Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions frequently focus on facilitating ‘healthy choices’, with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable (...) to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours, as well as with doctors’ frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians’ ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities. No data are available. (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)

Drawing on the views of donors and recipients about anonymity in a country that is experiencing a transition towards non-anonymous gamete donation mandated by the Constitutional Court, we explore how the intersection between rights-based approaches and an empirical framework enhances recommendations for ethical policy and healthcare. Between July 2017 and April 2018, 69 donors and 147 recipients, recruited at the Portuguese Public Bank of Gametes, participated in this cross-sectional study. Position towards anonymity was assessed through an open-ended question in a (...) self-report questionnaire, which was subject to content analysis. Preference for an anonymous donation regime was mentioned by 82.6% of donors and 89.8% of recipients; and all those with children. Instead of the rights-based reasoning used by the Constitutional Court, donors highlighted concerns over future relationships and recipients focused on socioethical values linked with the safeguard of safety, privacy and confidentiality. The remaining participants advocated the choice between anonymity or non-anonymity, invoking respect for their autonomy. The complex, diverse ethical views and reasoning of donors and recipients expand a traditionally dichotomous discussion. Their perspectives challenge the transition towards non-anonymity and international guidelines, raising awareness to the need for their involvement in the design of policies to enable choice according to their values and preferences, and of psychosocial counselling responsive to their socioethical concerns and sensitive to their parental status. Empirical frameworks complement rights-based approaches to uphold justice, fairness and equal respect, and to incorporate utility, beneficence and non-maleficence in policymaking and healthcare in the transition towards non-anonymity. (shrink)

In a recent response to our paper on developing a philosophical framework to guide the design and delivery of a just health service, Sarela raises several objections. We feel that although Sarela makes points which are worthy of discussion, his critique does not undermine either the need for, or the worth of, our proposed model. First, the law does not negate the need for ethics in determining just healthcare policy. Reliance on legal processes can drive inappropriate focus on ensuring policies (...) avoid judicial review, as opposed to ensuring they are truly just; the law affords protection against unjust policies but does not put a commitment to avoiding them at the heart of policy-making. We defend the need for Scanlonian supplementation by emphasising the practical value of adding a step based on reasonable rejection, particularly in ensuring that the views of vulnerable stakeholders are robustly considered. We discuss the similarities and differences between the work of Daniels and Sen in considering the relationship between health and opportunity, concluding that Sen’s capability approach is both valuable and compatible with our proposed model. Finally, the practical use of our model requires consideration of what constitutes a reasonable person. Our model is explicitly intended to help develop a healthcare system which is just to all its users. With this in mind, we suggest that those involved in decision-making should meet Scanlon’s definition of reasonable: they should be motivated to justify their actions to, and seek agreement with, others. (shrink)