID-19 are raging, these apps are playing a less important role than anticipated. We argue that this is because most countries have opted for app configurations that cannot provide a means of rapidly informing users of likely infections while avoiding too many false positive reports. Mathematical modelling suggests that differently configured apps have the potential to do this. These require, however, that some pseudonymised data be stored on a central server, which privacy advocates have cautioned against. We contend that their influential arguments are subject to two fallacies. First, they have tended to one-sidedly focus on the risks that centralised data storage entails for privacy, while paying insufficient attention to the fact that inefficient contact tracing involves ethical risks too. Second, while the envisioned system does entail risks of breaches, such risks are also present in decentralised systems, which have been falsely presented as ‘privacy preserving by design’. When these points are understood, it becomes clear that we must rethink our approach to digital contact tracing in our fight against COVID-19. There are no data in this work.

Were governments justified in imposing lockdowns to contain the spread of the COVID-19 pandemic? We argue that a convincing answer to this question is to date wanting, by critically analyzing the factual basis of a recent paper, “How Government Leaders Violated Their Epistemic Duties During the SARS-CoV-2 Crisis” (Winsberg et al. 2020). In their paper, Winsberg et al. argue that government leaders did not, at the beginning of the pandemic, meet the epistemic requirements necessitated to impose lockdowns. We focus on Winsberg et al.’s contentions that knowledge about COVID-19 resultant projections were inadequate; that epidemiologists were biased in their estimates of relevant figures; that there was insufficient evidence supporting the efficacy of lockdowns; and that lockdowns cause more harm than good. We argue that none of these claims are sufficiently supported by evidence, thus impairing their case against lockdowns, and leaving open the question of whether lockdowns were justified.

As many Western countries emerged from initial periods of lockdown in spring 2020, they had brought COVID-19 infection rates down significantly. This was followed, however, with more drastic second and third waves of viral spread, which many of these same countries are struggling to bring under control, even with the implementation of further periods of lockdown. Could this have been prevented by policymakers? We revisit two strategies that were focus of much discussion during the early stages of the pandemic, and which were implemented in several Western countries, albeit in a weakened form. These strategies both proceed by targeting certain segments of the population, while allowing others to go about their lives unhindered. The first suggests selectively isolating those that would most likely suffer severe adverse effects if infected – in particular the elderly. The second involves identifying and quarantining those who are likely to be infected through a contact tracing app that would centrally store users’ information. We suggest that both strategies showed promise in preventing the need for further lockdowns, albeit in a significantly more stringent form than anything that was implemented in Western countries. We then proceed to an ethical evaluation of these more stringent policies. We contend that selective isolation strategies face severe ethical problems due to its discriminatory nature, while the ethical issues with a more aggressive contact tracing regime can be mitigated. This analysis has implications for how to respond effectively and ethically to future pandemics, and perhaps contains lessons on how to successfully emerge from our current predicament.

When talking about personal identity in the context of medical ethics, ethicists tend to borrow haphazardly from different philosophical notions of personal identity, or to abjure these abstract metaphysical concerns as having nothing to do with practical questions in medical ethics. In fact, however, part of the moral authority for respecting a patient’s self-regarding decisions can only be made sense of if we make certain assumptions that are central to a particular, psychological picture of personal identity, namely, that patients will remain psychologically connected to a certain degree with their future selves. I draw this out, show problems with approaches in medical ethics based on alternate theories of personal identity that do not recognise this, and explore some important implications. Namely, I show how this recognition can better explain the circumstances under which we should respect advance directives and why, and how it can better make sense of patient fears that they will not "survive" personality-altering deep brain stimulation procedures, and provide guidance on approaching patient decisions concerning this type of procedure in a manner that captures and addresses such concerns.

At this stage of the COVID-19 pandemic, two policy aims are imperative: avoiding the need for a general lockdown of the population, with all its economic, social and health costs, and preventing the healthcare system from being overwhelmed by the unchecked spread of infection. Achieving these two aims requires the consideration of unpalatable measures. Julian Savulescu and James Cameron argue that mandatory isolation of the elderly is justified under these circumstances, as they are at increased risk of becoming severely ill from COVID-19, and are thus likely to put disproportionate strain on limited healthcare resources. However, their arguments for this strategy are contingent on the lack of viable alternatives. We suggest that there is a possible alternative: a mandatory, centralised contact-tracing app. We argue that this strategy is ethically preferable to the selective isolation of the elderly, because it does not target members of a certain group, relying instead on the movements of each individual, and because it avoids the extended isolation of certain members of the society. Although this type of contact-tracing app has its drawbacks, we contend that this measure warrants serious consideration.

