Immunology and its philosophy are a primary source for thinking about biological individuality. Through its discriminatory function, the immune system is believed to delineate organism and environment within one generation, thus defining the physiological individual. Based on the paradigmatic instantiations of immune systems, immune interactions and, thus, the physiological individual are believed to last only for one generation. However, in recent years, transgenerationally persisting immune responses have been reported in several phyla, but the consequences for physiological individuality have not yet (...) been explored. In this article, I will introduce an invertebrate immune system that is RNA-based and operates through a heritable silencing/licensing paradigm. I will discuss how such a perspective on immune systems can illuminate our conceptions of individuality. I will particularly introduce an account of immunological individuality that is not restricted to one generation. (shrink)

The discovery of RNA interference in 1998 has made a lasting impact on biological research. Identifying the regulatory role of small RNAs changed the modes of molecular biological inquiry as well as biologists' understanding of genetic regulation. This article examines the early years of small RNA biology's success story. I query which factors had to come together so that small RNA research came into life in the blink of an eye. I primarily look at scientific repertoires as facilitators of rapid (...) scientific change. I show that for a short period of time, between the years 1998 and 2002, different model organism communities, investigative strategies, technological innovations, and research interests could be successfully aligned to take small RNA research off the ground. I discuss how the keystone discoveries were situated in specific experimental traditions and what strategies were employed to establish these discoveries as more general phenomena. Providing thus a practice-based approach of rapid scientific change, I ask how to relate the change in propositional bits of scientific knowledge with changes in scientific practice. (shrink)

While scientific pluralism enjoys widespread popularity within the philosophy of science, a related position, epistemic relativism, does not have much traction. Defenders of scientific pluralism, however, dread the question of whether scientific pluralism entails epistemic relativism. It is often argued that if a scientific pluralist accepts epistemic relativism, she will be unable to pass judgment because she believes that “anything goes”. In this article, I will show this concern to be unnecessary. I will also argue that common strategies to differentiate (...) relativism and pluralism fail. Building upon this analysis, I will propose a new way of looking at both positions’ relations. This article aims to understand what explains the friction between scientific pluralism and epistemic relativism. I will demonstrate that conceptualizing both epistemic relativism and scientific pluralism as “stances” sheds better light on their relation and demonstrates that it is, in principle, possible to support both positions at the same time. Preferred policies and levels of analysis, however, cause friction in practice. (shrink)

In his insightful review, Eugene V. Koonin discusses various aspects of CRISPR-Cas systems with a strong focus on their qualities as "adaptive immune systems". The CRISPR-Cas system is most famous for its application as a gene-editing tool. Koonin provides a deeper insight into its biological function in bacteria, which is to immunize the cell against parasite DNA. I shall comment on one issue discussed in the text, in two steps. First, I shall elaborate on CRISPR-Cas systems and their supposed Lamarckian (...) character. Criteria for calling biological phenomena genuinely Lamarckian will be narrowed down and then applied to the CRISPR-Cas system, considering interference-driven spacer acquisition as an instantiation of a truly Lamarckian paradigm. Second, I shall consider whether Lamarckian and "canonical" instances of inheritance are a case of theoretical pluralism, being two non-reducible, yet interconnected paradigms. (shrink)

In recent years, immune systems have sparked considerable interest within the philosophy of science. One issue that has received increased attention is whether other phyla besides vertebrates display an adaptive immune system. Particularly the discovery of CRISPR-Cas9-based systems has triggered a discussion about how to classify adaptive immune systems. One question that has not been addressed yet is the transgenerational aspect of the CRISPR-Cas9-based response. If immunity is acquired and inherited, how to distinguish evolutionary from immunological adaptation? To shed light (...) on this issue and obtain conceptual clarity, I will investigate the inheritance of small RNA responses to pathogens in the nematode C. elegans as a further potential instantiation of a transgenerational adaptive immune system. I will explore how to make sense of systems that lie at the crossroads between genetic, immunological, and evolutionary spheres and explore the consequences of a transgenerational perspective on immune systems for immunology and its philosophy. (shrink)

