Analyzes the moral problems confronting health care practitioners from a wide variety of perspectives, especially those connected by four major ethical principles--respect for autonomy, beneficence, non-maleficence and justice.

The World Medical Association (WMA), the global representation of the medical profession, first adopted the International Code of Medical Ethics (ICoME) in 1949 to outline the professional duties of physicians to patients, other physicians and health professionals, themselves and society as a whole. The ICoME recently underwent a major 4-year revision process, culminating in its unanimous adoption by the WMA General Assembly in October 2022 in Berlin. This article describes and discusses the ICoME, its revision process, the controversial and uncontroversial (...) issues, and the broad consensus achieved among WMA constituent members, representing over 10 million physicians worldwide. The authors analyse the ICoME, including its response to contemporary changes and challenges like ethical plurality and globalisation, in light of ethical theories and approaches, reaching the conclusion that the document is a good example of international ethical professional self-regulation. (shrink)

edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

We thank our commentators for their thoughtful responses to our paper 1 covering among other issues the relationships of ethics law and professional codes, the tensions between ethical universalism and cultural relativism and the phenomenon of moral judgement required when ethical norms conflict, including the norms of patient care versus obligations to others both now and in the future. Although the comments deserve more extensive discussion, in what follows we respond briefly to specific aspects of each commentary and remind readers (...) that professional codes of ethics are necessarily brief and that the International Code of Medical Ethics (ICoME) explicitly refers to the World Medical Association’s (WMA) mutually concordant and far more extensive ‘body of policies’. 2 Should ethics shape law or vice versa? Sarela raises a fundamental and, as stated in the commentary, unresolved debate: ‘should ethics shape law or is it the converse’? 3... (shrink)

Ted Shotter's founding of the London Medical Group 50 years ago in 1963 had several far reaching implications for medical ethics, as other papers in this issue indicate. Most significant for the joint authors of this short paper was his founding of the quarterly Journal of Medical Ethics in 1975, with Alastair Campbell as its first editor-in-chief. In 1980 Raanan Gillon began his 20-year editorship . Gillon was succeeded in 2001 by Julian Savulescu, followed by John Harris (...) and Soren Holm in 2004, with Julian Savulescu starting his second and current term in 2011. In 2000 an additional special edition of the JME, Medical Humanities , was published, under the founding joint editorship of Martyn Evans and David Greaves. In 2003 Jane Macnaughton succeeded David Greaves as joint editor. Deborah Kirklin, under whose auspices MH became an independent journal, took over in 2008, and she was succeeded in 2013 by Sue Eckstein. This short paper offers reminiscences and reflections from the two journals’ various editors.From the start the JME was committed to clearly expressed reasoned discussion of ethical issues arising from or related to medical practice and research. In particular, both Edward Shotter and Alastair Campbell, each a cleric , were at pains to make clear that the JME was not a religious journal and that it had no sort of partisan axe to grind.Campbell's appointment as founding editor was something of a surprise, as the original intention had been to appoint a medical doctor, who could be expected to know medical practice from the inside. However, in 1972 Campbell, a Joint Secretary of the Edinburgh Medical Group, had published Moral dilemmas in medicine. …. (shrink)

Medical Ethics has many unsung heros and heroines. Here we celebrate one of these and on telling part of her story hope to place modern medical ethics and bioethics in the UK more centrally within its historical and human contex.

This paper argues that Charlie Gard’s parents should have been the decision-makers about their son’s best interests and that determination of Charlie’s best interests depended on a moral decision about which horn of a profound moral dilemma to choose. Charlie’s parents chose one horn of that moral dilemma and the courts, like Charlie Gard’s doctors, chose the other horn. Contrary to the first UK court’s assertion, supported by all the higher courts that considered it, that its judgement was ‘objective’, this (...) paper argues that the judgement was not and could not be ‘objective’ in the sense of objectively correct but was instead a value judgement based on the judge’s choice of one horn of the moral dilemma. While that horn was morally justified so too was the horn chosen by the parents. The court could and should have avoided depriving the parents of their normal moral and legal right and responsibility to decide on their child’s best interests. Instead, this paper argues that the court should have acknowledged the lawfulness of both horns of the moral dilemma and added to its judgement that Charlie Gard’s doctors were not legally obliged to provide treatment that they believed to be against their patient’s best interests the additional judgement that Charlie’s parents could lawfully transfer his care to other doctors prepared to offer the infant a trial of the experimental treatment requested by his parents. (shrink)

