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Savulescu and Cameron supported selectively locking down the elderly during the COVID-19 pandemic on two grounds: first, that preserving total lockdown would entail levelling down and, second, that levelling down is wrong. Their first assumption has been thoroughly addressed, but more can be said about their wider antiegalitarian point that levelling down is simply wrong. Egalitarians are not defenceless against the levelling-down objection. Even though some consider it the most serious challenge to supporters of equality, egalitarianism possesses sound reasons to assert, not only that something valuable is preserved when we level down, but also that preserving it may be, in certain circumstances, preferable to pursuing other fundamental moral goals. Although troublesome from a well-being maximising standpoint, levelling down ensures that healthcare policy reflects a commitment with the idea that people are equal in moral worth. That commitment is important enough to trump certain improvements in individual well-being. In the case of pandemic lockdowns, not all the interests protected by free movement are as fundamental as to pursue them at the cost of equality. Savulescu and Cameron's framework is so reliant on the view that levelling down is wrong that it fails to account for the valuable loss that having the elderly suffer alone represents., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Reproduction is broadly recognised as fundamental to human flourishing. The presumptive priority of reproductive freedom forms the predominant position in the literature, translating in the non-sexual reproductive realm as an almost inviolable right to access assisted reproductive technology (ART). This position largely condemns refusal or restriction of ART by clinicians or the state as discriminatory. In this paper, I critically analyse the moral rights individuals assert in reproductive pursuit to explore whether reproductive rights entitle hopeful parents to ART. I demonstrate that none of the protected actions performed, or entitlements generated are sui generis 'reproductive' rights, leading to the claim that there is no such thing as a right to reproduce. Under scrutiny, the reproductive right is a far narrower and weaker rights assertion than is recognised in the literature. I argue that the predominant position is grounded in a fundamental misunderstanding of the scope and strength of reproductive claims.I also highlight a significant conceptual inconsistency in the literature. On one hand, there is broad consensus that reproductive rights are predominantly negative, yet access to fertility treatment is framed as a component of the right. This wrongly contorts the negative nature of reproductive rights into a positive claim-right to ART. I conclude that this mistakenly frames ART access as sitting within the scope of reproductive freedom. I offer a revised conceptual paradigm of reproductive rights that has important clinical and policy implications for the provision and regulation of ART., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Self-harm within immigration detention centres has been a widely documented phenomenon, occurring at far higher rates than the wider community. Evidence suggests that factors such as the conditions of detention and uncertainty about refugee status are among the most prominent precipitators of self-harm. While important in explaining self-harm, this is not the entire story. In this paper, we argue for a more overtly political interpretation of detainee self-harm as resistance and assess the ethical implications of this view, drawing on interviews with detainees from Australia's offshore system. Self-harm by detainees is not only a medical 'condition' arising in response to oppression but a form of political action to lessen or contest it. We first establish how self-harm could be conceptualised as resistance. We then discuss its political purpose, noting it serves at least three functions: intrinsic, instrumental and disruptive or coercive. Viewing detainee self-harm as political resistance is a supplement to (rather than a substitute for) a medical approach. However, conceptualising self-harm this way has several advantages, namely, moving away from the idea that such behaviour is 'maladaptive', recognising detainees as political agents, combatting government claims of 'manipulation' and 'blackmail' and clarifying the duties of healthcare workers who work in detention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The idea of a 'right to mental integrity', sometimes referred to as a 'right against mental interference,' is a relatively new concept in bioethics, making its way into debates about neurotechnological advances and the establishment of 'neurorights.' In this paper, we interrogate the idea of a right to mental integrity. First, we argue that some experts define the right to mental integrity so broadly that rights violations become ubiquitous, thereby trivialising some of the very harms the concept is meant to address. Second, rights-based framing results in an overemphasis on the normative importance of consent, implying that neurointerventions are permissible in cases where people consent to have their mental states influenced or read off, a confidence in consent that we argue is misguided. Third, the concept often collapses the ethics of brain inputs and brain outputs, potentially resulting in a loss of important conceptual nuance. Finally, we argue that the concept of a right to mental integrity is superfluous-what is wrong with most violations of mental integrity can be explained by existing concepts such as autonomy, manipulation, privacy, bodily rights, surveillance, harm and