Nathan Emmerich

Concern for those who will benefit from a transplant has led to a variety of proposals to increase the supply of organs. Some, like opt-out organ donor registers, annual publicity campaigns and the involvement of specially trained professionals in caring for families of potential donors in the perimortem period, have been taken up. Others, such as organ markets, elective ventilation and declarations that the organs of the dead are the legal property of the state, have not. While existing challenges to the dead donor rule (DDR) are often framed in terms of the way we conceptualise death,1 that abandoning it will increase the number of organs available for transplant often plays a role in such arguments. This is, however, conjecture. Thus, while one might consider Masek’s argument for abandoning the DDR on its own terms,2 it is also important that we examine the (more or less implicit) assumption that doing so will positively impact donation rates. Although not explicitly formulated until the late 1980s, the DDR has arguably guided the practice of organ transplantation since it first began.3 4 Thus, although one participant in the first symposium on transplant ethics expressed support for having their organs taken after being ‘put to sleep’, others maintained that organs should not be harvested until after the donor’s death.5 Consistent with such views, since they first began to be drawn up, procedures governing organ donation have sought to ensure that potential conflicts of interest in declaring death …

This paper considers if certain sexual activities or practices can legitimately be thought of as raising concerns about an individual’s professionalism and, therefore, as matters which fall within the purview of bodies which regulate healthcare professionals. There seems prima facie reason to think that healthcare professionals should be able to enjoy the same socio-political rights as anyone else. Given that this includes the right to privacy, then the suggestion that a professional regulator might legitimately concern themselves with the sex lives of those they regulate seems problematic on its face. However, some of the activities discussed are not entirely private matters. Equally, whilst the practices addressed are not unlawful, it is not unusual for them to be the subject of judgmental attitudes, prejudice, and stigma. Coupled with the fact that regulatory bodies are commonly charged with maintaining public trust and confidence it may be that there is some reason to consider the kinds of activities discussed with regard to the professionalism of those who engage in them. Nevertheless, one might question the legitimacy of impugning an individual’s professionalism on the basis of intolerance, and whilst I note that there may be a need for empirical research into public opinion, this essay concludes that the distinction between the personal and professional should be maintained. Assuming that it is conducted within the bounds of the law, the sex lives of healthcare professionals should not draw the attention of professional regulators.

Cet essai porte sur une question théorique susceptible de se poser dans le cadre de l’avortement tardif dans des juridictions particulièrement libérales ou très permissives, c’est-à-dire celles qui n’exigent pas que des critères soient remplis pour que la procédure soit légale. En n’établissant pas de critères limitant la pratique de l’avortement tard(if), la procédure devient légale « à la demande », du moins en principe. Cela soulève la possibilité que les professionnels de santé soient confrontés à des demandes spécifiques d’interruption de grossesse qu’ils considèrent comme moralement injustifiées, ce qui signifie que certains d’entre eux pourraient chercher à s’abstenir de pratiquer l’avortement dans de tels cas en faisant appel à la notion d’objection de conscience. La littérature existante qualifierait probablement ces appels de cas d’objection de conscience sélective. Tout en soutenant que cette notion est erronée, je suggère également qu’il est nécessaire de reconnaître un certain degré de nuance dans les positions éthiques des professionnels de la santé lorsqu’il s’agit de pratiquer des avortements à des âges gestationnels tard(ifs) dans des juridictions qui adoptent des formes de réglementation très permissives. Toutefois, étant donné que l’objection de conscience ne devrait pas être autorisée à entraver la réalisation d’interventions légalement autorisées, il existe un impératif moral de garantir l’accès et les systèmes de soins de santé doivent prendre des mesures pour assurer la réalisation de l’intervention. Bien que cela soit possible, il est peu probable que ce soit simple et cela pourrait nuire à l’établissement d’une légalisation très permissive.