This paper argues that the central issue in the abortion debate has not changed since 1967 when the English parliament enacted the Abortion Act. That central issue concerns the moral status of the human fetus. The debate here is not, it is argued, primarily a moral debate, but rather a metaphysical debate and/or a theological debate—though one with massive moral implications. It concerns the nature and attributes that an entity requires to have “full moral standing” or “moral inviolability” including a (...) “right to life”. It concerns the question when, in its development from newly fertilised ovum to unequivocally mature, autonomous morally inviolable person does a human being acquire that nature and those attributes, and thus a “right to life”. The paper briefly reviews standard answers to these questions, outlining some problems associated with each. Finally there is a brief discussion of one way in which the abortion debate has changed since 1967—notably in the increasingly vociferous claim, especially from disability rights sectors, that abortion on grounds of fetal abnormality implies contempt for and rejection of disabled people—a claim that is rebutted. (shrink)

Justice, one of the four Beauchamp and Childress prima facie basic principles of biomedical ethics, is explored in two excellent papers in the current issue of the journal. The papers stem from a British Medical Association essay competition on justice and fairness in medical practice and policy. Although the competition was open to all comers, of the 235 entries both the winning paper by Alistair Wardrope1 and the highly commended runner-up by Zoe Fritz and Caitríona Cox2 were written by practising (...) doctors—a welcome indication of the growing importance being accorded to philosophical reflection about medical practice and practices within medicine itself. Both papers are thoroughly thought provoking and represent two very different approaches to the topic. Each deserves a careful read. The competition was a component of a BMA 2019/2020 ‘Presidential project’ on fairness and justice and asked candidates to ‘use ethical reasoning and theory to tackle challenging, practical, contemporary, problems in health care and help provide a solution based on an explained and defended sense of fairness/justice’. In this guest editorial I’d like to explain why, in 2018 on becoming president-elect of the BMA, I chose the theme of justice and fairness in medical ethics for my 2019–2020 Presidential project—and why in a world of massive and ever-increasing and remediable health inequalities biomedical ethics requires greater international and interdisciplinary efforts to try to reach agreement on the need to achieve greater ‘health justice’ and to reach agreement on what that commitment actually means and on what in practice it requires. First, some background. As president I was offered the wonderful opportunity to pursue, with the organisation’s formidable assistance, a ‘project’ consistent with the BMA’s interests and values. As a hybrid of general medical practitioner and philosopher/medical ethicist, and as a firm defender of the Beauchamp …. (shrink)

This paper, based on a talk given at a conference on compassion in health care held at the Royal Society of Medicine in November 2012, argues that the ethical requirement for humanity in health care is obvious and needs little ethical analysis – the problem is to get the results of ethical reflection, ordinary humanity and everyday common sense, into everyday behaviour. The author offers some suggestions that might help to achieve this aim and bring back the human face of (...) health and social care. These suggestions concern organisational structural changes (including `humanity objectives' in appraisal and reward schemes); individual attitudes (including self assessment of their own humanity in their work by all health and social care workers – `does my own practice manifest a human face?'); and a possible research agenda (and a concomitant effort to remind all health care research funders that `humanity is an integral component of medical, health and care research'. And the author proposes a standing high level `humanity task force' to implement and oversee Health Education England's recent `humanity mandate'. (shrink)

This commentary briefly argues that the four prima facie principles of beneficence, non-maleficence, respect for autonomy and justice enable a clinician (and anybody else) to make ethical sense of the author's proposed reliance on professional guidance and rules, on law, on professional integrity and on best interests, and to subject them all to ethical analysis and criticism based on widely acceptable basic prima facie moral obligations; and also to confront new situations in the light of those acceptable principles.

This chapter contains sections titled: References.

