The purpose of this multi-study article was to investigate the roles of adaptability and social support in predicting a variety of psychological outcomes. Data were collected from Year 12 college students, university students, and non-studying members of the general public. Findings showed that, beyond variance attributable to social support, adaptability made a significant independent contribution to psychological wellbeing and psychological distress across all studies. Beyond the effects of adaptability, social support was found to make a significant independent contribution to most (...) wellbeing outcomes. In a multi-group analysis comparing predictors of psychological wellbeing in university students and non-studying adults, where the same outcome measures were used, it was found that adaptability played a stronger role for university students, whereas social support played a stronger role for non-studying adults. Finally, there was no evidence of an interaction between adaptability and social support predicting psychological outcomes—adaptability and social support operated as independent main effects. These findings demonstrate the importance of adaptability and social support in uniquely predicting psychological wellbeing in different sample groups. It is argued here that these two factors, should be given greater consideration in discussions of psychological wellbeing, and are relevant to psychological wellbeing at different major developmental life stages. (shrink)

The child was 2 years, 8 months old and weighed 25 pounds, one-fifth the weight of her mother, for whom she was to be the bone marrow donor. The mother had suffered a relapse of acute myelogenous leukemia; her physicians recommended a bone marrow transplant. The child was the closest human leukocyte antigen match and thus the best donor candidate for her mother's transplant.

As a powerful tool in the production of knowledge, comparing plays a crucial part in the sciences and the humanities. This volume explores the relationship between comparing and narrating in epistemic practices and clarifies the ways in which narratives enable or impede practices of comparing. It takes into account related activities, such as measuring and classifying, modeling, establishing norms and categories, as well as organizing and popularizing knowledge, to analyze the ambivalent relationship between narratives, scientific explanation, and understanding. The contributions (...) bring out the epistemic role of narratives, and elucidate how narratives are connected to comparisons and scientific explanations."--Publisher description. (shrink)

In April, the UK House of Commons Science and Technology committee published a report evaluating the readiness of the National Health Service to incorporate genomic testing into mainstream service provision.1 The committee also examined some of the research and regulatory considerations in relation to the ongoing development of genome editing. ### Genomics in the NHS The main focus of the report is the 100,000 Genomes Project and the various practical and ethical challenges associated with the planned roll-out of the Genomics (...) Medicine Service in the NHS. The 1 00 000 Genomes Project was launched in 2012 and is the first large-scale whole genome sequencing research study of its kind in the world. The overall objective is to sequence genomes from NHS patients with a rare disease and their families, and from patients with specific cancers. The study seeks to benefit patients by potentially providing a diagnosis, gain new scientific insights, increase public knowledge of genomic medicine, encourage investment, and accelerate the uptake of genomic medicine in the NHS. At the time of writing the project had sequenced over 55 000 genomes and it is expected that the full 1 00 000 will be completed by the end of 2018. Building on the success of the project NHS England announced the establishment of a national NHS Genomic Medicine Service to provide ‘comprehensive and equitable access to the latest in genomic testing and management for the whole country, regardless of condition and where people live.’2 The service is set to be operational this year. The committee acknowledged the range of potential benefits that whole genome sequencing could have for patient care, however it also highlighted that there was a currently a lack of ‘sufficiently unambiguous evidence’ for its …. (shrink)

Ever so often in the UK, there is a flurry of activity around the information requirements of donor-conceived individuals. In April 2013, it was the launch of a report from the Nuffield Council on Bioethics that brought the issue back to public consciousness.1Since 1991, information about treatment with donor gametes or embryos has been collected by the Human Fertilisation and Embryology Authority . Since then, over 35 000 donor-conceived individuals have been born through treatment in licensed clinics. Medical information and (...) information about donors’ appearance are collected by clinics, and donors are encouraged to put together a ‘pen portrait’ giving information about themselves for any resulting children. One focus of the new report is on improving the quality and quantity of information available about donors.Traditionally, gamete and embryo donations were practised on an anonymous basis, so that those born as a result of such donation may receive only non-identifying information about the donor when they reach the age of 18 . This changed in 2005 when donor anonymity was removed so that anyone donating after that time could be identified to individuals born as a result of the treatment. Those who have donated in the past are also able to reregister as identifiable donors. Much concern was expressed at the time that this would exacerbate the shortage of donors although the Nuffield Council on Bioethics reports that, 8 years on, those clinics that actively recruit donors appear to be successful in finding sufficient donors. The report recommends that the option of anonymous donation should not be reintroduced.A big issue of debate in the UK has been, and continues to be, whether parents should tell their …. (shrink)

Force-feeding of detainees at Guantánamo BayIn April, the US Department of Defense reportedly sent 40 additional military medical personnel, including doctors and nurses, to the Guantánamo Bay Naval Base to carry out the force-feeding of detainees on hunger strike.1 By the end of June, up to 104 of the remaining 166 individuals held in US military detention at Guantánamo were refusing food. The protest against conditions at the base, and the fate of those being held there—including those already cleared for (...) transfer or release—began in February 2013. In June, it was reported that as many as 44 of the hunger strikers were being force-fed by military medical teams.2The response by the US authorities to the hunger strike prompted expressions of outrage from the international medical community.3,4 In April, the American Medical Association wrote to the US secretary of defense, insisting that ‘forced feeding of [competent] detainees violates core ethical values of the medical profession.’5 Adding the voice of the profession in the UK to these calls, at its annual conference in June, the British Medical Association condemned the participation of doctors and nurses in the force-feeding, calling on governments worldwide to ensure that all prisoners have access to confidential, independent medical treatment, and supporting any clinician who challenged cruel, inhuman or degrading treatment. Also in June, the BMA Chairman wrote to President Obama and US secretary of defense, Hagel, urging them to immediately suspend medical involvement in force-feeding at Guantánamo, and to institute an urgent inquiry into how the current situation was allowed to develop.Force-feeding mentally competent adults who are refusing food is a clear violation of medical ethics and is unjustifiable, as articulated by the World Medical Association's Declaration of Malta.6 Doctors with dual loyalties, including military doctors, are bound by the same …. (shrink)