Despite significant progress in the legalization and decriminalization of abortion in Australia over the past decade or more recent research and government reports have made it clear that problems with the provision of services remain. This essay examines such issues and sets forth the view that such issues can and should be seen as (bio)ethical concerns. Whilst conscientious objection—the right to opt-out of provision on the basis of clear ethical reservations—is a legally and morally permissible stance that healthcare professionals can adopt, this does not mean those working in healthcare can simply elect not to be providers absent a clear ethical rationale. Furthermore, simple non-provision would seem to contravene the basic tenants of medical professionalism as well as the oft raised claims of the healthcare professions to put the needs of patients first. Recognizing that much of the progress that has been made over the past three decades can be attributed to the efforts of dedicated healthcare professionals who have dedicated their careers to meeting the profession’s collective responsibilities in this area of women’s health and reproductive healthcare, this paper frames the matter as a collective ethical lapse on the part of healthcare professionals, the healthcare professions and those involved in the management of healthcare institutions. Whilst also acknowledging that a range of complex factors have led to the present situation, that a variety of steps need to be taken to ensure the proper delivery of services that are comprehensive, and that there has been an absence of critical commentary and analysis of this topic by bioethicists, I conclude that there is a need to (re)assess the provision of abortion in Australia at all levels of service delivery and for the healthcare professions and healthcare professionals to take lead in doing so. That this ought to be done is clearly implied by the healthcare profession’s longstanding commitment to prioritizing the needs of patient over their own interests.

This essay engages with the (re)emergence of psychedelic medicine and the idea of psychedelics drugs and the experiences they induce as a developing therapeutic modality. It does so in the context of the provision of psychedelics to terminally ill patients experiencing existential distress as they approach the end of their lives. Reflecting on such suggestions facilitates an examination of a specific aspect of psychedelics and/ as medicine (or palliative care), namely questions of meaning and meaninglessness. Understood as impacting one’s ability to make or _realise_ meaning in life, existential distress commonly entails a degree of demoralisation. In some cases, individuals can be thought of as inhabiting (and being inhabited by) a sense of meaninglessness. In contrast, the experiences psychedelics seem to induce are often imbued with a great deal of meaning, a sense of which seems to continue long after the psychoactive effects of such drugs have ceased. Whilst briefly considering whether or not meaning can properly be thought of as a matter for healthcare or a medical concern, this paper seeks to highlight some of the implications that the advent of psychedelic medicine might have. By way of a conclusion, I enjoin bioethics in recognising itself as a meaningful cultural discourse that is implicated in the future(s) of medicine, psychedelics and being human.

The COVID-19 pandemic has occasioned a great deal of ethical reflection both in general and on the issue of reverse triage; a practice that effectively reallocates resources from one patient to another on the basis of the latter having a more favourable clinical prognosis. This paper addresses a specific concern that has arisen in relation to such proposals: the potential reallocation of ventilators relied upon by disabled or chronically ill patients. This issue is examined via three morally parallel scenarios. First, the standard reallocation of a ventilator in accordance with reverse triage protocols; second, the reallocation of a personal ventilator from a chronically ill patient ordinarily reliant on it; and, third, the reallocation of a personal ventilator owned by a financially privileged individual but who is not ordinarily reliant on it. This paper suggests that whilst property rights cannot resolve these scenarios in a satisfactory manner, it may be possible to do so if we draw on the resources of phenomenology. However, in contradistinction to a recent paper on this topic, we argue that ethical claims to ventilators are not well grounded by the overly demanding notion that they are embodied objects. We suggest that the alternative phenomenological notion of homelikeness provides for a more plausible resolution of the issue. The personal ventilators of individuals who commonly rely upon them become part of their ordinary, everyday or homelike being. They are a necessary part of the continuation or maintenance of their basic state of health or wellbeing and the reallocation of such objects is unethical. Keywords: Phenomenology, COVID-19, Pandemic, Triage, Reverse triage, Ventilation, Chronic illness, Allocation of resources.

While there is a great deal to agree with in the essay Expanded Terminal Sedation in End-of-Life Care there is, we think, a need to more fully appreciate the humanistic side of both palliative and end-of-life care.1 Not only does the underlying philosophy of palliative care arguably differ from that which guides curative medicine,2 dying patients are in a uniquely vulnerable position given our cultural disinclination towards open discussions of death and dying. In this brief response, we critically engage Gilbertson et al ’s essay and seek to contextualise the perspective they put forward. According to Cassell, we should distinguish between pain and suffering.3 The former often gives rise to the latter, but suffering has other causes. This includes existential distress, indicating that, unlike pain, suffering is not simply physiological phenomena. Suffering involves the disintegration of the person, meaning that it can impact patient autonomy. Certainly, that a patient is suffering does not equate to a lack autonomy. Nevertheless, we should take care when making decisions in circumstance where the integrity of our embodied personhood is under threat, something that is clearly the case for those who are dying, particularly those who have refractory symptoms while doing so. Generally speaking, refractory symptoms are those which are intractable. They persist despite attempts at palliation. While this implies that such symptoms—and the suffering they cause—cannot be reversed this is not necessarily the case. Not only can the symptoms experienced by dying patients change …