In this journal, Dr Daniel Daly, an American bioethicist, uses a principlist approach (respect for autonomy, non-maleficence, beneficence and justice) to argue that intravenous opiate users should not be denied repeat heart valve replacements if these are medically indicated, ‘unless the valve replacement significantly violates another’s autonomy or one or more of the three remaining principles’.1 In brief outline, the paper seeks to use a widely accepted ethical theory—‘principlism’ as developed by Beauchamp and Childress over the last 40 plus years (...) and eight editions of their ground-breaking book Principles of Biomedical Ethics2—to resolve clinical disagreement about the ethics of denying medically indicated life-prolonging treatment to patients who continue or resume intravenous opiate use. The argument Dr Daly's argument in very brief summary is that in the context of contemporary American medical practice, such treatment is ethically justified—perhaps even ethically required—if requested or accepted by an adequately autonomous patient and thus respects the patient’s autonomy, if it is not harmful to the patient, if it is beneficial to the patient, and if it is fair and just in terms of Aristotle’s formal theory of justice according to which equals should be treated equally while unequals should be treated unequally in proportion to the morally relevant inequality or inequalities. Dr Daly focuses his argument around a typical case description where these conditions are met and therefore where, he concludes, repeat heart valve replacements ought to be provided. As Dr Daly notes, principlism ‘is not without its problems; nonetheless it does provide a viable set of principles that are widely held by medical ethicists and inform the work of ethics committees at many secular medical facilities’. DOI (declaration of interest): The writer of this editorial is a career-long supporter and defender of the use of ‘principlism’ or ‘the four principles …. (shrink)

We wish to describe and acknowledge the exceptional contributions to medical ethics, both in the UK and internationally, made by Edward Shotter1 who died at home on 3 July 2019. He was founder of the London Medical Group2 3 and instigator of similar student-led medical ethics groups throughout the UK; founder of the Institute of Medical Ethics4 and founder of the Journal of Medical Ethics. Ted Shotter transformed the study of medical ethics in the UK in the interests of patients (...) and professionals alike. In 1963, he established the pioneering ‘Medical Group’ model, an innovative bottom-up method whereby students in the health professions could gain a grounding in ethics that had previously been denied to the profession.5 It was with these Medical Groups that many of the leading figures in contemporary UK medical ethics and law began their careers in the subject including Sir Kenneth Calman, Sir Ian Kennedy, Professor Margaret Brazier OBE, Professor John Harris and Professor Sir Jonathan Montgomery to name but …. (shrink)

This paper describes the medical ethics scene in Britain. After giving a brief account of the structure of British medical ethics and of the roles of the different groups involved it mentions some of the important medico-moral events and issues of the fairly recent past, and describes in greater detail four important examples of professional, legal, governmental and media concerns with medical ethics, themselves illustrating the wide variety of interests wishing to influence the British medical profession's ethics. The examples offered (...) are the development of research ethics committees, the Sidaway case concerning informed consent, the Warnock Committee's Report on in vitro fertilisation and associated issues, and the 1980 Reith Lectures on Unmasking Medicine. In the final section a fairly new methodological development in British medical ethics is described in which the medical profession is increasingly recognising the need to add to traditional medical ethics education, with its longstanding history of the inculation and enforcement of ethical norms, an element of philosophical or critical medical ethics, at the heart of which is justification of substantive medico-moral claims in the light of counterarguments. (shrink)

Promoting respect for the four principles remains of great practical importance in ordinary medicineThe following are four “scenarios” with brief outlines of how Raanan Gillon has analysed them using the “four principles” approach. These are the four cases that the commentators were asked to analyse.Professor Gillon has for many years advocated the use of the Beauchamp and Childress four principles approach as a widely and interculturally acceptable method for medical ethics analysis . At present there seems to (...) be a backlash by some bioethicists against this approach, with among others, adherents of feminist ethics, narrative ethics, virtue ethics, and various varieties of regional ethics claiming to offer better approaches to medical ethics.At Raanan Gillon’s request this special issue of the Journal of Medical Ethics is intended to focus on this aspect of his work, with a view not only to discussing the issue of how different approaches to medical ethics are and/or are not compatible with the four principles approach but also to make clear to JME readers what alternative ethics analysis method is preferred and used by the various commentators.THE “STANDARD” JEHOVAH’S WITNESS CASEIn the first scenario, that of the “standard” Jehovah’s Witness case, a competent adult patient loses a massive amount of blood from a blood vessel bleeding in an acute duodenal ulcer. The best chance of …. (shrink)