In 1869, Johann Friedrich Miescher discovered a new substance in the nucleus of living cells. The substance, which he called nuclein, is now known as DNA, yet both Miescher’s name and his theoretical ideas about nuclein are all but forgotten. This paper traces the trajectory of Miescher’s reception in the historiography of genetics. To his critics, Miescher was a “contaminator,” whose preparations were impure. Modern historians portrayed him as a “confuser,” whose misunderstandings delayed the development of molecular biology. Each of (...) these portrayals reflects the disciplinary context in which Miescher’s work was evaluated. Using archival sources to unearth Miescher’s unpublished speculations—including an analogy between the hereditary material and language, and a speculation that a series of asymmetric carbon atoms could account for hereditary variation—this paper clarifies the ways in which the past was judged through the lens of contemporary concerns. It also shows how organization, structure, function, and information were already being considered when nuclein was first discovered nearly 150 years ago. (shrink)

Fundamental disagreement is at the core of many debates surrounding epistemic relativism. Proponents of epistemic relativism argue that certain disagreements are irresolvable because proponents base their views on fundamentally different epistemic principles and, thus, fundamentally different epistemic systems. Critics of epistemic relativism argue that this analysis is wrong since the particular epistemic principles in question are most of the time derived from or instances of the same, more basic, epistemic principle. With regard to the individuation of epistemic systems, there is, (...) thus, an impasse within the epistemic relativism literature. It is the aim of this article to employ the recently developed notion of ‘situated judgments’ as well as the concepts of ‘world-traveling’ and ‘epistemic friction’ to provide an epistemic agent-based, dynamic account of disagreeing and thereby also contribute to the question of how to individuate an epistemic system. (shrink)

In the postgenomic era, interactions between organism and environment are central in disciplines such as epigenetics, medical physiology, and immunology. Particularly in the more "applied" medical fields, an emphasis lies on interactions of the organism with other organisms, that is, other living things. There is, however, a growing amount of research investigating the impact of abiotic triggers on the immune system. While the distinction between biota and abiota features heavily in other contexts, its status is not explicit within immunology. Do (...) immunologists distinguish living from nonliving triggers? In this article, I will carve out whether and in which ways the biotic/abiotic distinction operates in immunology. I will look into responses to biotic and abiotic stressors in plant and invertebrate model species and ask how and why they are conceptually separated. I will trace the reasons by investigating the disciplinary situatedness of immune phenomena and the import of vertebrate immunology when conceptualizing immune responses in other model organisms. I will then investigate how the convergence of biotic and abiotic stress responses in plants and invertebrates adds to the recent philosophical programs advocating an ecological perspective on immune systems. (shrink)

Scientific pluralism has become a household position within the philosophy of science literature. There are numerous accounts of plurality within various research fields. Most scientific pluralists, however, focus on the plurality of theories, explanations, or mechanisms, while other potential targets of plurality that the philosophy of scientific practice has particularly emphasized have so far not received extensive treatment. How should we approach such practice-based candidates of plurality? And what are potential pluralist positions concerning the objects of scientific practice? In this (...) article, I set out to answer these questions. I combine approaching a widely influential topic within the philosophy of science, scientific pluralism, with social science methodology. Using interview data combined with sociological analysis, I provide a nuanced picture of the dynamics of one particular research field that displays plurality. Focusing on how sociological configurations resonate with intellectual commitments within a research field, I disentangle practice-based from theoretical plurality. I consider how these empirical results should feedback on the scientific pluralism literature. (shrink)

The “Encyclopedia of DNA Elements” (ENCODE) project was launched by the US National Human Genome Research Institute in the aftermath of the Human Genome Project (HGP). It aimed to systematically map the human transcriptome, and held the promise that identifying potential regulatory regions and transcription factor binding sites would help address some of the perplexing results of the HGP. Its initial results published in 2012 produced a flurry of high-impact publications as well as criticisms. Here we put the results of (...) ENCODE and the work on epigenomics that followed in a broad theoretical and historical context, focusing on three strands of research. The first is the history of thinking about the organization of genomes, both physical and regulatory. The second is the history of ideas about gene regulation, primarily in eukaryotes. Finally, and connecting these two issues, we suggest how to think about the role of genetic material in physiology and development. (shrink)

