Lucy Frith

This paper responds to the commentaries from Stacy Carter and Alan Cribb. We pick up on two main themes in our response. First, we reflect on how the process of setting standards for empirical bioethics research entails drawing boundaries around what research counts as empirical bioethics research, and we discuss whether the standards agreed in the consensus process draw these boundaries correctly. Second, we expand on the discussion in the original paper of the role and significance of the concept of ‘integrating’ empirical methods and ethical argument as a standard for research practice within empirical bioethics.

This paper examines the role of clinical ethics committees (CECs) in infertility clinics in the UK, focusing on whether they usefully support infertility clinicians' ethical decision-making. The overall aim of the study reported here was to investigate how infertility clinicians approached and handled ethical problems in their everyday practice and this paper reports on one aspect of these data – what they thought about the use of CECs. This paper gives an overview of what arrangements there are for such committees in infertility clinics; considers why the clinicians used CECs; and examines how these committees provided a useful function in the infertility setting and contributed to making ‘good’ ethical decisions. Finally, the paper examines how the form of ethics support can be developed and strengthened, and concludes with recommendations for a particular model of CECs in infertility units – a designated CEC for each infertility unit

The COVID-19 pandemic will generate vexing ethical issues for the foreseeable future and many journals will be open to content that is relevant to our collective effort to meet this challenge. While the pandemic is clearly the critical issue of the moment, it’s important that other issues in medical ethics continue to be addressed as well. As can be seen in this issue, the Journal of Medical Ethics will uphold its commitment to publishing high quality papers on the full array of medical ethics. At the same time, JME aims to be a premiere home for ground-breaking scholarship on the ethical issues raised by COVID-19. Toward this end, we have a number of papers that are freely available online and for which production has been fast-tracked.1–5 A challenge for authors who want to write about the pandemic is the rapidly evolving nature of the situation and the time it takes for journal content to be reviewed and published, even when fast-tracked. For that reason, all authors who would like to submit a paper on the pandemic can also submit a post to the JME blog prior to submitting a full paper to the journal. Those interested in writing for the JME blog should contact one of its editors, Hazem Zohny or Mike King. Over the last 3 weeks, 30 high-quality commentaries on the pandemic have been posted to the blog. These posts are circulated widely via the JME Twitter and Facebook feeds and have stimulated significant …

This document is designed to give guidance on assessing researchers in bioethics/medical ethics. It is intended to assist members of selection, confirmation and promotion committees, who are required to assess those conducting bioethics research when they are not from a similar disciplinary background. It does not attempt to give guidance on the quality of bioethics research, as this is a matter for peer assessment. Rather it aims to give an indication of the type, scope and amount of research that is the expected in this field. It does not cover the assessment of other activities such as teaching, policy work, clinical ethics consultation and so on, but these will be mentioned for additional context. Although it mentions the UK’s Research Excellence Framework, it is not intended to be a detailed analysis of the place of bioethics in the REF.

Like any discipline, bioethics is a developing field of academic inquiry; and recent trends in scholarship have been towards more engagement with empirical research. This ‘empirical turn’ has provoked extensive debate over how such ‘descriptive’ research carried out in the social sciences contributes to the distinctively normative aspect of bioethics. This paper will address this issue by developing a practical research methodology for the inclusion of data from social science studies into ethical deliberation. This methodology will be based on a naturalistic conception of ethical theory that sees practice as informing theory just as theory informs practice – the two are symbiotically related. From this engagement with practice, the ways that such theories need to be extended and developed can be determined. This is a practical methodology for integrating theory and practice that can be used in empirical studies, one that uses ethical theory both to explore the data and to draw normative conclusions

Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion. We conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection. Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons. The reasons and their associated mentions in this category outnumber those in the sum of the other three categories. We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.

