Michal Pruski

In their article, Sahan and colleagues have presented ethical dilemmas faced by clinical scientists working in genomics.1 This is a welcome development since thus far little has been published on the ethical issues faced by clinical scientists in general. In their article, the authors present the three themes which emerged from discussions with clinical scientists in respect to three case studies: ‘(1) the redistribution of labour and responsibilities resulting from the practice of genomic medicine; (2) the interpretation and certainty of results and (3) the proposal that better standardisation and consistency of ethical approaches (for example, more guidelines and policy) could resolve some of the challenges arising’.1 One theme which appeared not to emerge is that of ethics education received by clinical scientists during their training, and this is the theme on which this commentary will focus. As noted elsewhere, ‘Clinical Scientists receive some lectures on clinical and research ethics as part of their training, but it amounts to only to a couple of hours of lectures (references omitted)’.2 The usual route to becoming a clinical scientist involves undertaking the 3-year postgraduate Scientist Training Programme (STP), though the ‘equivalence’ route is quite commonly taken by clinical scientists working in …

There have been repeated calls to ensure that clinical artificial intelligence (AI) is not discriminatory, that is, it provides its intended benefit to all members of society irrespective of the status of any protected characteristics of individuals in whose healthcare the AI might participate. There have also been repeated calls to ensure that any clinical AI is tailored to the local population in which it is being used to ensure that it is fit-for-purpose. Yet, there might be a clash between these two calls since tailoring an AI to a local population might reduce its effectiveness when the AI is used in the care of individuals who have characteristics which are not represented in the local population. Here, I explore the bioethical concept of local fairness as applied to clinical AI. I first introduce the discussion concerning fairness and inequalities in healthcare and how this problem has continued in attempts to develop AI-enhanced healthcare. I then discuss various technical aspects which might affect the implementation of local fairness. Next, I introduce some rule of law considerations into the discussion to contextualise the issue better by drawing key parallels. I then discuss some potential technical solutions which have been proposed to address the issue of local fairness. Finally, I outline which solutions I consider most likely to contribute to a fit-for-purpose and fair AI.

With the increasing prevalence of artificial intelligence (AI) and other digital technologies in healthcare, the ethical debate surrounding their adoption is becoming more prominent. Here I consider the issue of gaining informed patient consent to AI-enhanced care from the vantage point of the United Kingdom’s National Health Service setting. I build my discussion around two claims from the World Health Organization: that healthcare services should not be denied to individuals who refuse AI-enhanced care and that there is no precedence to seeking patient consent to AI-enhanced care. I discus U.K. law relating to patient consent and the General Data Protection Regulation to show that current standards relating to patient consent are adequate for AI-enhanced care. I then suggest that in the future it may not be possible to guarantee patient access to non-AI-enhanced healthcare, in a similar way to how we do not offer patients manual alternatives to automated healthcare processes. Throughout my discussion I focus on the issues of patient choice and veracity in the patient–clinician relationship. Finally, I suggest that the best way to protect patients from potential harms associated with the introduction of AI to patient care is not via an overly burdensome patient consent process but via evaluation and regulation of AI technologies.

There is an ethical dilemma present when considering updating predictive clinical artificial intelligence (AI) models, which should be part of the departmental quality improvement process. One needs to consider whether withdrawing the AI model is necessary to obtain the relevant information from a naive patient population or whether to use causal inference techniques to obtain this information. Withdrawing an AI model from patient care might pose challenges if the AI model is considered standard of care, while use of causal inference will not be reliable if the relevant statistical assumptions do not hold true. Hence, each of these two updating strategies is associated with patient risks, but lack of reliable data might endanger future patients. Similarly, not withdrawing an outdated AI might also expose patients to risk. Here I propose a high level ethical framework – epistemic risk management - that provides guidance for which route of model updating should be taken based on the likelihood of the assumptions used during the creation of the original AI model and the assumptions required for causal inference holding true. This approach balances our uncertainty about the status of the AI as standard of care with the risk of not obtaining the necessary data, so as to increase the probability of benefiting current and future patients for whose care the AI is being used.

