In extreme situations such as war, genocide or refugee crises, anthropologists, who are usually closer to afflicted people than other scholars, face the crucial questions of the utility and responsibility of anthropology. However, anthropologists in particular are susceptible to the way of reasoning that concludes that anthropology as a science (or even as a technique or art) does not offer any answers to these questions. Some become engaged trying to help one way or the other, yet not as anthropologists, since (...) they hold that as an anthropologist one is powerless to help …. (shrink)

How do we teach medical students to protect patients? My initial reaction to the question posed by Taylor and Goodwin was like first glimpsing ‘Jaws’: we’re going to need a bigger boat. The authors’ answer makes two important claims: first, that safety should be ethically sourced by better integration between teaching of safety and ethics; second, that teaching should encourage students to think about organisational failure rather than focusing on individual blame and personal responsibility to whistleblow.1 On the first, they (...) highlight how ethics teaching often sits apart from that on safety. For the second, they use the concept normalisation of deviance, with its contained idea of structural secrecy, to depict organisational failure that is argued as largely immune to whistleblowing. Why wouldn’t these challenges warrant a bigger boat? On their first claim: it is not just for safety, but throughout the curriculum that ethics teaching needs to be integral. Given coming challenges, it should become the cake rather than the icing. Consider, for example, that artificial intelligence stands to transform many knowledge-based professions, medicine among them. Tomorrow’s doctors will have a surfeit of data and automated decision aids at their fingertips. So, as far as they remain necessary, doctors will …. (shrink)

Why would we prohibit people with disabilities from receiving the assistance needed to achieve similar goals as people without disabilities? On its face, this would seem to be a discriminatory appr...

Nietzche claimed that once we know why to live, we’ll suffer almost any how.1 Artificial intelligence (AI) is used widely for the how, but Ferrario et al now advocate using AI for the why.2 Here, I offer my doubts on practical grounds but foremost on ethical ones. Practically, individuals already vacillate over the why, wavering with time and circumstance. That AI could provide prosthetics (or orthotics) for human agency feels unrealistic here, not least because ‘answers’ would be largely unverifiable. Ethically, (...) the concern is that AI stands to frack our humanity. We form a fragile ecosystem of ethical subjects, our responsiveness to others’ suffering, enabled by our own. To deliberate together for incapacitated others is among those solemn privileges that verify our humanity. Having AI mine these delicate pain-forests risks treating our suffering as the new oil—to be extracted and exploited, but beyond our vision and at our cost. Let’s briefly develop each idea, starting with the how/why distinction. This is palpable, even for more prosaic questions like how or why to drive. The former admits of increasingly sophisticated technological fixes and nudge; the latter often remains very particular and personal. How much greater then, the difference between …. (shrink)

Video recording is widely available in modern operating rooms. Here, I argue that, if patient consent and suitable technology are in place, video recording of surgery is an ethical duty. I develop this as aduty to protect,arguing for professional and institutional duties, as distinguished forduties of rescue.A professional duty to protect is described in mental healthcare. Practitioners have to take reasonable steps to prevent serious, foreseeable harm to their clients and others, even if that entails a non-consensual breach of confidentiality. (...) I argue surgeons have a similar duty to patients which means that, provided the patient consents, surgery should be routinely videoed. This avoids non-consensual breaches of patient confidentiality and is aligned with stated professional obligations.An institutional duty to protect means institutions have to take reasonable steps to prevent serious, foreseeable harm at the hands of their surgeons. Rulli and Millum highlighted how institutions can meet their duty using a more consequentialist approach that balances wider interests.To test the force and scope of such duties, I examine potential impacts of routine videoing on aspects of autonomy, justice, beneficence and non-maleficence. I find routine videoing can benefit areas including safety, candour, consent and fairness in access (to surgical careers and expertise). Countervailing claims, for example, on liability, confidentiality and privacy can be resisted—such that where consent and the technology are in place, routine videoing meets aduty of easy protection. In other words, its use should be standard of care. (shrink)

‘Trust but verify’ is a translation of a Russian proverb made famous by former US President Ronald Reagan. In their paper, Grahamet alappear to take an alternate view that might be summarised astrust or verify. The contrast highlights a general question: how do we come to trust in authorities? More specifically, Grahamet alclaim: (1) that UK Trusted Research Environments (TREs) are misnamed as future custodians for big health data because their promised verification systems actually negate the uncertainty that trust requires; (...) (2) the public is mistaken if it believes such verification enhances trust; (3) the notion of building public trust in TREs is unclear or misconceived. In response, I propose a more relational, perhaps less reductionist account. I argue (1) that verification is itself a source of uncertainty, so it can’t extinguish the uncertainty needed for trust; (2) it’s nevertheless possible for verification to enhance feelings of trust thereby reducing our needs for the same; (3) trust is also social, even political, meaning institutions like TREs may become too big to fail—and end up shielding their ‘trusted’ brand by being less candid about inevitable flaws in their verification systems. (shrink)

