Biomedical Ethics

Extreme heat is emerging as one of the most consequential occupational hazards of the 21st century. More than 2.4 billion workers, over 70% of the global labour force, are exposed to excessive heat, with more than 22 million heat-related occupational injuries and nearly 19,000 deaths each year. By 2030, heat stress is projected to reduce global working hours by 2.2%, equivalent to 80 million full-time jobs, with the heaviest losses concentrated in low- and lower-middle-income countries. This paper argues that these (...) figures disclose not only a climate and labour crisis, but also a problem of health justice. To conceptualise this, the article develops the framework of ‘heat debt’ to articulate the physiological, economic, and temporal burdens disproportionately imposed on workers to sustain global production, supply chains, and essential services in a warming world. Synthesising evidence from agriculture, construction, garment manufacturing, informal urban labour, and healthcare, this paper demonstrates that this debt is systematically offloaded onto low-wage, migrant, informal, and feminised workforces. The analysis proceeds in three parts. First, it argues that excessive occupational heat must be analysed through the lenses of distributive and reparative justice. Second, it demonstrates how current labour law, climate policy, and corporate supply chain governance institutionalise thermal inequality. Third, it interrogates health systems in their dual capacity: as primary responders to heat-related morbidity, and as occupational environments that actively reproduce heat vulnerability among clinical staff. The article concludes by advancing a bioethical mandate of ‘cooling as care,’ positing that occupational thermal protection is an indispensable prerequisite for climate justice, decent work, and ethically defensible healthcare delivery. (shrink)

In Italy, controlled Donation after Circulatory Determination of Death (cDCDD) requires a 20-min no-touch period documented by continuous electrocardiographic monitoring. Since Italian law adopts a single brain-based definition of death, this procedure serves as an indirect determination of the irreversible cessation of all brain functions. This differs from other countries using 5-min no-touch periods and focusing on permanent cessation of circulation. This paper argues that the Italian 20-min no-touch period lacks a convincing scientific and ethical basis. No evidence shows that (...) 20 min is the minimum period required to establish beyond doubt the irreversible cessation of all brain functions after circulatory arrest. Moreover, the Italian legal definition of death relies on a standard that is not fully verifiable in practice, both regarding the cessation of all brain functions and irreversibility. It further maintains that the dead donor rule is vulnerable insofar as it is closely tied to legal definitions of death that do not fully capture the complexity of dying as a biological process. Donor protection should instead be based on what can be biologically proven, clinically confirmed, and ethically justified. The paper suggests a partial reformulation of the dead donor rule, based on the diagnosis of a permanent dying process that will inevitably lead to complete biological death. On this ground, Italy should reduce its no-touch period to the 5-min standard and revise death-determination protocols to document the permanent cessation of effective systemic circulation rather than the disappearance of cardiac electrical activity. (shrink)

Background Nursing students encounter ethically complex situations in culturally diverse healthcare settings where ethical decision-making requires more than the application of ethical principles alone. Cultural humility and ethical sensitivity may play a critical role in shaping ethical decision-making competence in nursing education and practice. Aim This study aimed to examine the relationship between cultural humility, ethical sensitivity, and ethical decision-making competence among undergraduate nursing students in Egypt and to investigate whether ethical sensitivity mediates this relationship. Research design A descriptive cross-sectional (...) survey design was used. Data were analyzed using descriptive statistics, Pearson’s correlation, multiple linear regression, and structural equation modelling. Participants and research context A total of 900 undergraduate nursing students were recruited from three public universities representing lower, middle, and upper regions of Egypt. Participants completed Arabic-translated versions of the Cultural Humility Scale for Nursing Students (CHSNS), Ethical Sensitivity Questionnaire for Nursing Students (ESQ-NS), and Ethical Decision-Making Competence Scale (EDM-CS). Ethical considerations Ethical approval was obtained from the Institutional Review Board of the Faculty of Nursing, Zagazig University (Approval No. 313). Written informed consent was obtained from all participants, and confidentiality and anonymity were maintained throughout the study in accordance with the Declaration of Helsinki. Findings Students demonstrated moderate-to-high levels of cultural humility and ethical sensitivity. Cultural humility was positively associated with ethical sensitivity and ethical decision-making competence. Multiple regression analysis revealed that cultural humility and ethical sensitivity significantly predicted ethical decision-making competence. Mediation analysis further showed that ethical sensitivity partially mediated the relationship between cultural humility and ethical decision-making competence. Conclusions Cultural humility directly and indirectly enhances ethical decision-making competence through ethical sensitivity among nursing students. Integrating cultural humility and ethical sensitivity into nursing ethics education may strengthen students’ moral awareness, ethical reasoning, and culturally responsive nursing practice. (shrink)

Background Advance directives (ADs) document the patient’s preferences regarding future medical care and are used to ensure goal-concordant care and patient autonomy when the patient becomes incapacitated. In a clinical setting, goals of care (GOC) discussions are a tool that helps health care providers (HCPs) provide goal-concordant care. A lack of documentation of the patient’s wishes, either as AD or following GOC discussions, can, especially in emergency or critical situations, lead to moral distress among HCPs, a psychological disequilibrium that stems (...) from the perceived inability to act in the best interests of the patient. Objectives This study aimed to (1) assess attitudes toward GOC discussions among patients and HCPs in general wards at Vienna General Hospital, (2) identify barriers and facilitators for their implementation, and (3) measure and compare moral distress between HCPs. Methods A cross-sectional survey was conducted between October 2022 and June 2023 across six wards (cardiology, pulmonology, infectious diseases, maxillofacial surgery, palliative care, and chronic haemodialysis). Paper-based questionnaires were administered to patients ( n = 47) and HCPs ( n = 75). Moral distress among HCPs was assessed using a culturally adapted German translation of the Measure of Moral Distress – Health Care Professionals (MMD-HP). Ethical considerations The study was approved by the ethics committee and the data protection commission of the Medical University of Vienna. Informed consent was obtained from all participants. The questionnaires contained no identifying information. Participation was voluntary and not participating carried no disadvantages. Results Most patients (70.5%) considered GOC discussions appropriate during hospitalisation, 71.4% considered them relieving, and 79.1% considered them helpful. Only 10.9% had ever been asked about ADs during a hospital stay. Among HCPs, the majority considered GOC discussions suitable for patients with multimorbidity (80.0%) and life-shortening conditions (86.7%) as well as those with a simple medical condition (54.7%). However, the majority (51.4%) of HCPs practice GOC discussions for less than 10% of their patients. The lack of standard operating procedures (SOPs), personnel, time, translators, and material were reported as the most relevant barriers. The mean MMD-HP total score was 105.0. Nurses scored significantly higher than physicians (125.7 vs 86.9, p = 0.020). Conclusions Both patients and HCPs expressed strong support for GOC discussions, yet the implementation is hindered by resource limitations and the lack of standardised protocols. At the same time, nurses experience high levels of moral distress. There seems to be a need for organisational and policy measures to facilitate structured GOC discussions and goal-concordant care. (shrink)