In this essay I consider whether the political perspective of third wave science studies – ‘elective modernism’ – offers a suitable framework for understanding the policy-making contributions that ethical experts might make. The question arises as a consequence of the fact that I have taken inspiration from the third wave in order to develop an account of ethical expertise. I offer a précis of this work and a brief summary of elective modernism before considering their relation. The view I set out suggests that elective modernism is a political philosophy and that although its use in relation to the use of scientific expertise in political and policy-making process has implications for the role of ethical expertise it does not, in the final analysis, provide an account that is appropriate for this latter form of specialist expertise. Nevertheless, it is an informative perspective, and one that can help us make sense of the political uses of ethical expertise.

The study of bioethics has always been conducted by multiple disciplines. However the interaction between these disciplines has sometimes been marked by division, discord and disagreement, especially so between philosophically and sociologically minded contributors. This has been particularly true in recent years, and post the ‘empirical turn’ in bioethics. In our introduction we trace these disagreements and then take a wider look at the nature of disciplines and of interdisciplinary relations. These considerations are then brought back to the disciplines that contribute work to bioethics as an explanation of why relationships within the field are difficult, and how we can start to address these divides.

In the introduction to this volume we have argued that being an interdisciplinary scholar involves managing a complex interplay of disciplinary identities, as well as the ontologies and ways of knowing and understanding that are associated with the subject matter. We argued that trying to force a bioethical interdiscipline without a special regard to the individual epistemological, ontological and social aspects of the disciplines is unlikely to bear fruit in the long-term. Although bioethics has always been a multidisciplinary activity, the relations between the various disciplines involved have traditionally been fraught, particularly so at the intersection between sociological and philosophical bioethics. We therefore proposed approaching bioethical interdisciplinarity in a manner that is careful and measured. This does not involve abandoning disciplines or disciplinarity, rather we are advocating for an increased level of cross-fertilisation between established disciplines or the way in which research is done, in the broadest sense.

Recent research offers good reason to think that various psychedelic drugs—including psilocybin, ayahuasca, ketamine, MDMA, and LSD—may have significant therapeutic potential in the treatment of various mental health conditions, including post-traumatic stress disorder, depression, existential distress, and addiction. Although the use of psychoactive drugs, such as Diazepam or Ritalin, is well established, psychedelics arguably represent a therapeutic step change. As experiential therapies, their value would seem to lie in the subjective experiences they induce. As it is the only way for trainee psychedelic therapists to fully understand their subjective effects, some have suggested that firsthand experience of psychedelics should form part of training programs. We question this notion. First, we consider whether the epistemic benefits offered by drug-induced psychedelic experience are as unique as is supposed. We then reflect on the value it might have in regard to the training of psychedelic therapists. We conclude that, absent stronger evidence of the contribution drug-induced experiences make to the training of psychedelic therapists, requiring trainees to take psychedelic drugs does not seem ethically legitimate. However, given the potential for epistemic benefit cannot be entirely ruled out, permitting trainees who wish to gain first-hand experience of psychedelics may be permissible.

There have been many reports of medical students performing pelvic exams on anaesthetised patients without the necessary consent being provided or even sought. These cases have led to an ongoing discussion regarding the need to ensure informed consent has been secured and furthermore, how it might be best obtained. We consider the importance of informed consent, the potential harm to both the patient and medical student risked by the suboptimal consent process, as well as alternatives to teaching pelvic examinations within medical school. The subsequent discussion focuses on whether medical students should perform pelvic examinations on anaesthetised patients without personally ensuring that they have given their explicit consent. Whilst we question the need to conduct pelvic examinations on anaesthetised patients in any circumstance, we argue that medical students should not perform such exams without personally securing the patients informed consent.