This year marks the 10th anniversary of the Female Genital Mutilation Act 2003.1 i The Act makes it an offence for any person to excise, infibulate or otherwise mutilate the whole or any part of a female's labia majora, labia minora or clitoris, or to aid, abet, counsel or procure the mutilation by another person. The exception is where a surgical or obstetric procedure is clinically indicated. There has long been UK legalisation against female genital mutilation but the 2003 Act (...) extended the criminal offence to UK nationals and permanent residents who are overseas, including in countries where the practice is legal. A person found guilty of an offence under the Act can be imprisoned for up to 14 years.Precise figures for the number of girls and women who have undergone, or who are at risk of FGM, in the UK, are hard to establish because of the secrecy surrounding the practice. It is estimated, however, that over 21 000 girls under the age of 15, in England and Wales, are at high risk of FGM.2 Despite this prevalence, recent clinical and policy guidelines3,4 and the legislative framework to prosecute, there have been no prosecutions for FGM in the UK. Worryingly, there is a suggestion that some girls are being brought to the UK for FGM, as the UK is seen as having ‘fewer controls’ and ‘less awareness about FGM’. A recent quote in the BMJ noted ‘People from many countries in Europe go to the UK for this purpose’.5In response to the lack of prosecutions, in November 2012, the Crown Prosecution Service launched an action plan for improving prosecutions. Action points include: gathering more robust data on allegations of FGM; raising with Ministers what the existing reporting …. (shrink)

The Supreme Court has ruled in the case of Y that there is no requirement to seek the approval of the Court of Protection in decisions to withdraw clinically assisted nutrition and hydration from patients in a prolonged disorder of consciousness.1 Mr Y was 52-year-old man who suffered a cardiac arrest after a myocardial infarction as a result of coronary artery disease. It was not possible to resuscitate him for well over 10 min, resulting in severe cerebral hypoxia which caused (...) extensive brain damage. Mr Y’s family and the NHS Trust treating him agreed that Mr Y would not want to be kept alive through the provision of CANH given his poor prognosis. They sought a declaration that it was not mandatory for applications of withdrawal of CANH to come before the court, which was granted by Mrs Justice O’Farrell in the first instance.2 Permission was granted for the appeal to ‘leapfrog’ the Court of Appeal and to proceed to the Supreme Court for consideration. In the interim, Mr Y died after contracting acute respiratory sepsis, but the Supreme Court determined that the appeal should go ahead in light of the general importance of the issues raised. In delivering the opinion of the Supreme Court on 30 July 2018, Lady Justice Black rejected the historical distinction that had been drawn between patients in PDOC and non-PDOC patients, in a way that had justified judicial involvement for patients in PDOC but not for others.3 She was clear that the correct approach to all cases involving CANH was to make a decision based on what was in the best interests of the patient. She further outlined that: > The documentation supplied to us shows that the difficulty that there is in assessing the patient and in …. (shrink)

### High Court rejects assisted dying challenge The High Court has rejected the latest challenge to the law on assisted dying in the UK, brought by Noel Conway. Mr Conway, a retired college lecturer, was diagnosed with motor neuron disease in 2012. Since his diagnosis, his health has deteriorated and he is dependent on ever-increasing levels of assistance with daily life, including the use of non-invasive ventilation to help him breathe. He sought a declaration from the court that section 2 (...) of the Suicide Act 1961 was incompatible with his right to a private and family life under Article 8 of the European Convention on Human Rights. As part of his case, Mr Conway submitted the outline of an alternative statutory scheme, which he argued, if implemented, would provide sufficient safeguards. He submitted that the prohibition on assisted suicide should not apply where an individual is aged 18 and over; has been diagnosed with a terminal illness and has a clinically assessed prognosis of 6 months or less to live; has the mental capacity to make the decision; makes that decision in a voluntary, clear and settled manner; and retains the ability to undertake the final act. Additionally, two doctors must confirm that the individual meets the criteria, and permission for the provision of assistance must be authorised by a High Court judge. Previous challenges to the UK law on assisted dying, including Pretty and Nicklinson, had established that section 2 of the Suicide Act does engage individual’s Article 18 rights, but that such an interference could be justified under Article 8 of the ECHR, which permits interference ‘such as is in accordance with the law and necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country’. The question …. (shrink)

In August 2012, the drug manufacturer, Fresenius Kabi, barred the sale of the anaesthetic, propofol, for use in lethal injections. The company announced that it would not accept orders for the drug from US departments of correction, and put in place similar requirements on all its wholesalers and distributors.1Propofol is one of the world's most widely used anaesthetics. Earlier in 2012, US states began to use propofol in executions following shortages of other drugs which had previously been used in lethal (...) injections. In May 2012, the state of Missouri decided to move to a one-drug protocol, using propofol alone for lethal injections, in place of the three-drug protocol that had been used by most states carrying out the death penalty. Missouri took this decision when supplies of thiopental sodium and pentobarbital, drugs used in the three-drug protocol, became unavailable.2Fresenius Kabi said that it had imposed the restrictions in order to ‘prevent Propofol from being used for purposes other than its approved medical indications’ and to ensure that ‘the immediate access to Propofol needed by medical professionals’ was not hindered. The company said that it objected to the use of its products in any manner that was not in full accordance with the medical indications for which they have been approved by health authorities.3 All forms of Fresenius Kabi propofol are manufactured in Europe. A European Union Council regulation prevents products that may reasonably be expected to be used in executions from being exported from the EU. The company said that, should propofol begin to be used in executions in the USA, inadequate access to the drug in the country was a likely consequence. At the time of writing, the US Food and Drug Administration was reporting shortages of the drug in the USA for …. (shrink)