After the US Supreme Court’s reversal of Roe v. Wade, a number of states have immediately banned abortion. Pro-choice activists are responding by promoting medication abortions – a do-it-yourself form of abortion. Women can take pills at home to induce an abortion in the first few weeks of pregnancy. The Biden Administration [1] has backed the abortion pill, too. Attorney-General Merrick B. Garland and Health and Human Services Secretary Xavier Becerra both issued statements endorsing it. “We stand ready to work with other arms of the federal government that seek to use their lawful authorities to protect and preserve access to reproductive care,” said the Attorney-General. “In particular, the F.D.A. has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the F.D.A.’s expert judgment about its safety and efficacy.” As the New York Times [1] has noted, this sets the scene for legal battles. The obvious one is: will anti-abortion states prosecute medication abortions? But – based on experience in the United Kingdom - the use of the abortion pill could give pro-life doctors headaches as well. In the past year, UK has witnessed the saga of two Catholic doctors who have been brought in front of the professional regulator, the General Medical Council, after accusations of professional misconduct. Their crime? They had supplied abortion pill reversal (APR) treatment to women. Accusations of this misconduct have been brought forward by pro-choice organisations [2]. The problem is that some women might panic when they discover that they are pregnant or are pressured to make a rash decision. They obtain abortion pills, often without seeing a doctor faceto- face, and soon after taking the first pill, they regret their decision. Is it too late for them to save their pregnancy? Not necessarily. A treatment developed in the US works about half the time. It involves the woman taking progesterone after the first abortion pill to counteract the abortifacient action of the drug. Seventy-three women in the UK are reported to have taken a full APR course, of whom, 38 – more than half — successfully remained pregnant. Admittedly, the procedure is controversial [3], with pro-choice writers denouncing it as unproven, unscientific, and unethical. This has triggered some healthcare practitioners and scholars to analyse the commitments of the pro-choice movement to APR. In a recently published paper in The New Bioethics [4], two colleagues, Dominic Whitehouse and Steven Bow, and I argue that those espousing a pro-choice worldview should actually support abortion pill reversal and that the current evidence indicates that they should actually be doing it. While some pro-choice activists might be happy simply to expand women’s reproductive choices, some might also want to ensure that these choices are safe and effective at achieving the desired outcome, which in principle includes maintaining a pregnancy. We then review the scientific evidence with respect to the ability of APR to halt an abortion, look at the potential impact of APR on mental health, as well as its procedural safety. While highlighting that gold-standard evidence is lacking, we note that APR is associated with about two times higher rate of embryo survival compared to not completing the full early medical abortion course, that there is large agreement in the literature that women who are ambiguous about abortion are at risk of poorer mental health outcomes after abortion (and argue that women who request APR fall into this category), and highlight that there is no evidence that APR is more dangerous than abandoning an initiated early medical abortion. The latter fact is important, as the results of the only randomised-controlled trial of APR have been at times misrepresented in the media [5.6], creating the impression that APR is not safe while most of the adverse effects occurred in the study group that did not receive APR. As our paper argues, with respect to APR the two UK doctors were “champions of women’s choice and should be congratulated, not condemned, by pro-choice advocates”. While the cases against the two doctors have now been dropped (and there have even been accusations against a member of one of these pro-choice organisations that they pressurised a patient into complaining about one of the doctors and twisted the patient’s experience of the treatment [7]), we argue that it is important to set-up systems to facilitate the future provision of APR to protect both patients and healthcare staff. Our conclusion is that, while being open to any change in evidence, those espousing a pro-choice outlook should “support calls for an APR framework that will protect women and the healthcare professionals caring for them” “and certainly not oppose” APR. The debate over abortion pill reversal will be heading to the United States soon. It is quite possible that it will be denounced as dangerous misinformation. It’s not. But pro-life defenders should be prepared to defend their ground. This article was first published by Mercatornet.

Dear Editor, We are pleased to report that we have recently published an article in a well-established bioethics journal where we briefly review the evidence surrounding abortion pill reversal (APR) and argue that those who identify with the pro-choice standpoint should support APR provision (indeed, the ex-CEO of BPAS, Ann Furedi, has agreed in principle with this conclusion of ours in one of her tweets). We also hope that our article will serve as a record in the peer-reviewed and indexed literature of the struggles our fellow CMA UK members have gone through to support women who eventually decided to keep their pregnancies, and the tribulations they had to endure from their colleagues in the medical establishment. It is perhaps somewhat symbolic that our paper has been published in a special issue dedicated to the ‘feminist ethics of care’ as APR and the sacrifice of our colleagues shows what care for women should really look like.(1) We have made sure to spread the word about this as well. One of us has given an interview to Irish pro-life group Protect Life (still to be published) and we have submitted a post to a pro-life collaborative that also awaits publication. Finally, we have also published a post about this paper and current developments in the USA in a well-established bioethics news site, which has been republished in various online outlets.(2) We believe that this promotion of APR is vital, as recent statements from both the UK and the USA indicate that the pressure against APR might grow. The American College of Obstetricians and Gynecologists have published a post entitled ‘Facts Are Important: Medication Abortion "Reversal" Is Not Supported by Science’.(3) Similarly, the UK Royal College of Obstetricians and Gynaecologists, together with other bodies (including the British Society of Abortion Care Providers) have posted a position statement stating that there is no reputable evidence for using progesterone in APR.(4) One truly wonders why these organisations are pushing this narrative despite the weight of the evidence available being in favour of APR and their organisations’ professed support for women’s choice.