During the COVID-19 pandemic, England rationed access to critical care without any published national rule governing how that rationing would occur, allocating scarce intensive care resources through locally variable clinical discretion rather than any accessible framework. This article argues that governing acute scarcity in this way was normatively illegitimate, and that the illegitimacy cannot be cured by soft-law clinical guidance or retrospective judicial review. It defends three conditions: publicity, equal concern, and democratic accountability, grounded in Daniels and Sabin's accountability-for-reasonableness framework (...) and shown to be immanent in existing public-law standards. Through the Thomson litigation and the human-rights reasoning in Tracey and Winspear, it demonstrates that the legal architecture for a binding framework existed and was not used: a governmental choice, not a necessity. It argues that soft law fails not because it is legally unaccountable but because ministerial answerability cannot substitute for deliberation at the point of criterion-setting. It defends primary legislation as the constitutionally appropriate form, specifies a duty-and-activation structure, and situates the argument in relation to the Covid-19 Inquiry Module 3 Recommendation 7. (shrink)

Moral distress among healthcare clinicians is widely acknowledged but persistently misunderstood. The dominant institutional response has been to prescribe individual-level interventions, including resilience training, mindfulness programming, and wellness initiatives, to clinicians whose distress often arises from structural conditions beyond their control. This article argues that moral distress and its severe counterpart, moral injury, often arise from organizational ethics failure, while individual psychological factors shape how that distress is experienced rather than serving as its primary cause. Drawing on Pellegrino’s account of (...) institutional fidelity to the healing relationship, professional virtue ethics, and organizational ethics theory, the article identifies five structural drivers of moral distress, demonstrates that resilience-based responses constitute a form of moral offloading that compounds institutional harm, and proposes a four-component organizational ethics infrastructure as an affirmative institutional obligation. The article further argues that healthcare organizations must develop organizational ethics capacity beyond bedside consultation to include institutional review of the structures and policies that shape clinical practice. A healthcare institution that demands ethical commitment from its clinicians without ensuring the conditions necessary for ethical practice has violated a foundational professional obligation. (shrink)

The career of a surgeon is among the most challenging of medical specialties. Demands for exactitude, endurance, and equanimity pile an even higher burden on an already terribly complex scope of knowledge, judgement, and technical expertise. It is no wonder that, despite the marvels of modern medicine, pitfalls abound in the life of the surgical practitioner. Nature does not always abide by the scientific algorithms of evidence-based skills. Patients suffer, patients die, blame abounds, disappointment ripens, and personal merit wavers. In (...) its wake looms anger, volatility, depression, and withdrawal. Burnout: the triad of exhaustion, depersonalization, and discouragement sneaks in. The solution? Understanding of the pressures of surgical practice, compassion for fellow surgeons, an effort to teach better life-work balance, and, most of all, forgiveness for understandable acts of omission or commission; due diligence, of course, but also a recognition of the fallibility of not only human enterprises but the fallibility of medical science in general. (shrink)

Arthroscopic surgery (AS) for chronic joint pain has demonstrated limited and inconsistent long-term benefit over conservative management (CM), despite evidence of possible short-term symptomatic improvement in selected populations. Arguments supporting continued use often rely on informed consent. However, informed consent alone cannot justify an intervention without a reasonable expectation of meaningful patient benefit along with a favorable risk-benefit ratio. This paper proposes an ethical framework for evaluating when offering OAS may remain ethically justified despite limited evidence of long-term efficacy. We (...) first identify two primary ethical considerations that should generally guide decisions regarding OAS: (1) the expectation of meaningful patient benefit, including long-term clinical improvement, prevention of greater structural harm, or other sufficiently important patient-centered outcomes, and (2) a favorable risk-benefit assessment that incorporates procedural risk as well as financial and opportunity costs. We then explore additional categories of patient-specific benefit—including temporal; psychological and identity-related; social and caregiving; and harm-reduction considerations—which, in selected cases, may constitute ethically relevant forms of benefit or avoided harm that support offering surgery even when traditional measures of long-term efficacy would otherwise not. Together, these considerations suggest that AS should not be routine but may be ethically appropriate in carefully selected cases where patient-specific factors meaningfully influence the overall risk-benefit balance. (shrink)

This mixed-methods study examines the push–pull factors influencing physician emigration from Turkey and assesses the feasibility of reverse brain drain, framing physician migration as a challenge for health governance rather than merely an individual career choice. Quantitative data from 1331 physicians (700 specialists, 631 interns) across 19 provinces and qualitative interviews with 32 emigrated physicians in four destination countries reveal that violence against healthcare workers (81.6%), low salary (74.3%), and challenging working conditions (59.8%) constitute the primary push factors. A statistically (...) significant negative correlation between job satisfaction and brain drain attitudes (r = − 0.132, p < 0.01) confirms an association but explains only limited variance, indicating that structural and systemic conditions matter beyond individual satisfaction alone in shaping migration orientations. The qualitative findings identify professional burnout, performance system dysfunction, and sociopolitical instability as additional drivers. Only 2 of 32 emigrated physicians were considering return, and no female participant expressed return intention. Drawing on the ethics of health workforce governance, the study argues that when the state fails to protect physicians from violence and provide sustainable professional conditions, the normative responsibility for brain drain shifts from the emigrating individual to the institutional structures that render emigration rational. Policy interventions targeting salary alone are insufficient; comprehensive reforms in professional safety, meritocratic career pathways, workload standards, and sociopolitical stability are required. (shrink)