The burgeoning field of biomedical research involving the mixture of human and animal materials has attracted significant ethical controversy. Due to the many dimensions of potential ethical conflict involved in this type of research, and the wide variety of research projects under discussion, it is difficult to obtain an overview of the ethical debate. This paper attempts to remedy this by providing a systematic review of ethical reasons in academic publications on human-animal chimera research. We conducted a systematic review of the ethical literature concerning human-animal chimeras based on the research question: “What ethical reasons have been given for or against conducting human-animal chimera research, and how have these reasons been treated in the ongoing debate?” Our search extends until the end of the year 2017, including MEDLINE, Embase, PhilPapers and EthxWeb databases, restricted to peer-reviewed journal publications in English. Papers containing ethical reasons were analyzed, and the reasons were coded according to whether they were endorsed, mentioned or rejected. Four hundred and thirty-one articles were retrieved by our search, and 88 were ultimately included and analyzed. Within these articles, we found 464 passages containing reasons for and against conducting human-animal chimera research. We classified these reasons into five categories and, within these, identified 12 broad and 31 narrow reason types.15% of the retrieved passages contained reasons in favor of conducting chimera research, while 85% of the passages contained reasons against it. The reasons against conducting chimera research fell into four further categories: reasons concerning the creation of a chimera, its treatment, reasons referring to metaphysical or social issues resulting from its existence and to potential downstream effects of chimera research. A significant proportion of identified passages fell under Category C. We hope that our results, in revealing the conceptual and argumentative structure of the debate and highlighting some its most notable tendencies and prominent positions, will facilitate continued discussion and provide a basis for the development of relevant policy and legislation.

Andrea Wiggins and John Wilbanks’ article (2019) presents us with a welcome overview of the neglected, novel ethical issues raised by the advent of citizen science in health and biomedical contexts. This contribution takes a rather different approach, focusing on a very specific (yet also overlooked) problem in this context - the ethical implications of self-administered genetic testing. This problem, however, is particularly illustrative of the “ethics gap” between traditional medical settings and new public-driven scientific practices, emphasized by Wiggins and Wilbanks in their more wide-ranging treatment.

Gerben Meynen (2019) invites us to consider the potential ethical implications of what he refers to as “thought apprehension” technology for psychiatric practice, that is, technologies that involve recording brain activity, and using this to infer what people are thinking (or intending, desiring, feeling, etc.). His article is wide-ranging, covering several different ethical principles, various situations psychiatrists might encounter in therapeutic, legal and correctional contexts, and a range of potential incarnations of this technology, some more speculative than others. Although Meynen’s article raises some highly relevant potential implications of some “thought apprehension”-based neurotechnologies, which are certainly worthy of further exploration, I suggest that Meynen’s analysis is beset by two problems. First, some of the technologies that form the focus of his discussion are too speculative, and second, due to the many issues under consideration, some problems are not adequately characterized, relevant ethical principles are misidentified, and valuable literature is not sufficiently engaged with. Consideration of these weaknesses might allow us to better see how to conduct a fruitful analysis of speculative neurotechnologies.

The prospective introduction of autonomous cars into public traffic raises the question of how such systems should behave when an accident is inevitable. Due to concerns with self-interest and liberal legitimacy that have become paramount in the emerging debate, a contractarian framework seems to provide a particularly attractive means of approaching this problem. We examine one such attempt, which derives a harm minimisation rule from the assumptions of rational self-interest and ignorance of one’s position in a future accident. We contend, however, that both contractarian approaches and harm minimisation standards are flawed, due to a failure to account for the fundamental difference between those ‘involved’ and ‘uninvolved’ in an impending crash. Drawing from classical works on the trolley problem, we show how this notion can be substantiated by reference to either the distinction between negative and positive rights, or to differences in people’s claims. By supplementing harm minimisation with corresponding constraints, we can develop crash algorithms for autonomous cars which are both ethically adequate and promise to overcome certain significant practical barriers to implementation.