On 22nd September 2020 the UK Government announced new lockdown restrictions to supress the COVID-19 virus, with some areas of England having more restrictive lockdown guidance. Students in a number of cities have been confined to their halls of residences after outbreaks of COVID-19 and in Manchester security guards were preventing students leaving the buildings. The scientific community are, unsurprisingly, divided over the question of how far lockdowns should extend.1 Monday 21st September 2020 saw the publication of two open letter to the UK government and Chief Medical Officers. One group, Sunetra Gupta et al,2 argued for a selective lockdown targeting the most vulnerable. The other, headed by Trisha Greenhalgh, arguing that attempts to suppress the virus should operate across the whole community.3 As we enter what appears to be a second wave of COVID-19 infections and accompanying lockdown measures, ethical debates over the appropriateness and extent of such measures are critical. Julian Savulescu and James Cameron4 in their article on lockdown of the elderly and why this is not ageist, put forward the case that, ‘an appropriate approach may be to lift the general lockdown but implement selective isolation of the elderly.’ Their central claim is that selective isolation of the elderly is to be preferred to imposing lockdown on all members of society. The aim of lockdown, restricting movement and key activities, is designed to reduce the number of deaths from COVID-19 and also to prevent the healthcare system from becoming overwhelmed. As the elderly are at significantly more risk of having severe cases of COVID-19 and therefore more likely to place demands on healthcare services, they are clearly prime candidates for lockdown measures, measures that will not only benefit them but the whole of society. This is not ageist as …

There are substantial numbers of frozen embryos in storage that will not be used by those who produced them for their own fertility treatment. One option for such embryos is to donate them to others to use in their fertility treatment. There has been considerable debate about how this process should be organized. In the US, there are embryo adoption programmes that mediate between those relinquishing embryos and potential recipients. This is a form of conditional embryo donation, where the relinquishing couple can choose the recipient of their embryo. This article examines the ethical debate over conditional embryo donation for family building and explores the question of whether those who have unused frozen embryos should be able to determine who receives their embryos. The main objections to conditional embryo donation are examined: first, the embryo is not a person and therefore such concern over the placement of an embryo is unwarranted; secondly, potential donors might impose morally problematic conditions on who should receive their embryo; and thirdly, there are practical difficulties regarding organizational arrangements and the associated costs involved. It will be concluded that these objections can be countered and that if people wish to donate and receive embryos in this way there is no ethical objection to them doing so

People should be allowed to decide how and where they wish to be tested for HIV without there being a formal requirement for pretest counsellingIn his paper, Ethics of HIV testing in general practice without informed consent, Fraser argues that pretest counselling and informed consent are pillars of the ethical conduct of HIV testing. In my response I want to look critically at these contentions. While I will agree with Fraser that it is always necessary to get informed consent from a patient for an HIV test I will argue that an emphasis on pretest counselling as a prerequisite for testing can actually undermine a patient’s autonomy, the very principle that informed consent seeks to promote.This response will start with an analysis of Case Two as this highlights the fundamental importance of informed consent. It will then go on to look at Case One and show how the special application of informed consent in the field of HIV testing can, in certain circumstances, lead to a reduction in patient autonomy.CASE TWOIn Fraser’s second case a 43 year old married clergyman presented with a recurrent infection of his little toe and the preliminary lab reports queried Kaposi’s sarcoma. The general practitioner thought that because of the patient’s lifestyle there was little risk of HIV infection, “suggesting the possibility of HIV, when it is unexpected and the risk low, can in itself cause anxiety and distress”. On these grounds the GP did not call the patient in for an HIV test.Some might argue that the GP should have tested the clergyman. This could have been done in one of two ways: by seeking his explicit consent for an HIV test, or by getting blanket consent for a range of tests, including HIV, without HIV being explicitly mentioned. …

Population-level biomedical research offers new opportunities to improve population health, but also raises new challenges to traditional systems of research governance and ethical oversight. Partly in response to these challenges, various models of public involvement in research are being introduced. Yet, the ways in which public involvement should meet governance challenges are not well understood. We conducted a qualitative study with 36 experts and stakeholders using the World Café method to identify key governance challenges and explore how public involvement can meet these challenges. This brief report discusses four cross-cutting themes from the study: the need to move beyond individual consent; issues in benefit and data sharing; the challenge of delineating and understanding publics; and the goal of clarifying justifications for public involvement. The report aims to provide a starting point for making sense of the relationship between public involvement and the governance of population-level biomedical research, showing connections, potential solutions and issues arising at their intersection. We suggest that, in population-level biomedical research, there is a pressing need for a shift away from conventional governance frameworks focused on the individual and towards a focus on collectives, as well as to foreground ethical issues around social justice and develop ways to address cultural diversity, value pluralism and competing stakeholder interests. There are many unresolved questions around how this shift could be realised, but these unresolved questions should form the basis for developing justificatory accounts and frameworks for suitable collective models of public involvement in population-level biomedical research governance.