Dear Editor, One of the recent changes in the UK cabinet, after Liz Truss became the Prime Minister, was that Dr Therese Coffey become the new Health Secretary. Some news outlets were quick to point out her anti-abortion stance (see e.g. (1–3)) and that this, according to them, might be a problem. While pro-lifers might not completely rejoice over this situation as Coffey stated that ‘she wouldn’t “seek to undo” abortion laws’(3), I do not wish to focus here on speculating on the future status of UK abortion legislation. Rather, I wish to focus on some statements quoted by the media as made by Clare Murphy, chief executive of the British Pregnancy Advisory Service (BPAS), who stated that: (2,4) ‘Earlier this year, our new Health Secretary voted to revoke access to at-home abortion care, and recriminalise women who end their own pregnancies without the approval of two doctors.’ ‘In doing so, Therese Coffey voted against the advice of leading medical bodies.’ ‘To have a health secretary who would place their personal beliefs above expert clinical guidance is deeply concerning.’ Coffey is a Catholic, and this brings back to mind some of the aspects of the debate surrounding conflicts of interest in bioethics. There have been, for example, discussions and proposals that having a religious belief should be declared as a conflict of interest.(5,6) But something seems to be missing in these portrayals of conflict of interest and the disagreement between Coffey and these ‘leading medical bodies’. If we regard financial conflicts of interests as the classical case of such conflicts that is used as a reference to other types of conflicts of interest,(5,6) then why do we not see the media complaining that ‘leading medical bodies’ support procedures that will give them more work oppor-tunities and improve their financial stability? To paraphrase Murphy who (according to the BBC 'said while politicians were entitled to their own views on abortion, what mattered was whether their "personal convictions stand in the way of women's ability to act on their own”. (4) perhaps ‘BPAS and the leading medical bodies are entitled to considerations of their financial interests, but what matters is whether the advice they give is clinically sound and founded in the principles of ethical clinical practice. In Matthew 6:24 Our Lord said that one cannot serve two masters, so perhaps we should not be so concerned with Coffey consulting her conscience, but rather scrutinise clinical institutions.

Ectogenesis (artificial wombs) might soon become a reality. This paper will analyse how the development of such technologies will affect Judith Jarvis Thomson’s defence of abortion, and what the potential consequences of this will be for society. Thomson attempts to justify abortion by appealing to the mother’s right to bodily autonomy. We will argue that once these technologies have been developed, the right to abortion can no longer be justified by such appeals. As a result, when justifying abortion, Thomson-style arguments will no longer work, and a very different strategy will have to be adopted by those wishing to justify its permissibility. Anticipating a consequent weaker position of the pro-choice view, we briefly consider some of the practical implications of ectogenesis for society: effects on parental dynamics, governmental expenditure, research, and gender equality.

The case of Alta Fixsler, where a judge ruled that withdrawing life sustaining care was in her best interest rather than transferring her to Israel, as her parents wanted, is the latest in a series of controversial paediatric best interest decisions. Using this case, as well as some other recent cases, I argue that the UK exhibits a high degree of medico-legal paternalism in best interest decisions, even though paternalism seems to be ubiquitously negatively perceived in medical ethics. Firstly, I explain what I mean by medico-legal paternalism and defend my claim that this phenomenon is present in the UK. I then argue that at least philosophically (rather than legally) such a situation is impossible to justify in a secular state and that how we treat paediatric best interest decisions is very different from other areas of medical law. Lastly, I discuss proposals that aim to rectify this situation.