This paper synthesizes two predecessor documents — The Chain Completed (July 2026) and A5 at Population Scale (June 2026) — into a single argument that runs without gap from the October 2022 semiconductor export controls to three conditional political outcomes, and corrects a logical deficiency the predecessor chain left in its fifth link. The prior chain's five links were: chokepoint restriction originates in October 2022 semiconductor controls, not the June 2026 model directive; the chokepoint generalizes unevenly across the compute stack; (...) ALRP's hard floor at biological response time marks the point beyond which no upstream restriction reaches; Frontier Rotation — the Generative Paradox applied to states — predicts that a second state reaching the AI frontier relocates rather than dissolves the enclosure; and Frontier Rotation accelerates the Attribution stage of the Grief–Attribution–Legitimation–Concentration sequence by removing a diffusing explanation. The fifth link was correctly identified but incompletely specified: removing a diffusing explanation is not sufficient to constitute Attribution, which requires a specific, nameable defendant rather than merely the absence of a rescue narrative. -/- This paper corrects that gap using two independent literatures. Fuller's (2022) reformulation of Rose's population epidemiology establishes that Claim 2 of the A5 framework — the incidence claim, governing when A5's standing charge converts into organized political force — requires a temporal contrastive question: why is A5 converting now, in this population, rather than not converting, as it did not for most of recorded history in the same population? Frontier Rotation answers the temporal component of that contrast (why now: the rescue narrative is permanently foreclosed, not merely delayed). The Biological Zero-Day Mechanism's discreteness property answers the defendant component (who: a specific coverage decision, at a specific date, authored by a specific institution). Together, and not separately, these two already-established mechanisms jointly constitute Attribution in Fuller's technically correct sense, closing the prior gap without introducing new premises. -/- The sixth link — Concentration is not sufficient to determine outcome — stands from the predecessor paper, grounded in Skocpol's (1979) comparative-revolutionary analysis. This paper adds the causal architecture the predecessor's fifth link lacked: Millstein's (2006, 2013) population-level causal production criterion, applied to Legitimation-density; Hoel, Albantakis, and Tononi's (2013) formal causal emergence measure, applied to Concentration; and Santos's (2023) account of downward causation, applied to explain why the Governance Paradox is structurally stable — not merely psychologically stable — under population-level legitimation dynamics no individual governance actor can exit by disclosure or recusal alone. The complete chain runs from a 2022 export license to a conditional political outcome, with every link specified, every gap named and addressed, and every branch stated at the precision the evidence supports. (shrink)

Eva Erman and Markus Furendal's "Artificial Intelligence and the Political Legitimacy of Global Governance" (Political Studies, 2022/2024) is, on this corpus's own assessment, the most precise account currently available of what makes a governance body legitimate rather than merely effective, and this paper's argument depends on that assessment being correct rather than being softened for the sake of contrast. Their apparatus distinguishes governance of AI, the regulation of AI's own development and deployment, from governance by AI, the use of AI (...) within existing governance structures; it distinguishes authorized entities, whose right to make coercive law derives from democratic procedure, from mandated entities, which receive delegated, non-coercive policymaking authority and remain legitimate only so long as a genuine right of revocation is retained by whoever delegated it; and it requires the resulting legitimacy chain to be secured by transparency, so that revocation can be meaningfully exercised, and publicity, a right to justification for individual decisions. Applied to the landscape of actually existing global AI governance — the GDPR, the EU AI Act, NATO's AI strategy, the soft-law ethics guidelines issued by AI labs and industry bodies such as IEEE, IBM, DeepMind, and the Future of Life Institute — this apparatus produces a genuinely important negative finding: non-state private actors issuing guidelines that nobody delegated to them and nobody can revoke constitute a legitimacy deficit, whatever the quality of the guidelines' actual content. This paper does not dispute a clause of that finding. -/- What Erman and Furendal's 2022/2024 paper does not do, because the case in front of them never required it, is examine AI-driven longevity governance specifically: a domain their framework's stated scope covers in principle, since it is a case of AI governance, but whose specific dynamics none of their published case studies touch, because none of the GDPR, the AI Act, NATO's strategy, or algorithmic administrative decision-making involves allocating a scarce, life-determining biological intervention under the conditions this corpus's own Biological Zero-Day Mechanism formalizes: discreteness, permanence, and institutional authorship. This paper's question is offered as an extension of their project, not a rebuttal to it: does the legitimacy chain built for AI governance's examined cases transfer cleanly to this further case, or does AI-driven longevity allocation belong to a different category of political good, one their apparatus, reasonably, was never asked to handle? The paper's diagnostic distinction, developed in Section I and independently confirmed by Guido Calabresi and Philip Bobbitt's 1978 theory of tragic choices, is that democratic-legitimacy theory generally, including E&F's own apparatus, is built for goods that are divisible (allocable at the margin), iterable (this cycle's loser contests the next), and recoverable (a wrong decision can be reversed). The Biological Zero-Day Mechanism's own formal properties make longevity-relevant allocation none of these things in the timeframe that determines who lives. -/- The paper then runs each of this corpus's five structural paradoxes against a distinct, specific component of E&F's apparatus, to locate precisely where and how the transfer breaks down rather than asserting a general mismatch. First, the Governance Paradox is run against the democratic minimum: it shows that equal opportunity to participate does not produce equal access to a capacity-constrained slot, and that the specific reason this fails is structural rather than contingent — A5 is not a preference that deliberative processes were built to transform, because it is constitutive of the participants themselves in the sense Bernard Williams identifies for ground projects, and deliberative iteration presupposes precisely the kind of preference-transformability under public reason that constitutive attachments do not have. Second, the Reform Acceleration Paradox is run against E&F's implicit assumption that increasing transparency, revocability, and publicity monotonically increases legitimacy and public acceptance: it shows this assumption, exactly right for the divisible goods E&F examine, can reverse under zero-sum stakes, because greater transparency converts diffuse, unattributed exclusion into specific, attributable decision, and attributable decision is what activates A5's political sequence. Third, the Generative Paradox is run against E&F's own implicit recommendation that a body like the AI for Good Global Commission be strengthened into a genuine, accountable, mandated authority: it shows that Michels's iron law of oligarchy operates with maximal force specifically in this domain because longevity allocation uniquely combines four factors — extraordinary resource value, extreme technical specialization, explicit zero-sum structure, and permanent stakes — that Michels's mechanism requires to be jointly present to produce durable capture, and that E&F's apparatus has no built-in resource for detecting this conjunction. Fourth, the Dam Paradox is run against the revocability condition: it shows revocability has always depended on an unstated second mechanism, biological turnover among officeholders and elites, that BZM disables selectively for whichever class is best positioned to occupy legitimate seats over multi-decade horizons. Fifth, the ARSI–Longevity Resonance Paradox is run against the deliberative process itself: it shows that under λ_bz's documented compounding, a fully legitimate authorization-delegation-revocability cycle takes longer to complete than the frontier it is adjudicating remains current, so that legitimate allocation of frontier F(t) arrives only after the operative frontier has already become F(t+Δ). -/- Two further findings, developed in Sections I, IV, and VIII, confirm this extension rather than merely asserting it, and both are offered in a spirit of continuity with Erman and Furendal's own project rather than correction of it. Calabresi and Bobbitt's independent 1978 study of tragic allocation — draft conscription, dialysis machines, childbearing limits — found that societies facing indivisible, irreversible allocation problems do not converge on one stable, fully legitimated method and hold it, but cycle between methods, because sustained visibility of the same method's cumulative toll is what societies cannot bear, a finding arrived at from law and economics, decades before BZM existed, that independently locates the same category boundary this paper is describing. And Erman's own 2020 foundation, which holds that legitimacy principles are function-sensitive rather than uniform across every type of decision, already contains the resource for this paper's extension: if lawmaking, policy-making, implementation, and monitoring each properly receive their own principles, then whether terminal, one-shot allocation of a life-determining good constitutes a further function-category, requiring principles of its own, is a question her own method invites. This paper does not derive those further principles. It shows, using Erman's own method and reaching the same boundary Calabresi and Bobbitt reached from outside political theory entirely, that they are the next, natural extension of a framework this paper treats throughout as correct, necessary, and worth building on rather than replacing. -/- Two developments since this project's initial drafting confirm the argument empirically rather than only structurally, and Section V discusses both in full. The UN and International Telecommunication Union's AI for Good Global Commission — launched 1–2 July 2026, holding its inaugural session 8 July 2026 in Geneva, composed of heads of state alongside the chief executives of Nvidia, Amazon, Microsoft, Anthropic, and Cohere — is the exact strengthened, high-composition-legitimacy body Section V anticipates, and its own inaugural output, a call for action rather than binding commitments with named parties and timelines, resolved in the direction the Generative Paradox predicts. Dubai's Law No. 17 of 2026, issued 10 June 2026, establishing the Dubai Longevity Authority, is the first governance body formed anywhere specifically to regulate longevity access — and its founding statute names international investment attraction as a formal objective coordinate with, not subordinate to, public health. Neither development is evidence of bad faith by any named actor. Both are the paper's theoretical prediction arriving before the paper itself was finished. (shrink)