Nancy Jecker and Andrew Ko (2017) wish to present an account of personal identity which captures what matters to the patient and places the patient at the center of medical decisions. They focus particularly on medical interventions in the brain that can cause drastic changes in personality; under what circumstances should we say the patient has 'survived' these changes? More specifically, how can we best understand the notion of survival in a way that captures what is of concern to the patient? This goal is laudable, however, their chosen account of narrative identity is ill-suited to this task for one reason in particular; it does not give sufficient guidance in predicting which medical decisions are likely to be experienced as disruptive to identity.

The notion of respect for autonomy dominates bioethical discussion, though what qualifies precisely as autonomous action is notoriously elusive. In recent decades, the notion of autonomy in medical contexts has often been defined in opposition to the notion of autonomy favoured by theoretical philosophers. Where many contemporary theoretical accounts of autonomy place emphasis on a condition of “authenticity”, the special relation a desire must have to the self, bioethicists often regard such a focus as irrelevant to the concerns of medical ethics, and too stringent for use in practical contexts. I argue, however, that the very condition of authenticity that forms a focus in theoretical philosophy is also essential to autonomy and competence in medical ethics. After tracing the contours of contemporary authenticity-based theories of autonomy, I consider and respond to objections against the incorporation of a notion of authenticity into accounts of autonomy designed for use in medical contexts. By looking at the typical problems that arise when making judgments concerning autonomy or competence in a medical setting, I reveal the need for a condition of authenticity—as a means of protecting choices, particularly high-stakes choices, from being restricted or overridden on the basis of intersubjective disagreement. I then turn to the treatment of false and contestable beliefs, arguing that it is only through reference to authenticity that we can make important distinctions in this domain. Finally, I consider a potential problem with my proposed approach; its ability to deal with anorexic and depressive desires.

The purpose of this dissertation is to identify some of the most pressing problems in the dominant contemporary approach to research ethics, and to devise an alternative approach that avoids these problems. I contend that the fundamental ethical values invoked in human research are often appealed to in contradictory or ambiguous ways, or in ways that do not adequately capture or do not show an adequate understanding of the specific ethical concerns of human research. One significant problem in this domain is that values for ethical research are often unreflectively imported from medical therapy, producing ill-suited guidelines that cannot capture the different ethical situations that arise in the context of research. Furthermore, ethical guidelines in this area are often not developed with a sufficient understanding of the deep philosophical issues that they invoke. I suggest that we can address these problems through examining the fundamental ethical concerns of research on a philosophical level. This method will reveal severe problems with the approach to two of the ethical values underlying research; beneficence and respect for autonomy (or respect for persons). Once the nature of these problems has been revealed, and with reference to ethical problems that typically arise in the domain of research, I construct a coherent philosophical foundation for research ethics, which both avoids these deep-seated problems and better captures the ethical issues that arise in the domain of human research. I argue that we need to radically depart from the values of beneficence and autonomy/respect for persons as they are currently understood in the guidelines. We need an idea of beneficence that is clearly distinct from that which is used in the therapeutic medical context from which this notion is currently drawn. I also contend that we need to move away from autonomy as a central value in research ethics. I posit an alternative choice-based approach to informed consent which is concerned both with respecting agents’ freedom of choice, and also with their wellbeing, as providing a good means of protecting and promoting the interests of the individual research subject. Although these two imperatives are often thought to clash on a fundamental level, I will show that, in research ethics, they can be reconciled with minimal conflict. Though this represents a departure from the ethics of medical therapy, this approach is far more suited to the context of research. This theoretical basis for informed consent can help to clarify the ethical problems that are specific to this domain and provide us with relevant ethical guidance in research ethics.