Dear Editor, It is the responsibility of healthcare professionals to present patients with the available options for managing their conditions, including the potential benefits and anticipated negative consequences of each option. Patients then weigh the potential benefits and drawbacks of each option, and juxtapose them with their wider life goals and preferences. We generally accept that patients might not choose the option that is most health or life preserving because they might value other things more. We accept that forms of cancer treatment that might only minimally extend life are not always a reasonable choice or that a patient might chose not to wish to have CPR performed if they suffer a cardiac arrest. While all people tend to value health to some extent some might value friendship and family life over their health. Of course, having good health helps with having fulfilling relationships with others, but often it is having these relationships is the primary goal of tending to one's health. If you are elderly and might die soon anyway, you might wish to take the risk of meeting others and dying sooner over living longer and potentially not meeting anyone. Not everyone values the same basic goods of life (e.g. as presented by New Natural Law theorists) to the same extent. Governments need to balance how they prioritise these goods, which is very difficult, especially in a liberal and pluralistic society which largely tries to refrain from making judgments on how to prioritise such goods. The authors of the original article have rightly highlighted the potential consequences of the Christmas relaxation of the lockdown measures (which relaxation has now been cancelled). Yet, we should simultaneously not expect governments and citizens to make decisions based on their consequences on the NHS and people's health. Health is a good, but not the only, or even supreme, good. Liberty, friendship and family are other goods. People also need to have hope to live their lives well, and governments need to be trusted if people are to obey them. It is not clear that the general mood in society following the cancellation of the Christmas relaxations will not have graver consequences than the original relaxation would have - this is anyone's guess. But it would not be irrational for the government to allow these relaxations - it would simply not have aimed at maximising the benefit to the NHS and people's health. We would not expect patients to always act to maximise their health, why would we necessarily expect the government to do it - it did not get voted in solely on the basis of their health policies. Why we might wish people and governments to promote health in general, we should not be surprised if they make decisions where they balance different goods and not just maximise health. This might not be generally helpful to us as healthcare professionals, but it is neither irrational nor is it different how we often make decisions in our personal lives.

In his ‘When conscientious objection runs amok: A physician refusing human immunodeficiency virus preventative to a bisexual patient’, Brummett has argued that Catholic physicians should not be able to raise conscientious objections to HIV pre-exposure prophylaxis for bisexual patients, as this constitutes discrimination. Brummett argues that such a conscientious objection represents an instance of conscience creep, which he argues is undesirable. Here I re-analyse the case presented by Brummett using a teleological framework and making reference to Catholic teaching on cooperation with evil. While I agree with Brummett that in this case the physician should not have had the right to conscientiously object, I argue that the teleological framework offers advantages over the argument Brummett has presented. I also comment on why only considering empirically measurable harm as a publicly defensible reason for one to hold a conscientious objection is problematic, as well as on the difficulties associated with cases of discrimination in a pluralistic society.

Healthcare professionals often need to make clinical decisions that carry profound ethical implications. As such, they require a tool that will make decision-making intuitive. While the discussion about the principles that should guide clinical ethics has been going on for over two thousand years, it does not seem that making such decisions is becoming any more straight forward. With an abundance of competing ethical systems and frameworks for their application in real life, the clinician is still often not sure how to proceed in the face of ethical dilemmas, either due to a lack of background ethical knowledge or experience in applying it. This paper will discuss whether considering what one would expect one’s friend to do if one was the patient, or what would one think they would do for a friend if they were the patient, can be a helpful, more intuitive, tool for clinical decision-making that can produce outcomes that are congruent with major ethical systems.

Giubilini and Savulescu in their recent Journal of Bioethical Inquiry symposium article presented an account of conscientious objection that argues for its recognition as a non-financial conflict of interest. In this short commentary, I highlight some problems with their account. First, I discuss their solicitor analogy. Second, I discuss some problems surrounding their objectivity claim about standards of medical care. Next, I discuss some issues arising from consistently applying their approach. Finally, I highlight that conscientious objection should be viewed not as a conflict of interest but as something that society has an interest in preserving. I conclude by arguing that clinicians who have a conscientious objection can be treated in the same way as those who decide to subspecialize and do not need to give up work in their specialty. While Giubilini and Savulescu present an interesting argument about conscientious objection, theirs is not a compelling view. Indeed, the way we approach conscientious objection has more to teach us about conflicts of interest than the other way around.

Informed consent, when given by proxy, has limitations: chiefly, it must be made in the interest of the patient. Here we critique the standard approach to parental consent, as present in Canada and the UK. Parents are often asked for consent, but are not given the authority to refuse medically beneficial treatment in many situations. This prompts the question of whether it is possible for someone to consent if they cannot refuse. We present two alternative and philosophically more consistent frameworks for paediatric proxy consent. The first allows meaningful consent (parents may say ‘yes’ or ‘no’ to treatment), provided that parents are medically informed/competent and intend the health and well-being of their child. In the second solution, medical practitioners or the state consent for treatment, with parents only being consulted to help give insight to the child’s circumstances. While we contend that either of these two options is superior to the insincerity of the present paradigm, we suggest that the first solution is preferable.