It is nearly 20 years since Tony Hope wrote an editorial in this journal on Empirical Medical Ethics,1 arguing for both a recognition of the increasing amount of work being done in ‘empirical ethics’ and for its importance as a new direction for medical ethics research. Since then empirical ethics has flourished, with debates over the role of ‘empirical’ data in ethical reasoning producing a growing body of literature and the JME and other bioethics journals regularly publishing empirical studies. While bio/medical ethics has grappled with ‘incorporating’ or using more empirical data in ethical analysis, with varying degrees of success, and some criticism, there has not been a corresponding willingness of more empirical disciplines to embrace ethical analysis. This is a particular lack for applied research areas that see their role as predominately influencing policy and practice, such as health services research. Health services research ‘is the integration of epidemiological, sociological, economic, and other analytic sciences in the study of health services.’ Whose ‘main goals … are to identify the most effective ways to organize, manage, finance, and deliver high quality care; reduce medical errors; and improve patient safety’.2 Health services research brings together a wide variety of disciplines and would seem ideally placed to include ethics. However, if you search health services research journals and conference programmes there is very little consideration of ethics as a substantive topic and often scant attention paid to the ethical issues that might be raised by an intervention or policy. Ethics and ethical issues are generally confined to discussions over priority setting, and occasionally health technology assessment, with other areas of health service research seldom engaging in ethical debate. In the Encyclopaedia of Health Services Research,3 ethics …

This paper examines a legal case arising from a workplace grievance that progressed to being heard at the UK’s Supreme Court. The case of Doogan and Wood versus Greater Glasgow and Clyde Health Board concerned two senior midwives in Scotland, both practicing Roman Catholics, who exercised their perceived rights in accordance with section 4 of the Abortion Act not to participate in the treatment of women undergoing abortions. The key question raised by this case was: “Is Greater Glasgow and Clyde Health Board entitled to require the midwives to delegate, supervise and support staff in the treatment of patients undergoing termination of pregnancy?” The ethical issues concerning conscientious objection to abortion have been much debated although the academic literature is mainly concerned with the position of medical practitioners rather than what the World Health Organization terms “mid-level professionals” such as midwives. This paper examines the arguments put forward by the midwives to justify their refusal to carry out tasks they felt contravened their legal right to make a conscientious objection. We then consider professional codes, UK legislation and church legislation. While the former are given strong weighting the latter was been ignored in this case, although cases in other European countries have been prevented from escalating to such a high level by the intervention of prominent church figures. The paper concludes by stating that the question put to the courts remains as yet unanswered but offers some recommendations for future policy making and research.

COVID-19 continues to dominate 2020 and is likely to be a feature of our lives for some time to come. Given this, how should health systems respond ethically to the persistent challenges of responding to the ongoing impact of the pandemic? Relatedly, what ethical values should underpin the resetting of health services after the initial wave, knowing that local spikes and further waves now seem inevitable? In this editorial, we outline some of the ethical challenges confronting those running health services as they try to resume non-COVID-related services, and the downstream ethical implications these have for healthcare professionals’ day-to-day decision making. This is a phase of recovery, resumption and renewal; a form of reset for health services.1 This reset phase will define the ‘new normal' for healthcare delivery, and it offers an opportunity to reimagine and change services for the better. There are difficulties, however, healthcare systems are already weakened by austerity and the first wave of COVID-19 and remain under stress as the pandemic continues. The reset period is operating alongside, rather than at the end, of the pandemic and this creates difficult ethical choices. ### Balancing the greater good with individual care Pandemics—and public health emergencies more generally—reinforce approaches to ethics that emphasise or derive from the interests of communities, rather than those grounded in the claims of the autonomous individual. The response has been to draw on more public health focused ethics, ‘if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual's need will give way to decisions about how to maximise overall benefit’.2 Alongside this, effective …