Ever so often in the UK, there is a flurry of activity around the information requirements of donor-conceived individuals. In April 2013, it was the launch of a report from the Nuffield Council on Bioethics that brought the issue back to public consciousness.1Since 1991, information about treatment with donor gametes or embryos has been collected by the Human Fertilisation and Embryology Authority. Since then, over 35 000 donor-conceived individuals have been born through treatment in licensed clinics. Medical information and information (...) about donors’ appearance are collected by clinics, and donors are encouraged to put together a ‘pen portrait’ giving information about themselves for any resulting children. One focus of the new report is on improving the quality and quantity of information available about donors.Traditionally, gamete and embryo donations were practised on an anonymous basis, so that those born as a result of such donation may receive only non-identifying information about the donor when they reach the age of 18. This changed in 2005 when donor anonymity was removed so that anyone donating after that time could be identified to individuals born as a result of the treatment. Those who have donated in the past are also able to reregister as identifiable donors. Much concern was expressed at the time that this would exacerbate the shortage of donors although the Nuffield Council on Bioethics reports that, 8 years on, those clinics that actively recruit donors appear to be successful in finding sufficient donors. The report recommends that the option of anonymous donation should not be reintroduced.A big issue of debate in the UK has been, and continues to be, whether parents should tell their …. (shrink)

In August, Amnesty International and the World Medical Association expressed concern at reports that a judge in Saudi Arabia had asked several hospitals in the country whether they could perform an operation to damage a man's spinal cord as punishment for attacking another man and leaving him paralysed. The man had already been sentenced to seven months imprisonment for the crime, the injured victim requested the further sentence under Sharia Law, which is strictly enforced across Saudi Arabia. According to reports, (...) one of the hospitals approached declined on ethical grounds. Another hospital stated that it was possible to damage the spinal cord in the way requested, but that the procedure would have to be done at a specialised hospital. 1In its statement, Amnesty International urged the authorities not to carry out the sentence, which it argued would be a grave violation of international human rights law and contravene the United Nations convention against Torture, to which Saudi Arabia is a state party. 2 The WMA expressed its support for the physicians who refused to carry out the request by the Saudi court, participation in which would constitute a severe breach of medical ethics. 3 The WMA reminded doctors that the Declaration of Tokyo clearly states that no physician should participate in the practice of torture or any other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty of. The Declaration also includes a prohibition of participation in the planning or advising for such a procedure. NHS white paperIn July 2010 the government published a White Paper outlining its plans to transform the delivery of National Health Services in England. 4 The White Paper has been described as ‘one of the biggest shake ups of the health system …. (shrink)

Proponents of fetal rights argue that, from the moment of conception, a fetus has significant human rights. There are degrees of opinion, however, about the scope of those rights, with some arguing that, in certain circumstances, such as where the conception is the result of rape, the mother's rights predominate. Others argue that the fetus' rights are absolute and should override the woman's right to life and health so that pregnancies cannot be terminated, even to save women's lives. Various countries (...) explicitly or implicitly recognise the status of the fetus as a separate person with varying degrees of rights. For example, the Irish Constitution recognises the ‘right to life of the unborn’ and the 2004 US Unborn Victims of Violence Act views violence against a pregnant woman as a crime against two people, one of whom is the child in utero. The 1969 American Convention on Human Rights has been signed by most Latin American countries and recognises full human rights as applying from conception. In the UK, the fetus has no legal rights but it is widely agreed that the closer a fetus is to being capable of independent existence outside the womb, the greater the moral obligations owed to it. This is reflected in the abortion law only permitting termination of a pregnancy at the later stages in restricted circumstances.In Brazil, the issue of fetal rights was highlighted in May 2010 when a Bill was put forward which aimed to give the fetus priority in law and to make illegal any act or omission that could have a negative impact on it. The bill proposes that the family, society and the …. (shrink)

This paper reviews and synthesizes emerging multi-disciplinary evidence toward understanding the development of social and political organization in the Last Glacial. Evidence for the prevalence and scope of political egalitarianism is reviewed and the biological, social, and environmental influences on this mode of human organization are further explored. Viewing social and political organization in the Last Glacial in a much wider, multi-disciplinary context provides the footing for coherent theory building and hypothesis testing by which to further explore human political systems. (...) We aim to overcome the claim that our ancestors’ form of social organization is untestable, as well as counter a degree of exaggeration regarding possibilities for sedentism, population densities, and hierarchical structures prior to the Holocene with crucial advances from disparate disciplines. (shrink)

Nanomedicine is yielding new and improved treatments and diagnostics for a range of diseases and disorders. Nanomedicine applications incorporate materials and components with nanoscale dimensions where novel physiochemical properties emerge as a result of size-dependent phenomena and high surface-to-mass ratio. Nanotherapeutics and in vivo nanodiagnostics are a subset of nanomedicine products that enter the human body. These include drugs, biological products, implantable medical devices, and combination products that are designed to function in the body in ways unachievable at larger scales. (...) Nanotherapeutics andin vivonanodiagnostics incorporate materials that are engineered at the nanoscale to express novel properties that are medicinally useful. These nanomedicine applications can also contain nanomaterials that are biologically active, producing interactions that depend on biological triggers. Examples include nanoscale formulations of insoluble drugs to improve bioavailability and pharmacokinetics, drugs encapsulated in hollow nanoparticles with the ability to target and cross cellular and tissue membranes and to release their payload at a specific time or location, imaging agents that demonstrate novel optical properties to aid in locating micrometastases, and antimicrobial and drug-eluting components or coatings of implantable medical devices such as stents. (shrink)

Designer Biology: The Ethics of Intensively Engineering Biological and Ecological Systems consists of thirteen chapters that address the ethical issues raised by technological intervention and design across a broad range of biological and ecological systems. Among the technologies addressed are geoengineering, human enhancement, sex selection, genetic modification, and synthetic biology.