In Where the ethical action is, Hardman and Hutchinson make some interesting and compelling points about the way in which ‘the ethical’—various values and various kinds of values—are embedded in everyday life, including the everyday life one finds in clinical interactions, understood as scientific or scientifically informed activities. However, even when one considers ‘the ethical’ from within the horizon of understanding adopted in their essay, they neglect several important features of healthcare and medical education. In this rejoinder, I argue that a fuller understanding would go some way to indicating the complexity of ethics and ‘ethical action’ in the clinic, as well as the nature of and need for ‘expert’ analysis and philosophical reflection on the ethical questions that modern healthcare continues to engender.

Some contributions to the current literature on conscience objection in healthcare posit the notion that the requirement to refer patients to a non-objecting provider is a morally questionable undertaking in need of explanation. The issue is that providing a referral renders those who conscientiously object to being involved in a particular intervention complicit in its provision. This essay seeks to engage with such claims and argues that referrals can be construed in terms of what Harman calls morally permissible moral mistakes. I go on to suggest that one might frame the (in)actions of those who exercise the right of non-participation generated by the claim to conscientiously object in similar terms; they can also be considered morally permissible moral mistakes. Finally, and given that the arguments already advanced involve simultaneously looking at the same issue from competing ethical perspectives, I offer some brief remarks that support viewing conscientious objection as an ethicopolitical device.

This article presents the notions of ethos and eidos as field level concepts for the sociology of morality and the anthropology of ethics. This is accomplished in the context of Bourdieuan social theory and, therefore, from the broad standpoint of practice theory. In the first instance these terms are used to refer to the normative structures of social fields and are conceived so as to represent the way in which such structures fall between two planes, that of the implicit and the explicit. Subsequently, they are used to further understand a distinction between morality—roughly, the implicit moral order of a social field—and ethics—the more explicit and often codified elements of a social field’s normative structure. When presented in relation to academic philosophical inquiries into the ethical issues in healthcare and the life sciences—meaning the disciplines of applied ethics in general and applied ethics in particular—the analytic perspective these terms facilitate enables us to represent the fundamental conditions required for academic enquiry; taken together the ethos and eidos of an intellectual field constitute the requisite background of its normative epistemic and methodological commitments, thereby providing the structures of disciplined intellectual practices. Seen in this light it not only becomes possible to grasp applied ethics as a socially structured practice but to understand it in terms that can also be used to frame our everyday moral practices. In this way applied ethics can be acknowledged as a relatively unique part of our contemporary moral culture.

Although one can argue that they do not represent a radical departure from existing practices, protocols for reverse triage certainly step beyond what is ordinarily done in medicine and healthcare. Nevertheless, there seems to be some degree of moral concern regarding the ethical legitimacy of practicing reverse triage in the context of a pandemic. Such concern can be taken as a reflection of the moral antipathy some exhibit towards current practices of withdrawing treatment—that is, when withdrawal of treatment is arguably in the best interests of patients—and a rejection of the purported normative insignificance of withholding and withdrawing. Given that the relevance of the psychological attitudes of some healthcare professionals to the moral assessment of withdrawing and withholding treatment continues to be debated, it would seem that some thought should be given to the introduction and implementation of reverse triage decisions in response to a pandemic. This brief paper will consider if provision should be made for healthcare professionals to conscientiously refuse to participate in reverse triage.

Until recently, Northern Ireland was infamous for having one of the most restrictive legal frameworks for abortion in Europe. This meant that few were performed in the country, and those who wished to terminate a pregnancy were forced to travel to other parts of the UK or further afield. In 2019 a continuing political stalemate in Northern Ireland has indirectly resulted in the relevant legislation recently being repealed by the UK government. For a short time, this meant that the legal position in Northern Ireland regarding abortion became one of the most permissive in Europe. This short paper sets out the current position and, in the light of the political and legislative roadmap set out by the Northern Ireland Office, identifies and briefly discusses some potential problems that might arise. Most notable are the points raised with regard to conscientious objection. Specifically, the potential for developments in Northern Ireland to further calls for healthcare professional’s ability to rely upon conscientious objection to be removed.