Data‐intensive health research complicates traditional requirements for informed consent, due to the amount of data contributors and data points, the open‐ended nature of research questions, and repeated or secondary data use. To still enable data‐intensive health research, there is a move towards other—generally lower—standards for consent such as opt‐out systems, in current developments such as the European Health Data Space (EHDS). This is premised on the social value that data‐intensive health research is assumed to provide through advancing research and innovation. (...) Traditionally, social value functions both as a fundamental requirement for research, as well as a ground to justify individual risk in research ethics. However, ongoing debates surrounding data‐intensive health research suggest that social value can also be used to justify lower standards of consent. Here, social value seems to obtain an additional and distinct function. This raises questions on the role of social value in research ethics and evaluations of the acceptability of research. In this paper, we examine three possible roles of social value: (i) to prevent research waste and set research priorities; (ii) to justify exposing research participants to risk; and (iii) to lower standards for consent. We discuss the presuppositions underlying these various roles. When social value is invoked to justify lower consent standards, this specifically impacts data contributors' ability to have control over when and how their data are used. Therefore, we propose that this use of social value requires arranging alternative forms of meaningful involvement and control for data contributors. (shrink)

While community engagement in biomedical research is widely lauded, and many reasons to engage communities have been adduced, it is unclear whether all these reasons are equally important, and, if not, which are most important. Here, I argue that, outside of rare circumstances, community engagement should not be understood as seeking permission from communities. Rather, it should be understood as adding value to research. I also argue that while community engagement may add value in a variety of ways—including making research (...) more respectful, more empowering, and more likely to successfully translate into health gains—it is the health gains that should be its primary focus. (shrink)

In this response, I examine Victor Kriska's defense of thanatism, the claim that a quick and painless death is necessarily most in one's self‐interest, and its stronger extension to all possible lives. I argue that Kriska's conclusion does not follow. The principles on which Kriska's argument relies are internally ambiguous. Once disambiguated, these principles either fail to support thanatism or require unpromising theoretical commitments. My criticism goes further. Even if these internal difficulties are somehow resolvable, Kriska's central principle of self‐interest (...) lacks independent justification. Without an adequate rationale, it assigns much weight to the minimization of bad while systematically subordinating the minimization of good. In conclusion, Kriska offers only controversial and under‐motivated principles of self‐interest rather than a compelling case for thanatism. (shrink)

Background Obstetric violence is a significant ethical and human rights concern in maternity care that undermines women’s dignity, autonomy, and respectful care during childbirth. Although women’s experiences of mistreatment are widely documented, less attention has focused on factors that enable midwives to prevent obstetric violence and provide respectful maternity care, particularly in low-resource settings. Research aim This study explored midwives’ perspectives on facilitators of respectful maternity care for the prevention of obstetric violence in maternity centres in South-West Nigeria. Research design (...) A qualitative descriptive design was adopted, and data were analysed using Braun and Clarke’s reflexive thematic analysis. Participants and research context Thirty registered midwives with at least 5 years of maternity care experience participated in three focus group discussions conducted in three state-owned secondary health facilities in Oyo State, South-West Nigeria. Ethical considerations Ethical approval was obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee and the Oyo State Ministry of Health Research Ethics Review Committee. Written informed consent was obtained from all participants. Findings/results Five themes were identified as facilitators of respectful maternity care and obstetric violence prevention: improvements in maternity facilities; improvement of midwives’ welfare; formal institutional and legal actions; training and re-training of midwives; and orientation of pregnant women. Midwives described how supportive infrastructure, staffing, remuneration, institutional policies, legal accountability, continuous professional education, and women’s awareness contribute to respectful and ethical maternity care practices. Conclusions Preventing obstetric violence requires supportive health systems that strengthen midwives’ capacity to provide dignified and respectful maternity care. Addressing structural, institutional, legal, and educational facilitators is essential for promoting ethical childbirth care and protecting women’s rights. (shrink)