Background Genuine uncertainty on superiority of one intervention over the other is called equipoise. Physician-investigators in randomized controlled trials need equipoise at least in studies with more than minimal risks. Ideally, this equipoise is also present in patient-participants. In pediatrics, data on equipoise are lacking. We hypothesize that 1) lack of equipoise at enrolment among parents may reduce recruitment; 2) lack of equipoise during participation may reduce retention in patients assigned to a less favoured treatment-strategy. Methods We compared preferences of (...) parents/patients at enrolment, documented by a questionnaire, with preferences developed during follow-up by an interview-study to investigate equipoise of child-participants and parents in the BeSt-for-Kids-study. This trial in new-onset Juvenile Idiopathic Arthritis-patients consists of three strategies. One strategy comprises initial treatment with a biological disease-modifying-antirheumatic-drug, currently not standard-of-care. Semi-structured interviews were conducted with 23 parents and 7 patients, median 11 months after enrolment. Results Initially most parents and children were not in equipoise. Parents/patients who refused participation, regularly declined due to specific preferences. Many participating families preferred the biological-first-strategy. They participated to have a chance for this initial treatment, and would even consider stopping trial-participation when not randomized for it. Their conviction of superiority of the biological-first strategy was based on knowledge from internet and close relations. According to four parents, the physician-investigator preferred the biological-first-strategy, but the majority stated that she had no preferred strategy. In phase 2, preferences tended to change to the treatment actually received. Conclusions Lack of equipoise during enrolment did not reduce study recruitment, mainly due to the fact that preferred treatment was only available within the study. Still, when developing a trial it is important to evaluate whether the physicians’ research question is in line with preferences of the patient-group. By exploring so-called ‘informed patient-group’-equipoise, successful recruitment may be enhanced and bias avoided. In our study, lack of equipoise during trial-participation did not reduce retention in those assigned to a less favoured option. We observed a change for preference towards treatment actually received, possibly explained by comparable outcomes in all three arms. (shrink)

IntroductionThe Managing Cancer and Living Meaningfully therapy for patients with advanced cancer was tested against a supportive psycho-oncological counseling intervention in a randomized controlled trial. We investigated whether CALM was delivered as intended ; whether CALM therapists with less experience in psycho-oncological care show higher adherence scores; and whether potential overlapping treatment elements between CALM and SPI can be identified.MethodsTwo trained and blinded raters assessed on 19 items four subscales of the Treatment Integrity Scale covering treatment domains of CALM. A (...) random sample of 150 audio recordings were rated on a three-point Likert scale with 1 = “adherent to some extent,” 2 = “adherent to a sufficient extent,” 3 = “very adherent.”ResultsAll 19 treatment elements were applied, but in various frequencies. CALM therapists most frequently explored symptoms and/or relationship to health care providers and allowed expression of sadness and anxiety about the progression of disease. The exploration of CALM treatment element SC_1 was most frequently implemented in a satisfactory or excellent manner, whereas the treatment element SMP_4: Therapist promotes acknowledgment that some life goals may no longer be achievable was not implemented in a satisfactory manner. In terms of treatment differentiation, no treatment elements could be identified which were applied significantly more often by CALM therapists than by SPI therapists.ConclusionResults verify the application of CALM treatment domains. However, CALM therapists’ adherence scores indicated manual deviations. Furthermore, raters were not able to significantly distinguish CALM from SPI, implying that overlapping treatment elements were delivered to patients. (shrink)

On 8 October 2020, the British Medical Association published the results of its survey of BMA members on physician-assisted dying. With 28 986 respondents, this was one of the largest surveys of medical opinion on this topic ever carried out. This represents 19.35% of those who received an invitation to participate and the respondents were broadly representative of the BMA’s overall membership. The BMA was clear throughout this process that the results of the survey would not determine its policy. Its (...) current policy of opposition to all forms of physician-assisted dying would remain unless and until the Representative Body, which makes BMA policy, decided otherwise. The survey results would, however, inform a future debate on policy, currently scheduled to take place in June 2021. When asked what the BMA’s position should be on whether there should be a change in the law to allow doctors to prescribe drugs for an eligible patient to self-administer to end their own life, 40% said the BMA should be supportive, 33% opposed, 21% thought the BMA should be neutral and 6% were undecided. In relation to their own personal views, 50% were supportive, 39% opposed and 11% undecided. When asked whether they would be willing to participate in some way in the process, if it were to be legalised, 36% said yes, 45% said no and 19% were undecided. The same three questions were asked about a change in the law to allow doctors to administer drugs to end the life of an eligible patient. In response, 40% thought the BMA should oppose such a change, 30% thought the BMA should be supportive and 23% thought the BMA should be neutral; 7% of members responding were undecided on this question. In …. (shrink)

During the first UK wave of the pandemic, there were two areas of immediate ethical concern for the medical profession. The first was the possibility that life-saving resources could be overwhelmed. Early reports from hospitals in the Italian city of Bergamo suggested that ventilatory support might need rationing and emergency ‘battlefield’ triage was a real possibility.1 In the UK, several professional bodies, including the British Medical Association and the Royal College of Physicians rapidly developed guidance for doctors should triage become (...) a reality.2 The second issue was the acute shortage of personal protective equipment. Where doctors were unable to protect their patients – and themselves – from the risk of COVID-19, ethical challenges emerged. Ordinarily, doctors and patients do not present risks of significant harm to each other. To shift to a position where every patient – and every health professional – could potentially be a threat presented serious clinical and ethical challenges. To treat with inadequate PPE, so options for mitigating harms are radically reduced, deepens the challenges. Among the questions the BMA wrestled with was the extent of doctors’ duties to treat infected or potentially infected patients in the absence of effective PPE. The BMA was clear that despite obligations to treat, medicine is not a self-sacrificing profession: there were limits to the risk doctors could be required to expose themselves to.3 These issues no longer seem so pressing. In the UK at least, there is adequate PPE and with the second steep wave behind us, and significant numbers vaccinated, it is less likely that triage will be required in the UK. But as those concerns have receded so other ethical questions have arisen. Among them is a cluster of issues associated with what might be called COVID-19’s indirect harms. Understandably, in response to …. (shrink)