The NHS in England is an organisation undergoing substantial change. The passage of the Health and Social Care Act 2012, consolidates and builds on previous health policies and introduces further ‘market-style’ reforms of the NHS. One of the main aspects of these reforms is to encourage private and third sector providers to deliver NHS services. The rationale for this is to foster a more competitive market in healthcare to encourage greater efficiency and innovation. This changing healthcare environment in the English NHS sharpens the need for attention to be paid to the ethical operation of healthcare organisations. All healthcare organisations need to consider the ethical aspects of their operation, whether state or privately run. However, the changes in the type of organisations used to provide healthcare (such as commercial companies) can create new relationships and ethical tensions. This paper will chart the development of organisational ethics as a concern in applied ethics and how it arose in the USA largely owing to changes in the organisation of healthcare financing and provision. It will be argued that an analogous transition is happening in the NHS in England. The paper will conclude with suggestions for the development of organisational ethics programmes to address some of the possible ethical issues raised by this new healthcare environment that incorporates both private and public sector providers

Infertility treatment is a speciality that has attracted considerable attention both from the public and bioethicists. The focus of this attention has mainly been on the dramatic dilemmas created by theses technologies. Relatively little is known, however, about how clinicians approach and resolve ethical issues on an everyday basis. The central aim of this study is to gain insight into these neglected aspects of practice. It was found that, for the clinicians, the process by which ethical decisions were made was of key importance. It will be argued that this focus on the process of decision-making is more than just empty proceduralism but is based on and facilitates certain substantive ethical principles. In conclusion, suggestions as to how ethical decision-making processes can be supported and improved in infertility practice will be made.

This issue of the Journal of Medical covers a range of ethical issues and care settings making the task of beginning to summarise these papers challenging. They reflect the diversity of our field, representing different branches of bioethics focussing on specific areas or topics using a variety of methodologies: but how do we categorise these branches of bioethics? What demarks one branch from another? And what function do such categorisations fulfil? From the early days of medical ethics we now have a growing proliferation of different branches, from those with a more specific focus: clinical ethics, global ethics, nursing ethics, public health ethics for example, to a widening out, in terms of bioethics becoming the broader usage and medical ethics sitting within that. More recently, a new area of ethical focus has arisen, One Health, the subject of Johnson and Degeling’s article in this issue. They define One Health as follows: ‘One Health is generally construed as an integrated approach to understanding and managing disease. Although primarily associated with the prevention and control of Emerging Infectious Diseases, the approach is also relevant to dealing with endemic and zoonotic animal diseases, as well as securing food safety. In its most comprehensive form, it extends to fostering the health of humans, animals and their shared environments.’ This raises, in many ways, a different set of ethical concerns from those usually encountered in bioethics and medical ethics and this leads Johnson and Degeling to ask whether One Health merits having its own ‘ethical framework’. They use ethical frameworks in two senses: as value neutral deliberative tools and as embodying values, and consider how each usage could be applied in One Health. In terms of the first usage they state: ‘When ethical frameworks are regarded as a procedural tool then, the One Health perspective can broaden …