exploitation of vulnerabilities. We conclude that bioethicists and policy-makers ought to either make use of these concepts rather than arguing for the existence of a new right, or they need to avoid making rights violations ubiquitous by settling on a narrower and more rigorous definition of the right., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The current human rights framework can shield people from many of the risks associated with neurotechnological applications. However, it has been argued that we need either to articulate new rights or reconceptualise existing ones in order to prevent some of these risks. In this paper, we would like to address the recent discussion about whether current reconceptualisations of the right to mental integrity identify an ethical dimension that is not covered by existing moral and/or legal rights. The main challenge of these proposals is that they make mental integrity indistinguishable from autonomy. They define mental integrity in terms of the control we can have over our mental states, which seems to be part of the authenticity condition for autonomous action. Based on a fairly comprehensive notion of mental health (ie, a notion that is not limited to the mere absence of illness), we propose an alternative view according to which mental integrity can be characterised both as a positive right to (medical and non-medical) interventions that restore and sustain mental and neural function, and promote its development and a negative right protecting people from interventions that threaten or undermine these functions or their development. We will argue that this notion is dissociated from cognitive control and therefore can be adequately distinguished from autonomy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The possibility of neurotechnological interference with our brain and mind raises questions about the moral rights that would protect against the (mis)use of these technologies. One such moral right that has received recent attention is the right to mental integrity. Though the metaphysical boundaries of the mind are a matter of live debate, most defences of this moral right seem to assume an internalist (brain-based) view of the mind. In this article, we will examine what an extended account of the mind might imply for the right to mental integrity and the protection it provides against neurotechnologies. We argue that, on an extended account of the mind, the scope of the right to mental integrity would expand significantly, implying that neurotechnologies would no longer pose a uniquely serious threat to the right. In addition, some neurotechnologies may even be protected by the right to mental integrity, as the technologies would become part of the mind. We conclude that adopting an extended account of the mind has significant implications for the right to mental integrity in terms of its protective scope and capacity to protect against neurotechnologies, demonstrating that metaphysical assumptions about the mind play an important role in determining the moral protection provided by the right., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Many technology ethicists hold that the time has come to articulate neurorights : our normative claims vis-à-vis our brains and minds. One such claim is the right to mental integrity ('MI'). I begin by considering some paradigmatic threats to MI (§1) and how the dominant autonomy-based conception ('ABC') of MI attempts to make sense of them (§2). I next consider the objection that the ABC is overbroad in its understanding of what threatens MI and suggest a friendly revision to the ABC that addresses the objection (§3). I then consider a second objection: that the ABC cannot make sense of the MI of the non-autonomous This objection appears fatal even to the revised ABC (§4). On that basis, I develop an alternative conception on which MI is grounded in a plurality of simpler capacities, namely, those for affect , cognition , and volition Each of these more basic capacities grounds a set of fundamental interests, and they are for that reason worthy of protection even when they do not rise to the level of complexity necessary for autonomy (§5). This yields a fully general theory of MI that accounts for its manifestations in both the autonomous and the non-autonomous., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Infertility patients and patient advocates have long argued for classifying infertility as a disease, in the hopes that this recognition would improve coverage for and access to fertility treatment. However, for many fertility patients, including older women, single women and same-sex couples, infertility does not represent a true disease state. Therefore, while calling infertility a 'disease' may seem politically advantageous, it might actually exclude patients with 'social' or 'relational' infertility from treatment. What is needed is a new conceptual framing of infertility that better reflects the profound significance of being infertile for many people and the importance of addressing infertility in order to improve their lives. In this paper, we argue that the capability approach provides this moral underpinning. The capability approach is concerned with what people are able to do , and whether they are able to act in a way that is in keeping with their own values and goals. The ability to procreate and build a family is a fundamental capacity and can be a major part of self-fulfilment, regardless of sexual orientation or family arrangement. Since the capability approach asks us to conceive of equality in terms of equal capabilities, it provides a strong ethical impetus for society to help those who cannot conceive on their own to do so with assisted