In mid-2019, the controversy regarding South African runner Caster Semenya’s eligibility to participate in competitions against other female runners culminated in a Court of Arbitration for Sport judgement. Semenya possessed high endogenous testosterone levels (arguably a performance advantage), secondary to a disorder of sexual development. In this commentary, Aristotelean teleology is used to defend the existence of ‘male’ and ‘female’ as discrete categories. It is argued that once the athlete’s sex is established, they should be allowed to compete in the category of their sex without obligatory medical treatment. Indeed, other athletes who possess advantageous genetic or phenotypic traits that fall outside of the human norm have been allowed to compete as humans without restraint. In both cases, if an athlete possesses the essential attributes of being a human or being male or female they should be permitted to compete in those respective categories; athletes’ eligibilities should not be based upon accidental attributes.

With recent guidance from the BMA and RCP on the withdrawal of nutrition from patients, and how the cause of death is being recorded (1), and the case of Vincent Lambert (2), the debate surrounding withdrawal of care and treatment has been rekindled in Catholic circles. In this article, I wish to highlight some of traditional principles that form the basis of such decision-making. I discuss these within the context of the withdrawal of nutrition and hydration (NaH), as well as ventilation, to elucidate the key points.

This paper follows on from a brief debate about the role of conscientious objection in healthcare, where the issue arose as to whether conscientious objection is (or can) be a tool of resistance against systemic injustice. The paper contributes to this debate by highlighting that some authors generally opposed to conscientious objection in healthcare have shown some support to this idea. Perhaps if there is one area in which all can agree, it is that in healthcare conscientious objection should be allowed so as to prevent cases of systemic injustice.

The English cases of Charlie Gard and Alfie Evans involved a conflict between the desires of their parents to preserve their children’s lives and judgments of their medical teams in pursuit of clinically appropriate therapy. The treatment the children required was clearly extraordinary, including a wide array of advanced life-sustaining technological support. The cases exemplify a clash of worldviews rooted in different philosophies of life and medical care. The article highlights the differing perspectives on parental authority in medical care in England, Canada, and the United States. Furthermore, it proposes a solution that accommodates for both reasonable parental desires and professional medical opinion. This is achieved by looking at concepts of extraordinary therapy, best interest, reasonable parenthood and medical objections.

While there is a prolific debate surrounding the issue of conscientious objection of individuals towards performing certain clinical acts, this debate ignores the fact that there are other reasons why clinicians might wish to object providing specific services. This paper briefly discusses the idea that healthcare workers might object to providing specific services because they are against their professional judgement, they want to maintain a specific reputation, or they have pragmatic reasons. Reputation here is not simply understood as being in good standing with a professional body. Rather, reputation is treated in the sense that a craftsman might wish to be known for providing a specific type, quality, and style of service. Professionalism is understood as acting according to the philosophical and scientific principles that are the basis of healthcare (such as acting for the benefit of the patient’s health and following well- evidenced treatment pathways).

This paper looks at the Catholic justification of medical interventions in ectopic pregnancies. The paper first shows that the way how Double Effect Reasoning is often applied to ectopic pregnancies is not consistent with the way Aquinas introduces this mode of reasoning. The paper then shows certain problems in common defences of the use of salpingectomies. The paper then re-evaluates the medical interventions used in the management of ectopic pregnancies, with both a focus on the aim of the treatment and the timing of the treatment.

Current developments in reproductive technology forecast that in the foreseeable future artificially generated gametes might be presented as a possible fertility treatment for infertile couples and for homosexual couples desiring to have children genetically originating from both partners. It is important to evaluate the ethical issues connected to this technology before its emergence. This article first reviews the meaning that gametes (sperm and eggs) might have to those who procreate, as well as their ontology. From this, suggestions are made as to what qualities artificially generated gametes need to be truly called gametes. Finally, different proposed routes for artificial gamete generation are examined on the basis of these qualities, with their prospective problems and advantages highlighted. Autotransplanted gametes (or their progenitors) generated solely from patient-derived tissue are deemed to be the most ethically suitable route for the development of this technology.

Humans often seek to improve themselves, whether through self-discipline or through the use of science and technology. At some point in the future, techniques might become available that will change humans to such a degree that they might have to be regarded as something other than human: posthuman. This essay tries to define the point at which such a human-to-posthuman metamorphosis may occur. This is achieved by discerning what is it that makes human substance distinct, i.e. what is the human essence. This is accomplished by examining the features of the human body, looking at the mode of human existence in society and trying to grasp the importance of the body–soul relationship. Throughout the process, humans are compared to animals as well as entities from literature, film, and the gaming world. These are used as case studies to shape and test the ideas developed throughout the essay. This essay's conclusions might become useful when decisions will have to be made as to the legal status of posthumans,...