Spontaneous surgical innovation (SSI) is surgical innovation that occurs in response to an intraoperative emergency, where standard approaches are either unknown to the surgeon or not available. But whereas the ethics and appropriate oversight of planned surgical innovation have been discussed in some detail in the literature, SSI has been neglected. There are various reasons for this, mainly that questions concerning the ethics and oversight of surgical innovation tend to focus on the period preceding the performance of a surgical innovation (...) (eg, questions about informed consent for an innovative procedure). Because SSI happens without any prior planning and cannot be anticipated, these preoperative steps or oversight measures cannot be applied. As such, SSI poses a unique challenge both to the ethics and epistemology of surgical innovation. There are many questions that are raised by SSI. These might include how surgeons make decisions to pursue it, when/how it is justified, what kinds of ethical obligations the surgeon might have when they engage in SSI and when/where these obligations might end. SSI can provide surgeons with significant epistemic gains and has the potential to contribute to important advancements in surgery. In this paper, I will provide a more detailed account of what SSI is and discuss some of the ethical and epistemic implications of SSI. (shrink)

One of the most dangerous forms of wrongdoing in healthcare occurs when harm no longer appears as wrongdoing at all. The failures at Mid Staffordshire National Health Service Foundation (NHS) Trust illustrate this phenomenon: substandard practices became so embedded in routine clinical life that they ceased to be recognised as ethically problematic. Drawing on Diane Vaughan’s concept of the normalisation of deviance, this article examines how repeated departures from established standards, once tolerated and legitimised by organisational processes, can erode the (...) conditions that ordinarily underpin individual responsibility. It argues that intention-based accounts of culpability are inadequate where practitioners no longer perceive their conduct as a significant breach of norms. Building on accounts of culpable ignorance and affected ignorance, the article argues that responsibility for wrongdoing in healthcare must be understood as both graded and distributed across individuals and institutions. Responsibility varies according to differences in role, authority, awareness and practical capacity, while institutions bear responsibility where they tolerate or cultivate conditions in which moral attention is diminished and unsafe practice becomes normalised. The article concludes that a defensible account of responsibility in healthcare must extend beyond isolated intentional acts to include the organisational conditions that shape what agents are able to recognise, question and resist. (shrink)

Unilateral Do Not Attempt Resuscitation (UDNAR) orders remain contentious in the care of seriously ill patients. While some regard UDNAR orders as reducing non-beneficial treatment, others raise concerns around patient autonomy, potential discrimination, and the risk of relational stress between healthcare teams and families. Ethics consultation services (ECS) are often engaged when these decisions are disputed, but data on their role is limited. In this study, we conducted a retrospective analysis of ethics consultations over a 10-year period at a quaternary (...) academic hospital to identify consultations involving UDNAR orders. We identified 58 ethics consultations (55 adult and 3 pediatric) requested in the context of UDNAR orders. There were thirty-seven (63.7%) cases in which the patient and/or surrogate actively disagreed with the proposed code status change, 21 (36.2%) cases in which they assented. We explored contextual features and palliative care involvement using a qualitative conceptual content analysis. We found that Black or African American patients were disproportionately represented among cases of conflict with a proposed UDNAR status change (p = 0.0015). Palliative care was involved in most conflict cases (28, 75.6%) while less frequently in assent cases (8, 38.0%). Our study aims to inform best practices and underscore the ethical intricacies of UDNAR decisions and the need for interdisciplinary collaboration and direct engagement with patients and families. (shrink)

Background: With prison populations expanding and aging, palliative care (PC) is an urgent concern. People in prison (PIP) face chronic illness, mental health conditions, and social vulnerabilities, creating ethical and psychosocial challenges to dignified end-of-life (EOL) care. Objective: This scoping review mapped key ethical and psychosocial domains in the provision of PC in prisons. Methods: PubMed, Web of Science, and ScienceDirect were searched using the strategy: Population—individuals in prison; Concept—ethical and/or psychosocial issues in PC; Context—PC provision in prisons across regions (...) and healthcare models. Data were coded inductively, organized into ethical and psychosocial domains, and synthesized narratively. Results: Sixteen studies were included, mainly conceptual analyses (n=10), most from North America (n=11). Ethical domains included structural neglect of PIP with life-limiting illness, barriers to compassionate release, compromised autonomy, denial of death in prison culture, and inadequacies in care quality and access. Psychosocial domains encompassed stigma, mistrust, isolation, existential suffering, and fractured social bonds. PIP-led hospice models offered companionship but raised tensions around labour, confidentiality, and the normalization of death in custody. Conclusion: Prison-based PC requires systemic reforms, staff training, family and advocacy involvement, and legal safeguards to ensure equitable, compassionate, and dignified EOL care. (shrink)

Interest in the field of consumer neuroscience and neuromarketing (CNNM) has increased rapidly in recent years due to its ability to gain unique insights into consumer behavior, overcoming some of...