reproduction., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In research involving patients with implantable brain-computer interfaces (BCIs), there is a regulatory gap concerning post-trial responsibilities and duties of sponsors and investigators towards implanted patients. In this article, we analyse the case of patient R, who underwent non-voluntary explantation of an implanted BCI, causing a discontinuation in her sense of agency and self. To clarify the post-trial duties and responsibilities involved in this case, we first define the ontological status of the BCI using both externalist (EXT) and internalist (INT) theories of cognition. We then give particular focus to the theories of extended and embedded cognition, hence considering the BCI either as a constitutive component of the patient's mind or as a causal supporter of her brain-based cognitive capacities. We argue that patient R can legitimately be considered both as an embedded and extended cognitive agent. Then, we analyse whether the non-voluntary explantation violated patient R's (neuro)rights to cognitive liberty, mental integrity, psychological continuity and mental privacy. We analyse whether and how different mental ontologies may imply morally relevant differences in interpreting these prima facie neurorights violations and the correlational duties of sponsors and investigators. We conclude that both mental ontologies support the identification of emerging neurorights of the patient and give rise to post-trial obligations of sponsors and investigators to provide for continuous technical maintenance of implanted BCIs that play a significant role in patients' agency and sense of self. However, we suggest that externalist mental ontologies better capture patient R's self-conception and support the identification of a more granular form of mental harm and associated neurorights violation, thus eliciting stricter post-trial obligations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The Journal of Medical Ethics previously published on the debate in the UK and the Netherlands concerning the legal age limits imposed on donor-conceived people for access to information about the identity of gamete and embryo donors. In that publication, three arguments were foregrounded against lowering these age limits as a general rule for all donor-conceived people. In this contribution, we engage with these arguments and argue why we think they are insufficient to maintain the age limits. In contrast, we argue for a more suited, contextual and relational ethical framework based on care ethics, which emphasises relational autonomy and its dynamic, contextual development. This framework, we argue, provides a comprehensive approach for the analysis we made of the question of age limits and was applied in research performed in the Netherlands, commissioned by the Dutch Minister of Health. The framework enabled us to weigh the multidisciplinary-legal, psychological, phenomenological and ethical-findings of our research., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

In a recent article, I argued that all humans are morally equal, and that this generates an argument against abortion. Here, I defend my argument against two objections from Räsänen: that it is possible to ground equal human value in the ability to flourish in a particular kind of way, and that being human is not, in fact, a binary property in the way needed for the argument to work. I show that this proposed criterion for grounding human value falls prey to my original argument, and that Räsänen's attempt to conceive of subhuman entities fails., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the use of coercion in patients lacking mental capacity. The committee's recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The practice of placing men and women in the same hospital room (mixed gender rooms) has been prohibited in the UK National Health Service for over a decade. However, recent research demonstrates that the practice is common and increasing in a major New Zealand public hospital. Reports and complaints show that the practice also occurs in Australia. We argue that mixed gender rooms violate the fundamental human rights of personal security and dignity. The high rates of cognitive impairment, sensory impairment and frailty in hospital wards exacerbates the risk for these violations and subsequent harm. We argue for the adoption of specific national policies prohibiting mixed gender rooms and public reporting of breaches. Importantly, these guidelines can be adopted without compromising the rights of gender minorities. In the long term, hospitals should be built with single occupancy rooms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The reality of current clinical practice in the UK is that where a patient's family refuses to agree to testing for brain stem death (BD), such cases will ultimately end up in court. This situation is true of both adults and children and reinforced by recent legal cases. While recourse to the courts might be regrettable in such tragic cases, if public trust in the medical diagnosis of BD is to be maintained all aspects of the process must be conducted in a way that is transparent and open to scrutiny. This is not an 'ineffective expenditure' of resources, but an essential element of a human rights-compliant legal system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Canada has recently published a new Clinical Practice Guideline on the diagnosis and management of brain death. It states that consent is not necessary to carry out the interventions required to make the diagnosis. A supporting article not only sets out the arguments for this but also contends that 'UK laws similarly carve out an exception, excusing clinicians from a