In February 2014, the Belgian Parliament passed legislation allowing euthanasia for terminally ill children of all ages by 86 votes to 44, with 12 abstentions. The Bill became law in early March after being signed by the King, making Belgium the first country in the world to abolish age restrictions for euthanasia. Previously, the youngest age at which euthanasia was permitted was 12 years old in The Netherlands.1Euthanasia was legalised in Belgium in 2002, and the new legislation introduces amendments to (...) the law extending euthanasia to minors in certain circumstances. Euthanasia is now permissible for children of all ages where the child has a “terminal and incurable illness”, experiences “constant and unbearable physical suffering”, and death is expected to occur within a “brief period”. The child must be deemed capable of making the decision, and have the agreement of their parents.Belgian law sets no timetable for euthanasia from the point at which the patient first expresses a wish to die. As with adults seeking euthanasia, any request must be made in writing. A physician and “outsider” brought in to give a second opinion must agree upon the diagnosis and prognosis, and a paediatric psychiatrist or psychologist must certify in writing that the child possesses “the capacity of discernment”. Following this, the child's physician must meet with the parents to inform them of the outcome of the consultation and ensure they are in agreement with the child's request. The child and the family must receive psychological care and support if so desired.The move provoked heated debate and divided the medical, legal and political professions in Belgium. A group of 160 of the country's paediatricians opposed a change in the law, citing concerns about the largely subjective assessment of the “capacity of discernment”, and drawing attention to advances in …. (shrink)

The British Medical Association has published a new report on health and human rights in immigration detention in the UK. Locked up, locked out outlines how aspects of current detention policies and practices are detrimental to the health of those detained and the challenges doctors face in providing healthcare in the immigration detention setting. It makes a number of recommendations aimed at addressing policy and practice which impact on health and well-being, including calling for an end to the routine use (...) of detention as a means of monitoring those facing removal from the UK and for the introduction of a time limit on the length of time individuals can be detained. It also provides guidance for doctors working in these settings on some of the common ethical and professional dilemmas they may face. The report can be accessed and downloaded at www.bma.org.uk/immigrationdetention. The Government has announced its intention to review mental health legislation for England and, in relation to non-devolved issues, for Wales.1 The Government states that it is ‘committed to delivering parity of esteem between mental and physical health’, although it does not clarify the meaning of ‘parity of esteem’. Similarly, the Government states that it wants to ensure that people with mental health problems ‘are treated with dignity, and that their liberty and autonomy is respected as far as possible’. Again, the Government has not indicated the meaning of ‘as far as possible’. Although not directly mentioned in the review’s terms of reference, it must be set against the background of changing legal and ethical expectations in relation to the rights of those with mental or cognitive disorders and disabilities. The UK is a signatory to the United Nations Convention on the Rights of People with …. (shrink)

Erdoğan intensifies assault on Turkish civil society Deeply worrying reports from the Turkish Medical Association suggest that the Turkish President Recep Erdoğan is hardening his attack on civil society in Turkey, using the legitimate activities of the TTB as the flimsiest of pretexts. In January 2018, the TTB issued a short statement raising concerns about the impact on public health of Turkey’s military operation in the Kurdish-controlled region of northern Syria. It denounced the operation saying ‘No to war, peace immediately’. (...) In response to the Association’s press release, the Turkish president publicly accused the 83 000 strong TTB of being terrorist sympathisers. ‘This institution has nothing to do with Turkishness and nothing about them is worthy of the notion of Turkishness’, he said. 1 Eleven of its senior doctors, including the Association’s chairman, were later detained following an order from a Turkish prosecutor. President Erdoğan made it... (shrink)

Doctors and medical students in the UK have voted in support of the decriminalisation of abortion for women who self-administer abortions and healthcare professionals who provide abortions within the context of their clinical practice. Abortion should be treated as a medical issue rather than a criminal one. ### Background to the vote The vote took place at the end of June during the British Medical Association’s Annual Representative Meeting, where representatives of doctors and medical students from across the British Isles (...) gathered to set BMA policy through democratic procedures. Representatives considered the issue of decriminalisation during a 2-hour debate, where diverse and opposing viewpoints were heard. The debate was informed by a neutral discussion paper that was published by the BMA in February, which provided a guide to some of the key legal and ethical issues raised by the debate around decriminalisation.1 The BMA’s new policy only relates to whether abortion should or should not be a criminal offence; the policy does not address the broader issue of when and how abortion should be available. The BMA has established policy on these issues which remains unchanged.2 ### The law on abortion Induced abortion is currently a crime throughout the British Isles. There are, however, a range of exceptions to the crime laid out in statute and/or common law, for example, in England, Scotland and Wales, under the Abortion Act 1967. Any healthcare professionals operating within those defined exceptions, which include grounds for authorising an abortion and procedural requirements, can lawfully carry out an abortion as a clinical procedure. Outside these defined exceptions, the criminal offences potentially apply both to those who participate in carrying out abortions for others, including doctors, nurses and midwives, and to women who carry out abortions on themselves. For example, healthcare professionals who do not follow procedural requirements can attract criminal sanctions …. (shrink)

Essex University, in association with Johns Hopkins Center for Public Health and Human Rights, has brought out a timely report highlighting the increasing global criminalisation of the provision of healthcare.1 The report, with a foreword by Professor Dainius Puras, United Nations Special Rapporteur on the right to health, explores the pressures on medical impartiality arising in large part from both global and national responses to the threat of terrorism. Both international humanitarian law, human rights law and long-established principles of medical (...) ethics—as set out in various declarations of the World Medical Association—establish an absolute principle that all people, regardless of their beliefs, affiliation or status, have rights of access to appropriate healthcare. And this right extends to wounded and sick combatants, as well as civilians, during times of armed conflict. One of the challenges in this area is that in recent years, many conflicts have become ‘asymmetric’. Contemporary conflicts seldom involve opposing state armies. Instead, they increasingly involve irregular combatants, often labelled ‘terrorists’ or ‘insurgents’ by the states they are opposing. In response to these threats, many states have developed sometimes draconian legislation outlawing terrorist groups and those offering support. The danger, outlined in some detail in the report, is that the vital distinction between the impartial provision of medical care and the criminal offence of materially aiding terrorism is lost. In 2016, largely in response to the deliberate targeting of healthcare personnel and facilities in the conflicts disfiguring the greater Middle …. (shrink)