Background When patients refuse basic nursing care in the hospital setting, ethical tension arises between promoting patient dignity by providing hygiene and honoring bodily autonomy by respecting patient refusal of interventions. Research Aim To describe patient factors, clinical context, and the role of ethics consultation when basic care is refused to identify implications for future practice and/or policy. Research Design We conducted a retrospective qualitative content analysis of adult and pediatric ethics consultation documentation between January 2015 and December 2025 at (...) a quaternary academic medical center, screening 2,381 consultations to identify cases involving refusal of basic nursing care. We collected patient demographics, admission and clinical information, reasons for ethics consultation, and actions taken by the ethics consultation service. Data were summarized via descriptive statistics, and categories were abstracted to develop a framework. Participants and Research Context Patients receiving inpatient care at an academic medical center in the Midwestern United States. Ethical Considerations University of Michigan IRBMED deemed the study exempt (HUM00256591). Findings 34 ethics consultations for 29 unique patients involved refusal of basic nursing care. Patients were adults (100%), with an average LACE score of 12.8; 15 (44%) had decision-making capacity. Care over objection was provided in 16 (47%) of cases, and physical restraints were used in 2 (6%) cases. Refusals involved hygiene (18, 53%), wound care (15, 44%), and repositioning (9, 26%), and occurred across nursing units and clinical services. Refusals were addressed through persuasion (9, 26%), soft paternalism (13, 38%), hard paternalism (3, 9%), or permitted refusal (9, 26%). Discussion Ethics consultation involvement resulted in four approaches to refusal of basic nursing care based on patient agency, decision-making capacity, and clinical context. Conclusions When refusal results in dignitary or physical harm, healthcare teams should address barriers and encourage participation. In rare circumstances, care over objection is ethically permissible with multidisciplinary input. (shrink)

Abortion rates in England and Wales have reached record levels, highlighting the increasing need for skilled and ethically grounded nurses in abortion care. Despite its clinical importance, nurses involved in abortion services frequently encounter ethical tensions when their personal beliefs conflict with professional responsibilities. This literature review explores how nurses navigate conscientious objection (CO) and related ethical challenges within emotionally complex clinical environments. A structured search was conducted across CINAHL Ultimate, SCOPUS, Embase, and PsychINFO (via EBSCO), using the SPIDER tool (...) to identify qualitative studies addressing nurses’ experiences in abortion care. After applying rigorous inclusion and exclusion criteria, five studies were selected for critical appraisal. Thematic analysis following Braun and Clarke’s six-step framework reveals three overarching themes: personal versus professional conflicts, institutional and organisational barriers to conscientious objection, and conscience formation and ethical growth. Findings indicate that nurses frequently suppress personal emotions to meet professional expectations, often without adequate institutional support. The absence of clear policies on CO, coupled with high workloads, staff shortages, and inadequate resources, further complicates their ability to exercise moral agency. Participants reported feeling ethically unsupported, emotionally isolated, and constrained by workplace cultures that discourage open discussion of values. At the same time, conscience was found to be fluid and shaped over time by experience, reflection, and contextual influences. This review concludes that systemic barriers and a lack of policy clarity undermine nurses’ ethical resilience in abortion care. To address this, healthcare organisations must implement clear and accessible CO protocols, offer structured ethics training and support emotionally reflective practice. Fostering a culture of inclusivity and ethical dialogue is essential to empower nurses and ensure equitable, compassionate care for women accessing abortion services. (shrink)

Miranda Fricker’s concept of epistemic injustice and Axel Honneth’s theory of recognition have each been applied, separately, to chronic pain. The relationship between them is usually construed as sequential: epistemic injustice is thought to produce failures of recognition, or prior misrecognition to ground later epistemic marginalisation. This article rejects that reading. It argues that, in the clinical encounter with a person in pain, the relation between the two is not exhausted by causal succession. They are analytically separable dimensions of a (...) single intersubjective relation, dimensions that cannot, in that encounter, be treated apart without descriptive and practical loss. The act by which a clinician withholds credibility from a patient’s testimony is the same act by which recognition is refused to that patient as a suffering subject. The claim is offered as a heuristic rather than an ontological thesis. Pain is presented not as uniquely paradigmatic but as a particularly illuminating case within a broader class of testimonially dependent suffering, since its privacy, its dependence on testimony, and the mediating role of diagnostic language converge in it with unusual clarity. The argument bears on recognition theory; on medical ethics, where remedies addressed to one dimension alone prove insufficient; and on clinical practice, where diagnostic classification operates as a technology of recognition. (shrink)

This article examines contemporary discourses within French psychoanalysis through the lens of Gilles Deleuze and Félix Guattari’s concept of the minor. Against the backdrop of anti-trans positions advanced by influential psychoanalytic figures, it analyzes alternative theoretical and clinical perspectives that challenge the discipline’s dominant and often normative assumptions. More specifically, the article focuses on the work of two psychoanalysts, Thamy Ayouch and Fabrice Bourlez, both of whom mobilize the concept of the minor to develop queer, trans, and decolonial approaches to (...) psychoanalytic theory and practice. Without overlooking certain tensions, I argue that the minor functions less as a fixed method than as a critical horizon. In this light, the minor challenges claims of universality, foregrounds minoritized forms of experience, and reimagines the unconscious in relation to social, historical, and political powers. The article concludes by considering both the transformative potential and the conceptual limits of this framework for rethinking psychoanalysis in the twenty-first century. (shrink)

According to standard philosophical and clinical understandings, pain is an essentially mental phenomenon (typically, a kind of conscious experience). In a challenge to this standard conception, a recent burst of empirical work in experimental philosophy, such as that by Justin Sytsma and Kevin Reuter, purports to show that people ordinarily conceive of pain as an essentially bodily phenomenon—specifically, a quality of bodily disturbance. In response to this bodily view, other recent experimental studies have provided evidence that the ordinary (‘folk’) concept (...) of pain is more complex than previously assumed: rather than tracking only bodily or only mental aspects of pain, the ordinary concept of pain can actually track either of these aspects. The polyeidic (or ‘many ideas’) analysis of the folk concept of pain, as proposed by Emma Borg et al., captures this complexity. Whereas previous empirical support for the polyeidic view has focused on the context-sensitivity of the folk concept of pain, here we discuss individual differences in people’s ‘pain priors’—namely, their standing tendencies to think of pain in relatively mind-centric or body-centric ways. We describe a preliminary empirical study and present a small number of findings, which will be explored further in future work. The results we discuss are part of a larger programme of work which seeks to integrate philosophical pain research into clinical practice. For example, we hypothesise that variations in how patients with chronic pain are thinking about pain could help predict their responses to treatment. (shrink)