Promoting respect for the four principles remains of great practical importance in ordinary medicineThis is a special edition of the journal to celebrate the contribution of Raanan Gillon to the field of medical ethics. The papers in this issue are from a festspiel in honour of Raanan held on the 17th of October 2003. The theme of the festspiel was method in medical ethics. Colleagues of Raanan were asked to outline their own approach to medical ethics, (...) and how this differed from the four principles approach advocated by Raanan, as applied to four hypothetical cases which are also reproduced in this issue of the journal.1It is a great privilege to be able to publish this series of papers, and Raanan’s reply, in the journal for several reasons.The first and most important of these is that they are a tribute to the enormous contribution Raanan has made to the field of medical ethics. Raanan has been a pioneer in medical ethics in the United Kingdom and beyond. He edited the Journal of Medical Ethics for over 20 years, retiring in 2001. He has been instrumental in establishing medical ethics as a discipline, particularly within medical schools, in the United Kingdom.2 His book Philosophical Medical Ethics is one of the classics.3While most people associate Raanan with his advocacy of the four principles, it is important to remember his approach is not restricted solely to application of the four principles. He is also one of the sharpest, wittiest, and most original thinkers in medical ethics. In a recent editorial,4—for example, Raanan disagreed with a judicial decision to impose separation of identical twins which caused the death of one twin. He described it as “hubris”. He argued that the …. (shrink)

This textbook, which is completely self-contained and can be read by anyone with a secondary school education, is the result of the author's material prepared over the past 15 years of teaching introductory natural language semantics to graduate and undergraduate students at McGill University. The intended audience comprises undergraduate and graduate students in linguistics as well as those in philosophy, computer science and psychology with an interest in natural language semantics. The aim of the textbook is to teach the fundamentals (...) of natural language semantics, with English as the principal, though not the exclusive, target language. The principal aim of the textbook is to provide the student with all the basics necessary to be able him or her read research in natural language semantics, regardless of the theory assumed by the author of the research. In contrast to other textbooks in the field, which aim to introduce students to a particular theory of natural language semantics, this textbook seeks to give to its reader a clear overview of the kind of natural language phenomena which, at least prima facie, fall within the ambit of an investigation of natural language semantics; to assist the reader in developing a mastery of the mathematical tools used to formulate hypotheses about the natural language phenomena studied; and to impart to the reader an appreciation of the interplay between hypothesis and data. As a result, the textbook is rich in its presentation of the patterns of English, drawing extensively on the best and most contemporary descriptive grammars of English. The textbook also has more than 500 exercises, with answers to half of them. (shrink)

It is hypothesised and argued that “the four principles of medical ethics” can explain and justify, alone or in combination, all the substantive and universalisable claims of medical ethics and probably of ethics more generally. A request is renewed for falsification of this hypothesis showing reason to reject any one of the principles or to require any additional principle(s) that can’t be explained by one or some combination of the four principles. This approach is argued to be compatible with a (...) wide variety of moral theories that are often themselves mutually incompatible. It affords a way forward in the context of intercultural ethics, that treads the delicate path between moral relativism and moral imperialism. Reasons are given for regarding the principle of respect for autonomy as “first among equals”, not least because it is a necessary component of aspects of the other three. A plea is made for bioethicists to celebrate the approach as a basis for global moral ecumenism rather than mistakenly perceiving and denigrating it as an attempt at global moral imperialism. (shrink)

The difficulty in the apostrophe of the has been noticed by commentators. So Barrett : ‘/ this cannot mean that the Amazon from Hipp, now that he is exiled: in all the forms of her legend … she meets a violent death at a time which cannot be long after Hipp.'s birth, and it is inconceivable that Eur. should mean his audience to think of her as still alive in Trozen or Athens.’ What seems to have passed unnoticed is that (...) there are, in this choral ode , two other passages which also suffer from at least prima facie incongruities with details of the story well known to the audience. (shrink)

Replacing logical coherence by effectiveness as criteria of rationality, Gigerenzer et al. show that simple heuristics can outperform comprehensive procedures (e.g., regression analysis) that overload human limited information processing capacity. Although their work casts long overdue doubt on the normative status of the Rational Choice Paradigm, their methodology leaves open its relevance as to how decisions are actually made.