Court of appeal ruling on assisted dyingIn July 2013, the Court of Appeal ruled on an assisted dying case brought by Paul Lamb, a 58-year-old man who has been quadriplegic and without function in any of his limbs, apart from a little movement in his right hand, since a car accident in 1990.1 Mr Lamb was permitted by the Court to take over the legal case of Tony Nicklinson, who died in August 2012, less than a week after his request (...) for judicial review was rejected by the High Court.2 Like Mr Nicklinson, the severity of Mr Lamb's injuries means that he is unable to take his own life, other than by starvation. He would like his life to be ended, preferably by lethal injection administered at home, and does not want to travel to Switzerland for an assisted suicide.Mr Lamb's case was heard, along with that of Mr Nicklinson's wife and that of another man, ‘Martin’, in the Court of Appeal in May.The Court identified three issues from the parties’ submissions: The common law should provide a defence to murder where that takes the form of euthanasia in circumstances where another party is giving effect to the settled wish of a competent person. The legal prohibitions on those providing assistance constitute a disproportionate interference with Article 8 rights to a private and family life. The Director of Public Prosecution's policy statement on factors which he will take into account when considering whether or not to exercise his discretion in favour of prosecuting does not satisfy the …. (shrink)

In February 2014, the Belgian Parliament passed legislation allowing euthanasia for terminally ill children of all ages by 86 votes to 44, with 12 abstentions. The Bill became law in early March after being signed by the King, making Belgium the first country in the world to abolish age restrictions for euthanasia. Previously, the youngest age at which euthanasia was permitted was 12 years old in The Netherlands.1Euthanasia was legalised in Belgium in 2002, and the new legislation introduces amendments to (...) the law extending euthanasia to minors in certain circumstances. Euthanasia is now permissible for children of all ages where the child has a “terminal and incurable illness”, experiences “constant and unbearable physical suffering”, and death is expected to occur within a “brief period”. The child must be deemed capable of making the decision, and have the agreement of their parents.Belgian law sets no timetable for euthanasia from the point at which the patient first expresses a wish to die. As with adults seeking euthanasia, any request must be made in writing. A physician and “outsider” brought in to give a second opinion must agree upon the diagnosis and prognosis, and a paediatric psychiatrist or psychologist must certify in writing that the child possesses “the capacity of discernment”. Following this, the child's physician must meet with the parents to inform them of the outcome of the consultation and ensure they are in agreement with the child's request. The child and the family must receive psychological care and support if so desired.The move provoked heated debate and divided the medical, legal and political professions in Belgium. A group of 160 of the country's paediatricians opposed a change in the law, citing concerns about the largely subjective assessment of the “capacity of discernment”, and drawing attention to advances in …. (shrink)

At the time of writing the COVID-19 pandemic was entering its ninth month, with nearly 800 000 recorded fatalities and 22 million infections in 188 countries and territories.1 In previous ethics briefings2 we raised concerns about the possibility that demand for life-sustaining treatment would overwhelm supply, with a consequent requirement for health professionals to make challenging triage decisions. Fortunately, to date, these have largely not been realised, although there is a possibility that countries in which containment measures have been less-successful, (...) such as South Africa, may still be required to triage.3 Despite the successful ‘flattening of the curve’ in many countries, there is a wide consensus that we remain firmly within the pandemic. Enormous practical challenges remain. It is unclear whether the pandemic will ultimately take the form of two or more successive waves, or whether the patchwork of global responses will lead to a sustained slow ‘burn’ with sporadic flare-ups.4 Areas of uncertainty include whether infection confers some immunity, how long any such immunity might last, whether effective vaccines can be developed and if seasonal temperature fluctuations alter the spread of the virus. The pandemic will also be fundamentally shaped by the decisions that governments make and the extent to which their diktats are complied with by citizens. With the – possibly temporary – retreat of urgent clinical ethics issues, such as triage, opportunities have arisen to reflect on some of the ethical questions that underlie and structure the demanding policy decisions that governments are wrestling with. One of the early questions was how to balance the complex constellation of costs and benefits associated with lockdown. Countries that …. (shrink)

In December, the National Data Guardian 1 for health and care in England, Dame Fiona Caldicott, published the outcomes of a public consultation about the Caldicott Principles and the role of Caldicott Guardians.1 The Caldicott Principles are good practice guidelines which have been used by health and social care organisations in the UK since 1997 to ensure that people’s data are kept safe and used in an ethical way.2 The role of the Caldicott Guardian is well-established in the UK. Caldicott (...) Guardians are senior people which support the upholding of the Caldicott Principles within organisations. In response to views expressed during the consultation the NDG has added an eighth Caldicott Principle to the existing seven and will use her statutory powers to issue guidance about the appointment of Caldicott Guardians for health and adult social care organisations. The new eighth Caldicott Principle is: ‘Inform patients and service users about how their confidential information is used’. It provides that: > A range of steps should be taken to ensure no surprises for patients and service users, so they can have clear expectations about how and why their confidential information is used, and what choices they have about this. These steps will vary depending on the use: as a minimum, this should include providing accessible, relevant and appropriate information - in some cases, greater engagement will be required. The NDG explains that the introduction of the new principle was prompted by consideration of the role that the legal concept of ‘reasonable expectations’ should play in shaping the circumstances under which health and care data may be legitimately shared. The NDG does not envisage that this principle will establish reasonable expectations as a legal basis in its own right …. (shrink)