In his ‘The Identity Objection to the future‐like‐ours argument’ (Bioethics, 2019, 33: 287–293), Brill argues that Marquis's 'future of value' account of the wrong of abortion is still vulnerable to the identity objection—the claim that the foetus and the later person are not numerically identical, so the later person's valuable experiences are not the foetus's future experiences—even if it is conceded that the future organism, as well as the person, has experiences. This is because the organism has these experiences in (...) a different way from the person. The person has them directly, and the organism has them only derivatively. This implies, he maintains, that the organism cannot be deprived of those experiences in a way that is wrong. Only the person can be deprived in this morally relevant way. But, I argue, if the organism genuinely has those experiences, it is not at all clear why its being deprived of them would be permissible. I argue that the reason why Brill can claim that having those experiences derivatively makes this moral difference is because the sense in which the organism has experiences is not a genuine sense. But that is a problem for this theory of personal identity, not for Marquis's account of the wrong of abortion. I also argue that supposing that one cannot morally harm the human organism has various implausible implications, which cast doubt on the idea that having experiences derivatively means that the organism is not morally harmed by being deprived of them. (shrink)

I explore the increasingly important issue of co-operation in immoral actions, particularly in connection with health care. Conscientious objection, especially as pertains to religious freedom in health care, has become a pressing issue in the light of the US Supreme Court judgment in Hobby Lobby. Section 2 outlines a theory of co-operation inspired by Catholic moral theologians such as those cited by the Court. The theory has independent plausibility and is at least worthy of serious consideration – in part because (...) it is an instance of double-effect reasoning, which is also independently plausible despite its association with moral theology. Section 3 examines Hobby Lobby in detail. Even if the judgment was correct in that case, the reasoning was not, as it involved applying a ‘mere sincerity’ test to the co-operation question. The mere sincerity test leads to absurd consequences, whereas a reasonableness test applied using the theory of co-operation defended here would avoid absurdity. Section 4 explores the post-Hobby Lobby problem further, examining opt-outs and accommodations: the Little Sisters of the Poor case shows how opt-outs are misunderstood on a mere sincerity test, which the court rightly rejected. Section 5 discusses the UK case of Doogan and Wood, concerning participation in abortion. Again, a judicially-recognised ethic of co-operation, if it were part of the fabric of legal reasoning in such cases, would have enabled the conscientious objectors in this and similar situations to have their freedom of conscience and religion respected in a way that it currently is not. (shrink)

For children with severe physical and cognitive disabilities (e.g. iatrogenic neurologic injury, congenital myelopathy, or quadriplegic cerebral palsy), there are limited therapeutic options. Scientific and clinical developments in implantable brain-computer interface (BCI) technology are in clinical trials in adults. The ethical issues around implantable BCI research in adults have recently been examined, but to date, only limited literature is available on the ethical issues that are attendant with implantable pediatric BCI research. Here, we summarize the ethical issues, focusing on (1) (...) whether invasive BCI research should proceed in children, (2) regulatory considerations, (3) study design considerations, (4) pediatric recipient selection for invasive BCI trials, (5) special problems regarding informed consent in this context, and (6) related psychosocial and public perception considerations. We conclude with specific recommendations regarding ethically informed design of invasive pediatric BCI trials. (shrink)

Democratic deliberation about health policy requires, as one of its inputs, ethical judgments from members of the public. These judgments may, however, be biased and unreliable—they may be systematically distorted by framing and emotion effects, by the effects of self‐interest, and by a whole host of other cognitive and affective biases. Supposing we find evidence of biased ethical judgments, can we deal with these judgments in ways that promote reliability while approximating, as far as possible, the moral and political ideals (...) of deliberation? In this paper, I explore this question by outlining and evaluating three respectful debiasing methods, which aim to mitigate bias but in a morally and politically respectful way. In brief, the methods are: (1) Improving the conditions of elicitation but accepting whatever judgments that result, (2) Suggesting to specific members of the public that they may be biased and leaving them to decide whether to debias, and (3) Surveying the public's standards for bias and applying these standards to their ethical judgments. (shrink)

Many of the most pressing policy choices we face are matters of health and science. How should we prepare for the next global pandemic? How should we manage the disruption and promise of artificial intelligence? How should we address the challenge of climate change? These choices are permeated by intractable disagreement, especially disagreement over the moral and prudential values we rely on to decide. Nonetheless, we must decide. Proceduralism is one of the most widely endorsed answers to the challenge that (...) such normative disagreement presents. The policy choices we face, however, also include descriptive questions. Given the significant difference between these types of questions, the respective roles they ought to play in our collective decision‐making, and the fact that their respective answers ought to be measured against different standards of justification and legitimacy, I argue that proceduralism fails as a complete account of legitimate decision‐making and offer a more nuanced and epistemically informed account of legitimate decision‐making. I conclude by assessing the implications the alternative account has for the role that the public should play in legitimate health and science policy‐making, arguing that the public ought to play a central role in making normative decisions, but should be largely excluded from a participatory role in inquiries meant to decide matters of policy‐relevant descriptive fact. (shrink)

With healthcare systems worldwide committing to reduce their greenhouse gas emissions, policymakers must navigate how to reconcile emissions reduction with the delivery of high-quality care. Two main distributive ideals have emerged to guide a just transition to decarbonized healthcare: subsistence emissions and prevention. The subsistence view holds that healthcare emissions that are necessary to meet a threshold of “enough health” are permissible, while emissions exceeding this threshold should be mitigated. The prevention approach, in contrast, prioritizes the most efficient uses of (...) limited emissions through emphasizing measures to prevent the onset of illness and to promote healthy living. Although both frameworks aim to reconcile pursuing the goals of healthcare with reducing the sector’s carbon footprint, their approaches to that end appear to conflict. Subsistence emissions tend to prioritize those below the threshold of enough health, whereas prevention focuses on maintaining health in the already relatively well off. As subsistence emissions offers a compelling strategy for decarbonizing healthcare fairly, the question arises: can it accommodate prevention? This paper argues that these two perspectives can be reconciled by detailing how a subsistence emissions approach can also endorse emissions for measures that prevent individuals from falling below a health threshold. (shrink)