prima facie duty to get consent'. This is supplemented by the claim that recent court decisions in the UK similarly confirm that consent is not required, referencing two judgements in Battersbee We disagree with the authors' interpretation of the law on consent in the UK and argue that there is nothing in Battersbee to support the conclusion that consent to testing is not necessary. Where there is a disagreement about testing for brain death in the UK, court authorisation is required., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Deciding the conflict between various rights and interests, especially in medical ethics where health and lives are in question, has significant challenges, and to obtain appropriate outcomes, it is necessary to properly apply the principles of non-discrimination and proportionality. Using the example of mandatory vaccination policies, we show that this task becomes even more difficult when these principles lead us to counterintuitive and paradoxical results. Although the general purpose of these principles is to ensure that decisions and policies seek the highest and broadest possible enjoyment of rights for all (ie, the least restrictive solution), they achieve the complete opposite when applied to mandatory vaccination policies. To highlight and explain these paradoxical results, we present a typology of fifteen hypothetical mandatory vaccination policies containing various degrees of restriction and apply well-established non-discrimination and proportionality tests from constitutional law to each. We argue that mandatory vaccination policies exhibit two characteristics, namely the non-linear relationship between their general purposes and specific goals and the involvement of life and health, suggesting that more restrictive policies should prevail even though less restrictive policies might fail these tests. Using clearly structured and rigorous methodology from constitutional law, the proposed approach delivers a fresh view on the core ethical principles of non-discrimination and proportionality and a potentially useful tool in helping resolve also other challenges encountered in medical ethics beyond mandatory vaccination policies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

In their paper titled Choosing death in unjust conditions: hope, autonomy and harm reduction, Wiebe and Mullin argue against the stance of diminished autonomy in chronically ill, disabled patients living in unjust sociopolitical environments who pursue medical assistance in dying (MAiD). They suggest that it would be paternalistic to deny these people this choice and conclude that MAiD should actually be seen as a form of harm reduction for them.This response to their article argues that basing discussions surrounding this important topic on a single bioethical concept does not address the needs of this cohort and is restrictively siloed. The discussion should include considerations of human rights and the need for legislative reforms to address social conditions, in addition to traditional bioethical principles. Work in this area needs to become interdisciplinary and collaborative as well as integrate input from the patients themselves. The concept of the dignity of these patients, in its broadest sense, needs to be infused into the discussion in order to optimise the exploration for solutions for this cohort.The stance of MAiD as harm reduction, in this context, does not meet the definition of harm reduction, nor does it represent a commitment to the best interests of these patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

A growing focus on pleasure in human rights discourse has been used to address patterns of sexual exclusion, often when addressing the problems of people with disabilities (PWD). As convincingly argued by Liberman, however, not all PWD suffer from sexual exclusion, and not all who suffer from sexual exclusion are PWD. Danaher and Liberman have thus argued in various ways for a broader range of measures, addressing sexual exclusion. This article builds on previous research and offers a conceptual framework for addressing sexual pleasure and exclusion in terms of human rights. It argues that human rights aim to safeguard autonomy, which is interpreted as multidimensional. It, thus, divides autonomy into the four dimensions of liberty (freedom from threat and coercion), opportunity (options to choose between), capacity (what an agent is capable of doing) and authenticity (the extent to which choices are genuine). Furthermore, it distinguishes between distinct egalitarian strategies, which offer different problems and possibilities, and may be combined. Thus, there is direct egalitarian distribution, indirect egalitarian distribution, baseline or threshold strategies and general promotion strategies. By way of conclusion, the importance of sexual authenticity as the ultimate aim of sexual rights is emphasised., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Miller has recently argued that the standard liberal and moderate positions on abortion are incapable of grounding the claim that 'all non-disabled adult humans are equal'. The reason, he claims, is such accounts base the intrinsic moral worth of a human being on some property (or set of properties) which comes in degrees. In contrast, he argues that moral equality must reside in some binary property, such as the property of being human. In this paper, I offer three criticisms of Miller's position., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