In April 2014, the European Parliament agreed the final text on a new EU Clinical Trials Regulation.1 The Regulation replaces the EU Clinical Trials Directive, which has long been criticised by various stakeholders for creating unnecessary bureaucracy and blamed, at least in part, for increased costs, time delays and a drop in clinical trial applications. The new Regulation seeks to remedy the faults of the previous legislation and make the EU an attractive place to conduct clinical trials.The Regulation aims to (...) streamline and harmonise the administrative procedures for clinical trial approvals but without compromising the safety of participants. A particular focus is placed on the importance of enabling trials in multiple or all member states, recognising that there is an increasing need to target ever more specific patient populations and the challenge this represents in recruiting sufficient numbers of participants to research studies. A new, two-part application process, designed to avoid the multiple submission of identical data is therefore to be introduced. Member states cooperate on certain aspects of trial approval but issues which are subject to specific national regulations will continue to be approved by individual countries. All applications will be submitted through a new EU portal, which will be set up and managed by the European Medicines Agency. The new process also takes a risk-based approach to some types of research study. Trials to test medicinal products that already have a marketing authorisation are classed as ‘low intervention trials’ and are subject to less stringent requirements.The ethical safeguards in the new Regulation remain similar to those in the 2001 Directive. A positive appraisal from a research ethics committee remains a prerequisite for a trial to be approved. Member …. (shrink)

Re AA and Re P : the ‘forced caesarean’ caseOn 30 November 2013 The Telegraph reported that Essex County Council Social Services had obtained a High Court Order against a woman that allowed her to be forcibly sedated and her child removed by caesarean section and taken into care.1 The original story reported that the woman, an Italian national who had been in the UK on a short-term basis for work, had experienced ‘something of a panic attack’ and, after calling (...) the police, was compulsorily detained under the Mental Health Act 1983. Five weeks later, the report said, she was restrained, forcibly sedated and awoke hours later to find that, pursuant to a court order obtained by Essex County Council Social Services, her baby had been removed by caesarean section and taken into care by social workers.The story was subsequently reported in a number of other media outlets and prompted such widespread outrage that the presiding judge, Mr Justice Mostyn, took the unprecedented step of releasing both the judgement of the initial application to the Court of Protection and the verbatim transcript of proceedings. It became apparent that the facts of the case had been drastically misreported by the media and that coverage had conflated two very separate issues: the medical procedure of the caesarean section and the taking of the child into local authority care.The initial case heard in the Court of Protection on 23 August 2012, Re AA,2 was the result of an application made not by the local authority or social workers seeking to remove the child but by Mid-Essex National Health Service Trust seeking a declaration and an order, on the basis of medical evidence, that the patient lacked capacity and that it would be in her best interests to undergo a caesarean section. Mr Justice Mostyn found in …. (shrink)

Previous Ethics briefings have charted the unprecedented developments in relation to the law on abortion in Northern Ireland this year,1 resulting in legislation being passed by the UK government that ‘decriminalised’ abortion in Northern Ireland, up to the point at which a fetus ‘is capable of being born alive’, from 22 October 2019. A new legal framework and supporting guidelines on abortion are now set to be introduced by 31 March 2020—which should reflect the recommendations in the 2018 United Nations’ (...) Committee on the Elimination of Discrimination against Women report on abortion in Northern Ireland.2 ### Interim guidance In anticipation of this period between decriminalisation and the introduction of a new legal framework, on 7 October 2019 the UK government’s Northern Ireland Office published interim factual guidance for healthcare professionals on their responsibilities to patients in light of these changes.3 Among other things, the guidance notes that there are no plans for additional services to be routinely available in Northern Ireland before 31 March 2020. There will, however, be fewer restrictions on which women in Northern Ireland can access funded abortion services in England via the Central Booking Service—doctors should direct women to this service.4 If healthcare professionals do offer additional abortion services in Northern Ireland itself ‘they should do so in line with their professional competence and guidance from their professional body’. The guidance recognises that some women may still purchase drugs that cause abortions online during this interim period. The difference now is that should a woman require medical assistance as a result, there is no obligation on healthcare professionals to report the woman to the police as abortion, in these circumstances, is not a crime. Previously, under section 5 of the Criminal Law Act 1967 a legal duty, unique to Northern Ireland, was placed …. (shrink)

Complementary and alternative therapiesThere has long been debate about the degree to which conventional health professionals should work closely with complementary and alternative medicine practitioners, if patients choose treatment from both. Some doctors are trained in conventional and alternative therapies but often, liaison depends on the type of therapy, whether it is regulated by law and whether it supplements conventional methods of diagnosis and treatment or claims to provide an alternative to them. Among the therapies often used by patients to (...) supplement conventional medicine, but which do not claim to have a diagnostic purpose, are aromatherapy, massage, stress therapy, reflexology and hypnotherapy. Chinese medicine and homoeopathy are among those which are not statutorily regulated but claim to provide diagnosis and treatment. Practitioners of conventional medicine are often wary of unregulated treatments that supplant evidence-based therapy—even though not all conventional medicine has been proven by randomised controlled trials.The role of complementary and alternative therapies came under scrutiny in England in February 2010 when the Parliamentary Science and Technology Committee published a critical report on NHS funding for homoeopathy. 1 Focusing on whether government policy on homoeopathy was evidence-based, the Committee found a mismatch between the evidence and policy. Its main conclusion was that the evidence indicates that homoeopathy is not efficacious and does not produce results beyond the placebo effect. The Committee said that explanations for why homoeopathy was thought to work were implausible and that further homoeopathic clinical trials could not be justified. The amount that the NHS actually spends on homoeopathic therapies was left unclear and was subject to varying claims from the Society of Homoeopaths and the Health Minister.2 The Parliamentary report recommended that there should be a clear policy on prescribing placebos, including homoeopathic medicines, but the government has been …. (shrink)