This post-holiday edition of the JME brings together a number of papers, covering a range of methodologies, surveys on public opinion, the application of developmental neuroscience, comparative risk/benefit questionnaires, scoping reviews and analysis of guidance and health policy, alongside what might be seen as more traditional medical ethics, analysing concepts and advancing arguments. This range of methodologies is suggestive of the kind of discipline that bioethics has become, and how a wealth of disciplinary and methodological perspectives is needed to address the numerous challenges that face modern health systems. The Editors’ Choice article by Derbyshire and Brockman1 considers the contentious issue of fetal pain, and applies developmental neuroscience to the question of at what stage, if at all, a fetus can feel pain? The authors argue that new evidence suggests we cannot rule out that foetuses might experience pain before 24 weeks. The authors define pain as being ‘a raw experience’ and therefore, ‘the ability to feel pain does not have to be premised on self-reflection, which prevents a rejection of fetal pain because the fetal experience is not equivalent to an adult human experience.’1 Hence, for the authors, pain does not have to be equivalent to adult pain to matter morally. The authors have differing views on abortion and this provokes a thoughtful discussion, in terms of what are the implications of these, although tentative, conclusions on fetal pain for practical approaches to carrying out abortions. They conclude by exploring how abortions might be carried out in a more humane way, that is, using fetal analgesia, and what such a humane approach might look like in light of this new evidence. In this month’s feature article Brick and colleagues2 report on a study that surveyed a sample of the UK population on their views on allowing …

The purpose of this paper is to consider the role that values play in priority setting through the use of EBP. It is important to be clear about the role of values at all levels of the decision making process. At one level, society as a whole has to make decisions about the kind of health provision that it wants. As is generally accepted, these priority setting questions cannot be answered by medical science alone but involve important judgements of value. However, as I hope to show values come into priority setting questions at another level, one not often explicitly recognised in much of the literature: that of the very definition of the effectiveness of treatments. This has important consequences for patient care. If we do not recognise that the effectiveness of a treatment involve subjective elements — a patient's own assessment of the value of the treatment — then this could lead to the belief that we can purchase one treatment that is the most effective for all patients. This might result in a detrimental reduction in the range of options that a patient is given with some patients not receiving the treatment that is most effective for them

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,...

The use of rights based arguments to justify claims that donor offspring should have access to information identifying their gamete donor has become increasingly widespread. In this paper, I do not intend to revisit the debate about the validity of such rights. Rather, the purpose is to examine the way that such alleged rights have been implemented by those legislatures that have allowed access to identifying information. I will argue that serious inconsistencies exist between the claim that donor offspring have a right to know the identity of their gamete donor and the way such a right is currently met in practice. I hope to show that in systems where non‐anonymous donation is practised, an understanding of the proclaimed right of donor offspring to know their genetic identity is one composed of two different rights – the right to know the circumstances of their conception and the right to information identifying the gamete donor – can provide important insights into this important area of public policy.

This paper examines a legal case arising from a workplace grievance that progressed to being heard at the UK’s Supreme Court. The case of Doogan and Wood versus Greater Glasgow and Clyde Health Board concerned two senior midwives in Scotland, both practicing Roman Catholics, who exercised their perceived rights in accordance with section 4 of the Abortion Act not to participate in the treatment of women undergoing abortions. The key question raised by this case was: “Is Greater Glasgow and Clyde Health Board entitled to require the midwives to delegate, supervise and support staff in the treatment of patients undergoing termination of pregnancy?” The ethical issues concerning conscientious objection to abortion have been much debated although the academic literature is mainly concerned with the position of medical practitioners rather than what the World Health Organization terms “mid-level professionals” such as midwives. This paper examines the arguments put forward by the midwives to justify their refusal to carry out tasks they felt contravened their legal right to make a conscientious objection. We then consider professional codes, UK legislation and church legislation. While the former are given strong weighting the latter was been ignored in this case, although cases in other European countries have been prevented from escalating to such a high level by the intervention of prominent church figures. The paper concludes by stating that the question put to the courts remains as yet unanswered but offers some recommendations for future policy making and research.

As John McMillan notes in January’s editorial, 1 many countries are reflecting on how they responded to the COVID-19 pandemic, what went wrong and how responses to such system shocks can be better managed in the future. However, while it is tempting to think that the COVID-19 pandemic is over and that what is now needed is a reflection on how countries could have responded better, some of the underlying issues and problems COVID-19 both highlighted and created are still with us. The legacy of the pandemic has continued particularly for healthcare workers at all levels, who have had to continue providing services with little time to rest and reflect and with new ‘shocks’ to the systems to cope with. For example, in England, industrial action by junior doctors has put already fragile systems under pressure, and the issues that staff are campaigning about remain unaddressed. Many of...