This paper introduces the reconstitutor as a comprehensive unit of heredity within the context of evolutionary research. A reconstitutor is the structure resulting from a set of relationships between different elements or processes that are actively involved in the recreation of a specific phenotypic variant in each generation regardless of the biomolecular basis of the elements or whether they stand in a continuous line of ancestry. Firstly, we justify the necessity of introducing the reconstitutor by showing the limitations of other (...) evolutionary conceptions of the unit of heredity, such as the replicator, the reproducer, and the Darwinian individual. We argue that these conceptions are based on the requirement of lineage formation, which we argue to be unnecessary for the existence of evolutionary heredity. In the second part, we introduce the reconstitutor, which we base on the concept of Stability of Traits, and illustrate how it covers cases of hereditary phenomena not covered by the previous accounts. Secondly, we illustrate how the reconstitutor could serve as a platform to rethink ecological inheritance and other forms of inheritance that have been recently introduced under the song/singer model of evolution. (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)

In June 2021, the BMA published its report on moral distress and moral injury in UK doctors.1 The report includes definitions of the terms ‘moral distress’ and ‘moral injury’ as well as a summary of how the concepts have developed over time. There is also an analysis of the BMA’s pan-profession survey of moral distress and moral injury of doctors in the UK, the first of its kind. The impact of COVID-19 and recommendations for tackling moral distress also feature. Many (...) may be unfamiliar with the concepts of ‘moral distress’ and ‘moral injury’. These terms are relatively new, and debate is ongoing in academic circles on the best way to understand them.2 Some use the terms interchangeably. The BMA defines moral distress as the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action. Even without an understanding of the morally correct action, moral distress can arise from the sense of a moral transgression. More simply, it is the feeling of unease stemming from situations where institutionally required behaviour does not align with moral principles. This can be as a result of a lack of power or agency, or structural limitations, such as insufficient staff, resources, training or time. The individual suffering from moral distress need not be the one who has acted or failed to act; moral distress can be caused by witnessing moral transgressions by others. Moral injury can arise where sustained moral distress leads to impaired function or longer-term psychological harm. Moral injury can produce profound guilt and shame, and in some cases also a sense of betrayal, anger and profound ‘moral disorientation’. It has also been linked to severe mental health issues. There is increasing recognition across the UK of the problem …. (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)

Thought experiments play a role in science and in some central parts of contemporary philosophy. They used to play a larger role in philosophy of science, but have been largely abandoned as part of the field’s “practice turn”. This chapter discusses possible roles for thought experimentation within a practice-oriented philosophy of science. Some of these roles are uncontroversial, such as exemplification and aiding discovery. A more controversial role is the reliance on thought experiments to justify philosophical claims. It is proposed (...) that if we adopt an underlying empiricist view of concepts, then thought experiments can be seen as affording us contact with scientific practice, despite their seemingly a priori character. The advantages and drawbacks of thought experiments are discussed via comparison with case studies, on the one, and simulations on the other hand. The chapter closes with some remarks on how to combine thought experiments with other methods. (shrink)

Thought experiments play a role in science and in some central parts of contemporary philosophy. They used to play a larger role in philosophy of science, but have been largely abandoned as part of the field’s “practice turn”. This chapter discusses possible roles for thought experimentation within a practice-oriented philosophy of science. Some of these roles are uncontroversial, such as exemplification and aiding discovery. A more controversial role is the reliance on thought experiments to justify philosophical claims. It is proposed (...) that if we adopt an underlying empiricist view of concepts, then thought experiments can be seen as affording us contact with scientific practice, despite their seemingly a priori character. The advantages and drawbacks of thought experiments are discussed via comparison with case studies, on the one, and simulations on the other hand. The chapter closes with some remarks on how to combine thought experiments with other methods. (shrink)