This paper applies Karl Jaspers’ and Martin Heidegger’s accounts of transcendence to their descriptions of Van Gogh’s art. I will contrast Jaspers’ more vertical account of immanent transcendence to Heidegger’s horizontal one. This difference between their separate understandings of transcendence manifests itself in their estimations of the significance of Van Gogh’s art. Using phenomenology to understand Van Gogh’s art in light of immanent transcendence, moreover, illuminates a new understanding of transcendence as the ‘beyond’ that is always already here in (...) the immanent and reveals the ability of an object to point beyond itself. Both of these concepts are at work in Van Gogh’s art as well as modern art in general as the expansion of reality through new sight. Immanent transcendence and Van Gogh’s art are different but interconnected ways of rethinking experience beyond the limits of positivism and the myth of the given. Van Gogh’s art thus embodies a sensible world transformed. In particular, Van Gogh’s landscapes and still life series suggest the inexhaustibility of the things we so often overlook in our everyday experience. (shrink)

A discussion of the influence of Martin Buber is not easily limited to the philosophical anthropology he espoused. Nor is the political thinking of Hannah Arendt easily removed from criticism of the philosophies that informed her. Both Buber and Arendt attacked the beastly shoulders of a misapplied messianism as it emerged in modern Germany. Hegel, Heidegger, Marx and to some degree Nietzsche would affect this misplacement, and Arendt and Buber for their part would enter into a shared critique that (...) is often neglected, despite promising attempts in a comparative direction made by Ellis, Engel and Riker. In this essay, I make the case that the contributions of Buber and Arendt – their shared assessments of the viability of the public realm, the need for common responsibility and the recurrent decision to engage with otherness in practical terms – point to an innovative critique of the forcible abstraction of a more traditional messianic made by German views of history. In the midst of the crises identified as correlates of a misapplied messianic, the hope as Buber and Arendt see it lies in the capacity for reflective and courageous identification and education between human individuals as they live towards one another. (shrink)

The dominant unspoken philosophical basis of medical care in the United States is a form of Cartesian reductionism that views the body as a machine and medical professionals as technicians whose job is to repair that machine. The purpose of this paper is to advocate for an alternative philosophy of medicine based on the concept of healing relationships between clinicians and patients. This is accomplished first by exploring the ethical and philosophical work of Pellegrino and Thomasma and then by connecting (...) Martin Buber's philosophical work on the nature of relationships to an empirically derived model of the medical healing relationship. The Healing Relationship Model was developed by the authors through qualitative analysis of interviews of physicians and patients. Clinician-patient healing relationships are a special form of what Buber calls I-Thou relationships, characterized by dialog and mutuality, but a mutuality limited by the inherent asymmetry of the clinician-patient relationship. The Healing Relationship Model identifies three processes necessary for such relationships to develop and be sustained: Valuing, Appreciating Power and Abiding. We explore in detail how these processes, as well as other components of the model resonate with Buber's concepts of I-Thou and I-It relationships. The resulting combined conceptual model illuminates the wholeness underlying the dual roles of clinicians as healers and providers of technical biomedicine. On the basis of our analysis, we argue that health care should be focused on healing, with I-Thou relationships at its core. (shrink)

In this book, Andreas Serafim sets out to investigate the use of religious discourse, by which he means any reference to religious ideas, beliefs, and attitudes in public speaking contexts in classical Athens. Like Gunther Martin (Divine Talk: Religious Argumentation in Demosthenes, 2009), Serafim examines religion primarily as a tool for persuasion, but he differentiates himself from Martin’s book by offering a more comprehensive study: he aims to take into account all extant speeches from t...

Should advance directives (ADs) such as living wills be employed to direct the care of the severely demented? In considering this question, I focus primarily on the claims of Rebecca Dresser who objects in principle to the use of ADs in this context. Dresser has persuasively argued that ADs are both theoretically incoherent and ethically dangerous. She proceeds to advocate a Best Interest Standard as the best way for deciding when and how the demented ought to be treated. I (...) put forth a compromise position: both ADs and the Best Interest Standard have roles to play in guiding the care of the severely demented. (shrink)

We prove that there exists a noncomputable c.e. real which is low for weak 2-randomness, a definition of randomness due to Kurtz, and that all reals which are low for weak 2-randomness are low for Martin-Löf randomness.

We examine the sequences A that are low for dimension, i.e. those for which the effective dimension relative to A is the same as the unrelativized effective dimension. Lowness for dimension is a weakening of lowness for randomness, a central notion in effective randomness. By considering analogues of characterizations of lowness for randomness, we show that lowness for dimension can be characterized in several ways. It is equivalent to lowishness for randomness, namely, that every Martin-Löf random sequence has effective (...) dimension 1 relative to A, and lowishness for K, namely, that the limit of KA/K is 1. We show that there is a perfect [Formula: see text]-class of low for dimension sequences. Since there are only countably many low for random sequences, many more sequences are low for dimension. Finally, we prove that every low for dimension is jump-traceable in order nε, for any ε > 0. (shrink)

Focusing on the paradoxes revealed in the multibillion dollar mistake of the Universal Camouflage Pattern and the expansive ambit of a leaked National Security Agency briefing on its approach to “identity intelligence,” this article analyzes security glitches arising from the state’s application of mechanized logics to security and visibility. Presuming that a digital-looking pattern would be more deceptive than designs inspired by natural forms, in 2004, the US Army adopted a pixelated “digital” camouflage pattern, a print that rendered soldiers more, (...) rather than less, visible in the field; it acknowledged this error in 2012. Two years later, “Identity Intelligence: Image Is Everything” visualized the episteme of National Security Agency surveillance with an illustration detailing hundreds of different types of data—biometric, biographic, and contextual—that the agency believes it could exploit to identify and monitor “targets of interest.” These glitches originate in technofetishistic convictions about the nature of digital images and information, limited ways of imagining bodies and lives, and reductive understandings of complex relationships between power and perception. Together, they expose the paradoxes that arise as the state tries to extend its power over the body and the contingency of that power on the smallest of things. (shrink)