In this paper we undertake an examination of the presence of similar “women-protective” discourses in policy debates occurring over two bills on reproductive-related topics considered during the 2013 California legislature session. The first bill, now signed into law, allows nurse practitioners, certified nurse midwives, and physician assistants to perform first-trimester aspiration abortions. The second bill, had it passed, would remove the prohibition on paying women for providing eggs to be used for research purposes. Using frame analysis we find evidence of (...) similar protective arguments by opponents of both bills, although these advocates do not share ideological positions on abortion rights or women's autonomy. In the case of AB154, anti-abortion advocates use language and frames that call for protecting the health of women against the imputed interests of the “abortion industry.” In the case of AB926, feminists and pro-choice advocates evoke similar frameworks for the protection of women against the interests of the “medical research industry.” Both sides argue for the “protection of women,” from opposing positions on the rights and autonomy of women in relationship to reproductive freedom. (shrink)

Kindness and its kindred concepts, compassion and empathy, are strongly valued in healthcare. But at the same time, health systems all too often treat people unfairly and cause harm. Is it possible that kindness actually contributes to these unkind outcomes? Here, I argue that, despite its attractive qualities, kindness can pose and perpetuate systemic problems in healthcare. By being discretionary, it can interfere with justice and non-maleficence. It can be problematic for autonomy too. Using the principalist lens allows us to (...) visualise kindness more clearly and to dissect out its key qualities. Ideally, kindness should be not just beneficent but also respectful of the person, fair and non-maleficent. I use examples to illustrate the adverse impacts when kindness runs short on each. Finally, I propose that we can improve on this, by diversifying our approach to inclusion. Outgroups should be more included, as a way to mitigate discrimination wrought by discretionary kindness. But we can do better. Ingroup health professionals too often sit ‘above the fray’. They should also be more included, but now as research subjects, so we can understand together how they benefit from discretionary kindness and deftly make it work for them and theirs. (shrink)

Parity of esteemdescribes an aspiration to see mental health valued as much as physical. Proponents point to poorer funding of mental health services, greater stigma and poorer physical health for those with mental illness. Stubborn persistence of such disparities suggests a need to do more than stipulate ethical and legal obligations toward justice or fairness. Here, I propose that we should rely more on our legal obligations toward informed consent. The latter requires clinicians to disclose information about risks in a (...) way that is sufficient to satisfy what a prudent patient would reasonably want to understand in their circumstances. I argue that inadequate disclosure of the mental health complications of common surgeries risks exposing the craft specialists performing them to clinical negligence claims. Patients could argue they were counselled about said risks, improperly or not at all: improperly, if advised by a craft specialist lacking sufficient expertise in mental health; not at all, if mental health complications were simply forgotten. From this, I argue that a prudent approach for craft specialists would be to support and fund ‘integrative’ specialists (from rehabilitation medicine, liaison psychiatry and health psychology), more often to work alongside them within a multidisciplinary team that is better placed to navigate consent (via a prehabilitation process, for example). Based on duties toward consent, the extension of this type of coworking is another way to improve the resource and understanding accorded to mental health—but by starting within the citadels of physical health. (shrink)

This response to Evanset alencourages broader consideration of what constitutes disability, extending beyond a protagonist’s capabilities toward society’s fuller chorus. Three avenues are submitted to encourage this. First, Engel’s biopsychosocial paradigm of health can be helpfully applied to the question of identity in general, and disability in particular. Second, the philosophy of language (and of naming) gives useful insight into the pitfalls of trying to define disability via descriptions of capability. Third, Kennedy’s critique ‘Unmasking Medicine’ offers a sociopolitical view that (...) builds on Foucault and Illich allowing us to recognise that it matters who judges who, as disabled, and on what grounds. Alongside this, I suggest alternative views first, on the authors’ liberal use of bell curves in the depiction of disability and second, on their terminology of capacity spaces. (shrink)

If “on what matters” captures Parfit’s search for objective moral truths (Parfit 2011), perhaps “on who matters (and why)” might be a working title for Shepherd’s enquiry into the moral status of n...