The present study tested the existence of a cognitive schema that guides people's evaluations of the likelihood that observed problem-solving processes will succeed. The hypothesised schema consisted of attributes that were found to distinguish between retrospective case reports of successful and unsuccessful real world problem solving (Lipshitz & Bar Ilan, 1996). Participants were asked to evaluate the likelihood of success of identical cases of problem solving that differed in the presence or absence of diagnosis, the selection of appropriate or inappropriate (...) solutions, and the pairing of diagnosis with appropriate or non-appropriate solutions. Consistent with the proposition, diagnosis affected perceived likelihood of success, albeit only when solution quality was held constant, and appropriate diagnosis with a compatible solution produced higher perceived likelihood of success than appropriate diagnosis with incompatible solutions. In addition, results showed that solution quality played a significant role, and that compatibility with a six-phase rational model of problem solving played no role in judging likelihood of success. (shrink)

This paper presents an integrative framework for analyzing decisions. Three generic modes of decision making are identified: consequential choice , matching and reassessment . The three generic modes are compared on a common set of attributes, and the conditions for their proper use are outlined. Two case analyses illustrate how the framework can be used to analyze specific decisions from multiple perspectives.

Considerable attention in bioethics has been devoted to moral expertise and its implications for handling applied moral problems. The existence and nature of moral expertise has been a contested topic, and particularly, whether philosophers are moral experts. In this study, we put the question of philosophers’ moral expertise in a wider context, utilizing a novel and global study among 4,087 philosophers from 96 countries. We find that despite the skepticism in recent literature, the vast majority of philosophers do believe in (...) moral expertise and in the contribution of philosophical training and experience to its acquisition. Yet, they still differ on what philosophers’ moral expertise consists of. While they widely accept that philosophers possess superior analytic abilities regarding moral matters, they diverge on whether they also possess improved ability to judge moral problems. Nonetheless, most philosophers in our sample believe that philosophers possess an improved ability to both analyze and judge moral problems and that they commonly see these two capacities as going hand in hand. We also point at significant associations between personal and professional attributes and philosophers’ beliefs, such as age, working in the field of moral philosophy, public involvement, and association with the analytic tradition. We discuss the implications of these findings for the debate about moral expertise. -/- . (shrink)

Study of Nyayabindu of Dharmakirti, 7th cent. and its commentary Nyayabindutika of Dharmottara.

In this issue of the journal “Lee Elder”,1 a pseudonymous dissident Jehovah's Witness , previously an Elder of that faith and still a JW, joins the indefatigable Dr Muramoto2–5 in arguing that even by their own religious beliefs based on biblical scriptures JWs are not required to refuse potentially life-saving blood transfusions. Just as the “official” JW hierarchy has accepted that biblical scriptures do not forbid the transfusion or injection of blood fractions so too JW theology logically can and should (...) permit the transfusion of whole blood when this is medically required.Few doctors would argue that they should override the adequately autonomous decisions of Jehovah's Witnesses to refuse blood transfusions even if they are likely to die as a result of such transfusions. However, there is a case to be made for doctors asking such patients to reflect on their potentially fatal refusal of blood and for drawing to these patients' attention the reasoning of members of their own faith that justifies acceptance of potentially life-saving blood transfusions. What is that case? Simply that doctors' primary professional duty to try to benefit the health of their patients entails trying to save their patients' lives when and if doing so will benefit their patients' health. Of course this is not an absolute duty overriding all other duties; in particular if patients who are adequately autonomous to do so refuse such life-prolonging treatment doctors must generally accept such refusal, however sadly. This editorial endorses that view in the case of adequately autonomous legally competent JWs. (In another paper in this issue of the journal Professor Shimon Glick argues that ethics committees should be empowered—as they now are in Israel—to override even competent refusals of life-prolonging treatment where the committee judges that …. (shrink)