Background Intensive care nurses may need to take proportionate first action before a revised medical order is available. In such moments, patient advocacy, role boundaries, and accountability intersect with fear of blame, uncertainty, and emotional burden, linking safe initiative to both patient safety and nurse well-being. Aim To explore how intensive care nurses in Turkey describe initiative in the absence of explicit orders, how they distinguish bounded professional courage from hesitation and recklessness, and what these experiences imply for supportive work (...) environments. Study Design A qualitative descriptive study was conducted using a structured qualitative written instrument with open-ended items and a ranking task completed by 23 nurses from medical, surgical, anaesthesia, coronary, and neonatal intensive care units. Data were analysed using reflexive thematic analysis. Results Five themes were developed: recognising deterioration through converging cues; bounded professional courage as proportionate first action; hesitation as socially organised self-protection; recklessness as action without calibration, communication, or limit-awareness; and safe initiative as an organisational achievement. Hesitation was linked not only to inexperience but also to fear of harm, blame, rigid hierarchy, and ambiguous protocols. Conclusions Safe initiative in intensive care is best understood as bounded professional courage supported by organisational conditions. Clear protocols, accessible senior support, mentoring, simulation, and non-punitive climates can make timely action more possible while reducing the moral burden carried by nurses. Relevance to Clinical Practice Critical care leaders should clarify low-risk first actions, strengthen escalation pathways, and reduce punitive responses so that nurses can act promptly, safely, and with less fear-related strain. (shrink)

Background Frontline nurses and nurse leaders faced profound psychological, ethical, and professional challenges during the COVID-19 pandemic. Less attention has been given to how meaning in life supports moral resilience and ethical nursing practice during prolonged public health crises. Research question/aim This study aimed to explore how frontline nurses and nurse leaders experienced pandemic-related stress, constructed meaning in life, and developed moral resilience within pandemic clinical settings. Research design A descriptive phenomenological design was used, and data were analysed using Giorgi’s (...) descriptive phenomenological method. Participants and research context Semi-structured in-depth interviews were conducted with 18 participants, including 14 frontline nurses and four nurse leaders, from four hospitals in southern Taiwan. Ethical considerations The study was approved by an institutional review board, and all participants provided informed consent. Findings Three major categories were identified: crisis conditions and ethical pressures, meaning-making as a source of moral resilience, and transformative meaning, professional identity, and moral agency. Meaning-making enabled frontline nurses to connect suffering with patient care, teamwork, and professional commitment, while nurse leaders constructed meaning through staff support, ethical decision-making, and reflective leadership. Discussion Meaning in life functioned not only as a psychological coping resource but also as an ethical resource supporting moral resilience, moral agency, and professional identity. Conclusions Meaning-centred reflection, moral resilience training, peer support, and reflective leadership development should be incorporated into organisational crisis preparedness to strengthen ethical nursing practice during future public health emergencies. (shrink)

In Inducing Immunity? Marcel Verwei and Roland Pierik sometimes concede too readily that a policy aimed at preventing infection violates some people’s right to bodily integrity, even though such a policy on their view may still be justifiable. I discuss some of these policies. To determine whether a policy is coercive, it must be compared to a baseline situation. However, the correct baseline for comparison is not the situation prior to the policy, since that situation could deteriorate at any time (...) due to the legitimate choices of others. (shrink)

In their recent book, Inducing Immunity (2024), Roland Pierik and Marcel Verweij develop an account of collective immunization according to which liberal-democratic governments are sometimes justified in restricting people's freedom to refuse vaccination. In this commentary, I focus on a specific argument in the book about misinformation, freedom of expression and mandatory vaccination. Pierik and Verweij argue that, when vaccine misinformation threatens vaccination rates, governments—in order to increase or maintain vaccination rates—should consider mandatory vaccination before restricting freedom of expression. I (...) summarize the argument and raise two issues to help advance the debate. (shrink)

In this article we respond to critical comments from colleagues on Inducing Immunity? Justifying Immunization Policies in Times of Vaccine Hesitancy (MITpress, 2024). We explain why we have chosen to focus on John Stuart Mill’s harm principle as a basis for developing our argument for mandatory immunisation policies. With help of our critics, we subsequently elaborate on our conception of harm and argue that this is not opening the door to illiberal policies. We discuss the role of coercion and the (...) idea of the ‘best-interest of the child’, and we further develop our account of trustworthiness of a vaccination policy. (shrink)

We know that vaccine hesitancy is closely related to distrust in health organisations, pharmaceutical industry or governments (Vuolanto et al. 2024). At the end of the book, I am left with the question what is necessary to bridge the gap of distrust and how this relates to discussions on coercive measures. Intuitively, it seems necessary to understand the different types of distrust non-compliant parent groups have and Pierik and Verweij discuss these in Chapter 3 in order to offer tailored approaches (...) to build trust. In Chapter 9, Pierik and Verweij discuss the lack of trust more specifically, but I question if their approach is well thought through: they are ambivalent on a so-called information deficit perspective on trust, which they reject and also seem to assume at the same time. I will first look at the various sources of distrust that Pierik and Verweij distinguish before I discuss their view on trust and trustworthiness. (shrink)

Roland Pierik and Marcel Verweij’s recent monograph is a rigorously argued and admirably comprehensive defense of vaccine mandates in liberal democratic states. Their book is a welcome and timely contribution, especially in the wake of heightened vaccine skepticism and policy disputes during and after the COVID-19 pandemic. Even readers who find themselves unconvinced by some aspects of their argument will benefit from the book’s careful exposition of the ethical terrain. That said, I am skeptical about Pierik and Verweij’s use of (...) concepts from the pediatric ethics literature. In particular, I argue that the idea of the harm threshold cannot substantively advance the authors’ core claims about vaccine mandates. (shrink)

In this commentary, I will contend that one of Pierik and Verweij’s central arguments for vaccine mandates faces significant obstacles because of their attempt to apply Mill’s harm principle. More specifically, they argue that vaccine refusal is harmful because of its relationship to the collective good of herd immunity. I suggest that Pierik and Verweij oscillate between two interpretations of the harm principle: a narrow interpretation and a broad one. The narrow interpretation, however, does not justify mandates because it is (...) implausible that one individual’s act of vaccine refusal makes a meaningful difference to whether herd immunity is achieved. The broad interpretation avoids this problem, but it risks abandoning the authors’ aspiration to advance a distinctively liberal argument. I conclude that those who wish to defend vaccine mandates by appealing to their role in achieving or maintaining herd immunity face a choice: they need to either (i) find argumentative resources within the liberal tradition that are more promising than the harm principle or (ii) develop defenses that are not liberal but indicate why this does not constitute a problem. (shrink)