How could we better use public inquiries to stem the recurrence of healthcare failures? The question seems ever relevant, prompted this time by the inquiry into how former nurse Letby was able to murder newborns under National Health Service care. While criminality, like Letby’s, can be readily condemned, other factors like poor leadership and culture seem more often regretted than reformed. I would argue this is where inquiries struggle, in the space between ethics and law—with what is awful but lawful. (...) In response, we should learn from progress with informed consent. Inquiries and civil litigation have seen uninformed ‘consent’ shift from being undesirable to unlawful. If better leadership and culture were sole drivers here, we would likely be doing far better in many other areas of healthcare too. Instead, one could argue that progress on consent has been made by reducingepistemic injustice—by naming and addressingepistemicissues in ways that enhancesocial powerfor patients. If this is an ingredient that transforms clinician–patient working, might it also shift conduct within other key relationships, by showing up what else should become unlawful and why? Namingmedical paternalismmay have helped with consent reform, so I continue this approach, first naming two areas of epistemic injustice:management feudalismandlegal chokeholds. Remedies are then considered, including the democratisation of management and reforms to legal ethics, legislation and litigation. In brief, public inquiries may improve if they also target epistemic injustices that should become unlawful. Focus on informed consent and epistemic relationships has improved the medical profession. Likewise, it could help healthcare leaders shift from fiat towards consent, and their lawyers from a stifling professional secrecy towards the kind of candour a prudent public expects. (shrink)

This concluding section applies the results of the previous part to some important thermodynamical systems. Even if time reversibility is allowed, it is shown that the flow vectors used to derive Onsager reciprocity from time translational invariance is of questionable validity. The fundamental fluctuation dissipation theorem of Callen, Welton, Green and Kubo which underpin descriptions of irreversibility, insofar as they are derived from time translational invariance, is also questioned; from Part I, they cannot be derived properly from time reversal symmetry. (...) The common view of entropy as some type of caloric fluid flow is critiqued as not conforming to the Kelvin Clausius Planck definition. An example of developing reciprocal relations to any order in the coupling indices based on the peculiar physical and defining characteristics of conductive heat is given for the steady state whenever a temperature gradient is present, free from time reversible and translation assumptions. A major challenge in the theory is to extend it to isothermal states. It is concluded that other more deterministic views mediated by authentic work anamnesis may be needed for long term coherence. (shrink)

Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important theoretical perspective of ethical decision making. These constructs represent salient determinants of ethical behaviour and (...) our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians. (shrink)

Liver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear. We studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates.

The intent of ethics is to establish a set of standards that will provide a framework to modify, regulate, and possibly enhance moral behaviour. Eleven focus groups were conducted with physicians from six culturally distinct countries to explore their perception of formalized, written ethical guidelines (i.e., codes of ethics, credos, value and mission statements) that attempt to direct their ethical practice. Six themes emerged from the data: lack of awareness, no impact, marginal impact, other codes or value statements supersede, personal (...) codes or values dictate, and ethical guidelines are useful. Overall, codes were valued only when they were congruent with existing personal morality. The findings suggest the need to re-evaluate the purpose, content, and delivery of codes for them to improve their function in promoting ethical conduct. (shrink)

Jesudason and Weitz's article examines two public policy debates in California, where both sides of the debate used similar language that had the potential to be detrimental to women. Specifically, they show how anti-abortion crusaders in California used similar language to describe why women's rights should be curtailed as pro-choice advocates use when fighting for more choice and privacy for women's reproductive decisions. This commentary builds upon their article by demonstrating the harm that such co-opting causes to women's rights (...) using the example of sex selective abortion. By examining the legislative history of state and national bills to ban sex-selective abortion, this commentary demonstrates how the anti-abortion lobby has adopted the language of pro-choice advocates quite effectively. Although the framing of this issue as being “woman-protective” is strategic and insincere, such political framing is powerful, as Jesudason and Weitz have noted. Anti-abortion activists have convinced lawmakers in many states that sex-selective abortion is a dire issue in their state and that they must restrict it in order to protect women. In fact, there is no evidence that sex selective abortion is a problem in the United States, yet these frames have been very effective in weakening women's privacy rights. Whenever woman-protective framings are invoked for self-serving purposes, women's rights advocates must work hard to uncover the truth behind these discourses to prevent successful legislative efforts that curtail women's reproductive freedom. (shrink)

We thank the commentators for their thoughtful engagement with our paper.1 In different ways, they make the same substantial point: our suggested interventions are not enough to solve the problems of organisational failure. On this we wholeheartedly agree. Organisational failure in healthcare is complex and multifaceted, it cannot be solved by one intervention in medical education. We did not intend to imply that our proposals alone would solve organisational failure, and this positioning misconstrues the aims of our paper. We had (...) more modest ambitions, we wanted to shift the analytical emphasis away from the individual and explore the implications raised by our analysis for our piece of the jigsaw—medical education. Having stepped away from such grand claims, the commentators make some valid points to which we would like to respond more specifically. Jesudason makes the distinction that normalisation of deviance (NoD) is well suited to understand institutional misfeasance but not malfeasance.2 We are inclined to agree; NoD can do some things but not all. Likewise, …. (shrink)