Since the ENCODE project published its final results in a series of articles in 2012, there is no consensus on what its implications are. ENCODE’s central and most controversial claim was that there is essentially no junk DNA: most sections of the human genome believed to be «junk» are functional. This claim was met with many reservations. If researchers disagree about whether there is junk DNA, they have first to agree on a concept of function and how function, given a (...) particular definition, can be discovered. The ENCODE debate centered on a notion of function that assumes a strong dichotomy between evolutionary and non-evolutionary function and causes, prevalent in the Modern Evolutionary Synthesis. In contrast to how the debate is typically portrayed, both sides share a commitment to this distinction. This distinction is, however, much debated in alternative approaches to evolutionary theory, such as the EES. We show that because the ENCODE debate is grounded in a particular notion of function, it is unclear how it connects to broader debates about what is the correct evolutionary frame- work. Furthermore, we show how arguments brought forward in the controversy, particularly arguments from mathematical population genetics, are deeply embedded in their particular disciplinary contexts, and reflect substantive assumptions about the evolution of genomes. With this article, we aim to provide an anatomy of the ENCODE debate that offers a new perspective on the notions of function both sides employed, as well as to situate the ENCODE debate within wider debates regarding the forces operating in evolution. (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 February 2020, the British Medical Association will be surveying members for their views on what the BMA’s position on physician-assisted dying should be. The BMA is currently opposed to physician-assisted dying in all its forms, a position that was agreed in 2006 at the annual representative meeting, the Association’s policy-making conference.1 As previously reported in Ethics briefing,2 the decision to survey members follows a motion passed at last year’s ARM which called on the BMA to “carry out a poll (...) of members to ascertain their views on whether the BMA should adopt a neutral position with respect to a change in the law on assisted dying”. The results from the survey will not determine BMA policy. Rather, the results be published ahead of this year’s ARM and provided to those attending to inform a debate and discussion on the BMA’s policy position. More information about the survey, including a briefing pack of useful information, and information for BMA members on how to participate can be found online at www.bma.org.uk/PAD. ### High Court rejects Judicial reviews on assisted suicide The High Court has refused permission for two separate challenges to the law on assisted suicide in the UK to proceed to a full hearing. In the first case, Phil Newby, who has motor neuron disease, applied for judicial review of the law on assisted suicide and asked for the court to carry out a detailed examination of what he termed “legislative facts” – that is, an examination of the existing evidence on the “costs, risks and benefits” of regulating assisted suicide – including a cross-examination of relevant expert witnesses.1 Handing down the judgement, Lord Justice Irwin and Mrs Justice May, held that assisted dying …. (shrink)

Healthcare professionals are currently working under extreme pressure as they respond to the pandemic outbreak of COVID-19. At the time of writing, there is currently no effective vaccine or anti-viral treatment. The pandemic is fast-moving, relatively unpredictable and of uncertain duration. In many countries, it is placing an enormous stress on healthcare resources and providing care to existing standards is proving difficult. Unfortunately, in some countries, health services have been overwhelmed. The impact of the pandemic on resource-poor countries is of (...) particular concern. This extraordinary situation is raising, or has the potential to raise, many ethical challenges for doctors delivering care to patients. It is possible, for example, that there may be points in this pandemic where decisions need to be made about who should have access to finite specialised intensive care beds, drugs and equipment. This has happened in some countries and, despite efforts by the UK Government to reduce demand and increase supply, it is still possible that this could happen in the UK. Some hospital trusts in the UK are already reporting concerningly low supplies of oxygen and vital medicines such as propofol and alfentanil.1 In these circumstances, where not everyone can be treated, difficult ethical decisions will have to made. For example, can some patients be prioritised over others? How should a doctor decide on which patients to treat? Can treatment be withdrawn from patients who are currently being treated, but are not responding, in order to offer treatment to those who may have a better chance of benefiting? The UK is also reporting concerningly low supplies of vital personal protective equipment for frontline workers, raising the question - what are a doctor’s obligations to treat patients, in circumstances that present a high …. (shrink)