In a globalised world, healthcare professionals will inevitably find themselves caring for patients whose first language differs from their own. Drawing on experiences in Australia, this paper examines a specific problem that can arise in medical consultations using professional interpreters: whether the moral objections of interpreters should be accommodated as conscientious objections if and when their services are required in contexts where healthcare professionals have such entitlements, most notably in relation to consultations concerning termination of pregnancy and voluntary assisted dying. We argue that existing statements of professional ethics suggest that interpreters should not be accorded such rights. The social organisation of healthcare and interpreting services in Australia may mean those who have serious objections to particular medical practices could provide their services in restricted healthcare contexts. Nevertheless, as a general rule, interpreters who have such objections should avoid working within healthcare.

There is a diversity of ‘ethical practices’ within medicine as an institutionalised profession as well as a need for ethical specialists both in practice as well as in institutionalised roles. This Brief offers a social perspective on medical ethics education. It discusses a range of concepts relevant to educational theory and thus provides a basic illumination of the subject. Recent research in the sociology of medical education and the social theory of Pierre Bourdieu are covered. In the end, the themes of Bourdieuan Social Theory, socio-cultural apprenticeships and the ‘characterological turn’ in medical education are draw together the context of medical ethics education. ​

Whilst the notion of bioethical expertise might raise a host of questions concerning moral authority it is nevertheless the case that bioethicists continue to advance well thought out, detailed and comprehensive arguments concerning the ethical implications of the biosciences and healthcare. Not to make use of such work or those who produce it when it comes to the work of government and the development of policies would seem misguided at best. Thus, in the light of existing analysis of scientific expertise and its proper contribution to democratic political processes, this essay explores the role expert bioethicists might legitimately play in the production of policy and broader public moral debates. However, given that ethics can shade into politics and, furthermore, does so in a way that is not the case for science and politics, the ethico-political limitations that constrains and constructs the exercise of bioethical expertise is examined. Particular attention is paid to the implications of this view when it comes to bioethical research predicated on religious perspectives in the context of public reason, the validity of which has recently been called into question. We conclude with the suggestion that, if they are to act as experts in political contexts, bioethicists cannot simply make expert contributions to policymaking processes, they should also acknowledge they are responsible for shaping the broader public moral discourses about science and medicine.

In his recent article, Ben-Moshe offers an account of conscientious objection (CO) in terms of the truth of the underlying moral objections, as judged by the standards of an impartial spectator. He seems to advocate for the view that having a valid moral objection to X is the sole criteria for the instantiation of a right to conscientiously object to X, and seems indifferent to the moral status of the prevailing moral attitudes. I argue that the moral status of the prevailing moral attitudes is relevant, and that a good faith disagreement between those who condone the relevant act and those who object to it is a criterion for CO. In this light, I suggest that CO is a sociopolitical device for managing differing ethical perspectives, particularly in the context of collective moral change. Thus, it is misguided to equate having a valid moral objection with the recognition of a CO.

This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term ‘crisis sedation.’ We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.

With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals’ disinclination to withdraw it, then the differences between these practices should be taken seriously.

This collection focuses on virtue theory and the ethics of social science research. A moral philosophy that has been relatively neglected in the domain of research ethics, virtue ethics has much to offer those who wish to go beyond the difficulties generated by the biomedical model of research ethics and positively engage with the ethics of social scientific research. As the chapters contained in this volume show, the perspective provided by virtue ethics also exhibits a certain affinity with the emerging discourse regarding research integrity. Contributors develop various facets of virtue ethics in order to illuminate a range of issues in the practice and governance of social science, including integrity, the ethics of ethical review, ethics education, and the notion of phrónēsis (wisdom).

This book is an interdisciplinary contribution to bioethics, bringing together philosophers, sociologists and Science and Technology Studies researchers as a way of bridging the disciplinary divides that have opened up in the study of bioethics. Each discipline approaches the topic through its own lens providing either normative statements or empirical studies, and the distance between the disciplines is heightened not only by differences in approach, but also disagreements over the values, interpretations and problematics within bioethical research. In order to converse across these divides, this volume includes contributions from several disciplines. The volume examines the sociological issues faced by interdisciplinary research in bioethics, the role of expertise, moral generalisations, distributed agency, and the importance of examining what is not being talked about. Other contributions try to take an interdisciplinary look at a range of specific situations, fetal alcohol syndrome in the media, citizen science, electronic cigarettes and bioethical issues in human geography.