Respect for autonomy and beneficence are frequently regarded as the two essential principles of medical ethics, and the potential for these two principles to come into conflict is often emphasised as a fundamental problem. On the one hand, we have the value of beneficence, the driving force of medicine, which demands that medical professionals act to protect or promote the wellbeing of patients or research subjects. On the other, we have a principle of respect for autonomy, which demands that we respect the self-regarding decisions of individuals. As well as routinely coming into opposition with the demands of beneficence in medicine, the principle of respect for autonomy in medical ethics is often seen as providing protection against beneficial coercion (i.e. paternalism) in medicine. However, these two values are not as straightforwardly opposed as they may appear on the surface. In fact, the way that we understand autonomy can lead us to implicitly sanction a great deal of paternalistic action, or can smuggle in paternalistic elements under the guise of respect for autonomy. This paper is dedicated to outlining three ways in which the principle of respect for autonomy, depending on how we understand the concept of autonomy, can sanction or smuggle in paternalistic elements. As the specific relationship between respect for autonomy and beneficence will depend on how we conceive of autonomy, I begin by outlining two dominant conceptions of autonomy, both of which have great influence in medical ethics. I then turn to the three ways in which how we understand or employ autonomy can increase or support paternalism: firstly, when we equate respect for autonomy with respect for persons; secondly, when our judgements about what qualifies as an autonomous action contain intersubjective elements; and thirdly, when we expect autonomy to play an instrumental role, that is, when we expect people, when they are acting autonomously, to act in a way that promotes or protects their own wellbeing. I then provide a proposal for how we might work to avoid this. I will suggest that it may be impossible to fully separate paternalistic elements out from judgements about autonomy. Instead, we are better off looking at why we are motivated to use judgements about autonomy as a means of restricting the actions of patients or research subjects. I will argue that this is a result of discomfort about speaking directly about our beneficent motivations in medical ethics. Perhaps we can reduce the incentive to smuggle in these beneficent motivations under the guise of autonomy by talking directly about beneficent motivations in medicine. This will also force us to recognise paternalistic motivations in medicine when they appear, and to justify paternalism where it occurs.

In accordance with a recent statement released by the World Health Organization, the Canadian province of Ontario is moving to ban payment for plasma donation. This is partially based on contentions that remuneration for blood and blood products undermines autonomy and personal dignity. This paper is dedicated to evaluating this claim. I suggest that traditional autonomy-based arguments against commodification of human body parts and substances are less compelling in the context of plasma donation in Canada, but that there is another autonomy-based objection to paid plasma donation that has not received sufficient attention. Namely, the stigma that surrounds exchanging plasma for payment makes it difficult to make an autonomous decision to engage in this activity. I suggest that this problem can be overcome in one of two ways; by banning payment for plasma, or by reducing the stigma surrounding this practice. I provide an indication of how we might work to achieve the latter, contending that this possibility should be taken seriously, due to the difficulties in achieving a sufficient supply of plasma without remuneration

Euthanasia and assisted suicide have proved to be very contentious topics in medical ethics. Some ethicists are particularly concerned that allowing physicians to carry out these procedures will undermine their professional obligations and threaten the very goals of medicine. However, I maintain that the fundamental goals of medicine not only do not preclude the practice of euthanasia and assisted suicide by physicians, but can in fact be seen to support these practices in some instances. I look at two influential views of the goals of medicine, one based on the broad guiding principles of autonomy, beneficence and nonmaleficence, and the other focusing on several more concrete aims, concluding that both approaches can be seen to support euthanasia and assisted suicide. I then turn to the popular concern that allowing physicians to carry out euthanasia and assisted suicide will lead to widespread abuse. I argue that the possibility for abuse can be minimised if we make the patient's autonomous consent an essential requirement of the practice.

Medical ethicists conventionally assume that the requirement to employ informed consent procedures is grounded in autonomy. It seems intuitively plausible that providing information to an agent promotes his autonomy by better allowing him to steer his life. However, James Taylor questions this view, arguing that any notion of autonomy that grounds a requirement to inform agents turns out to be unrealistic and self-defeating. Taylor thus contends that we are mistaken about the real theoretical grounds for informed consent procedures. Through analysing Taylor's arguments and showing that they do not stand up to scrutiny, it is possible to defend the view that autonomy is a plausible theoretical basis for informed consent, and to enhance our understanding of the relationship between autonomy and informed consent.

Recent developments in neuroscience have inspired proposals to perform deep brain stimulation on psychopathic detainees. We contend that these proposals cannot meet important ethical requirements that hold for both medical research and therapy. After providing a rough overview of key aspects of psychopathy and the prospects of tackling this condition via deep brain stimulation, we proceed to an ethical assessment of such measures, referring closely to the distinctive features of psychopathic personality, particularly the absence of subjective suffering and a lack of moral motivation. Scrutiny of these factors reveals that two essential bioethical criteria, individual medical benefit and voluntary informed consent, cannot be met in performing neurosurgical experiments or treatments on psychopathic inmates.