Legal battles continue in the UK over the Government’s plans to transport asylum seekers arriving on British shores to Rwanda in East Africa. Originally announced as a system for ‘processing’ asylum seekers, the Government has subsequently made it clear that there would not be an option for asylum seekers to return to the UK. The arrangement forms part of a deal between the UK and Rwanda, with the UK promising to invest £120 m in economic growth and development in Rwanda, (...) along with financing the cost of the ‘offshored’ asylum operation.1 The Government states that the policy is designed to break the business model of people traffickers involved in facilitating hazardous trips across the Channel in small, overcrowded and unseaworthy craft, leading to multiple drownings. Critics argue that the policy will do nothing to stop desperate people from seeking refuge in the UK, that transferring already traumatised people to Rwanda – which has been criticised for its human rights record – is inhumane and potentially outwith international law. Medical bodies, including the BMA, along with refugee organisations have expressed serious concerns about the health impact of such a system of ‘offshoring’. An equivalent system in Australia has been notorious for the devastating health impacts on those ‘offshored’ to the Pacific islands of Manus and Naura. Unusually in the UK the offshoring proposals have been greeted by unanimous condemnation by the Church of England. The lawfulness of the process is also subject to question. On the 14 July, a plane carrying a small number of asylum seekers to Rwanda was halted shortly before take-off following an intervention by the European Court of Human Rights. The ECtHR, part of the Council of Europe, of which the UK is still a member, said an Iraqi man known as KN faced ‘a real …. (shrink)

On 7 April 2022 – coinciding with World Health Day – the British Medical Association launched its new report, Health and human rights in the new world order.1 Written during the global upheaval triggered by the COVID-19 pandemic, and published just weeks after the Russian invasion of Ukraine, the report responds to a range of emerging and intensifying threats to health-related human rights globally. As the report establishes, human rights in health and healthcare matter because human suffering, and its relief, (...) are fundamental moral issues. As relief of human suffering is the primary purpose of medicine, it follows that doctors and other health professionals are often active in times of human challenge and extremity. During conflict, humanitarian crises, and, as we have so recently seen, global public health emergencies, health professionals are essential to the response. But these crises – and the response to them – can put fundamental human rights and interests under pressure. The Russian invasion of Ukraine has seen sustained indiscriminate shelling of civilian infrastructure. Whether health facilities were directly targeted is moot – the indiscriminate nature of the assault means they will inevitably be hit. Not only is this a violation of the Geneva Conventions, it undermines fundamental human rights, not least of which the right to health. Destroying health infrastructure drives further suffering and delays post-conflict recovery. Public heath emergencies can rightly require draconian measures – social distancing, enforced isolation, location tracking, economic shutdown. Although we saw their necessity during the COVID-19 outbreak, concerns were raised about disproportionate restrictions on basic rights, including rights to privacy and liberty. Human Rights Watch drew attention to the way governments unlawfully exploited COVID-19 to crack down on fundamental rights.2 Although conflicts and public health emergencies are not new, the report also tracks a number of …. (shrink)

Health, ethics and COP27 On the 20 November 2022, the United Nations Climate Change COP27 announced a breakthrough agreement to provide ‘loss and damage’ funding for resource-poor countries seriously affected by climate change. 1 The establishment of the funding stream acknowledges, and attempts to address, one of many thorny ethical issues driven by climate change – to what extent countries that have benefited economically from past emissions of greenhouse gases owe reparative obligations to countries who have contributed minimally to climate (...) change but are most at risk of its harms? One of the many reasons why this is such an important breakthrough is that it brings into the centre of climate policy-making questions of global – and intergenerational – justice and fairness. It acknowledges the critical importance of ethics in climate change deliberations. It is probably fair to say that climate change policy has been dominated to... (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)

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)