I have recently offered a defence of human equality, and consequently an argument against abortion. This has been objected to by Bozzo, on the grounds that my account of human equality is unclear and could be grounded in utilitarian or Kantian ethics, that my account struggles to ground the permissibility of therapeutic abortions, and that my proposed foundation for human equality itself is parasitic on a scalar property which generates the same difficulties I am attempting to solve. I provide an account of human equality which cannot easily be grounded in utilitarianism or Kantianism, offer a variety of defences of therapeutic abortion consistent with treating the mother and child equally, and show that even if the value of humanness is ultimately grounded in a scalar quality, my argument succeeds., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In the name of safeguarding public interests and ethical principles, China's National Health Commission bans unmarried women from using assisted reproductive technology (ART), including egg freezing. Supported by local governments, the ban has restricted single women's reproductive rights nationwide. Although some courts bypassed the ban to allow widowed single women to use ART, they have not adopted a position in favour of single women's reproductive autonomy, but quite the contrary. Faced with calls to relax the ban and allow single women to freeze eggs electively, the National Health Commission refused to amend their policy, partly to protect women's well-being paternalistically and partly to implement the central government's policies to boost the birthrate and maintain traditional family structures. While the government's concerns about elective egg freezing are not entirely unfounded, they have failed to demonstrate that banning single women's egg freezing is a suitable, necessary and proportionate means to safeguard societal interests and ethical principles. The authority's assumptions that women cannot make rational decisions for their health even with adequate informed consent procedures, that banning egg freezing by single women promotes a culture of having children 'at a proper age', and that egg freezing by single women offends China's public moralities have not been substantiated., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Humans and other species depend on the planet's well-being to survive and flourish. The health of the planet and its ecosystems is under threat from anthropogenic climate change, pollution and biodiversity loss. The promotion of planetary health against entrenched degradation of nature urgently requires ethical guidance. Using an ecocentric virtue jurisprudence approach, this article argues that the highest end of safeguarding planetary health is to secure the flourishing of the Earth community, of which the flourishing of humanity is but one component. The article demonstrates how law, despite its historic role in facilitating our present planetary crisis, has an untapped potential to redeem itself by promoting planetary flourishing through the creation of conditions conducive to the practice of moral virtues, which can help meet the challenges of the Anthropocene. Once given an ecocentric interpretation, the cardinal virtues of prudence, justice, courage and moderation, as well as their subvirtues, can justify or produce legal structures that address everything from the human right to a healthy environment to the rights of nature., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Law's processes are likely always to be needed when particularly intractable conflicts arise in relation to the care of a critically ill child like Charlie Gard. Recourse to law has its merits, but it also imposes costs, and the courts' decisions about the best interests of such children appear to suffer from uncertainty, unpredictability and insufficiency. The insufficiency arises from the courts' apparent reluctance to enter into the ethical dimensions of such cases. Presuming that such reflection is warranted, this article explores alternatives to the courts, and in particular the merits of specialist ethics support services, which appear to be on the rise in the UK. Such specialist services show promise, as they are less formal and adversarial than the courts and they appear capable of offering expert ethical advice. However, further research is needed into such services - and into generalist ethics support services - in order to gauge whether this is indeed a promising development. [ABSTRACT FROM AUTHOR]

Background: Concerns about decision making related to resuscitation have led to two important challenges in the courts resulting in new legal precedents for decision-making practice. Systematic research investigating the experiences of doctors involved in decisions about resuscitation in light of the recent changes in law remains lacking.Aim: To analyse the practice of resuscitation decision making on hospital wards from the perspectives of doctors.Design: The data presented in this paper were collected as part of a wider research study of end-of-life care in an acute hospital setting. Data collection comprised ethnographic non-participant observation on two acute hospital wards and individual interviews with patients, relatives and healthcare professionals caring for patients thought to be approaching the end of life. Data were analysed using a constructivist grounded theory approach.Results: Discussions and decision making about resuscitation present many challenges for those involved on acute medical wards. The data highlight the potential for multiple interpretations of legal precedents, creating misunderstandings that may impact patient care in less positive ways.Conclusions: This paper provides unique insights into how doctors respond to the changing medico-legal culture and the subsequent effects on patient care. It demonstrates how the juridification of medical practice can occur. It highlights the potential benefit of a structure to support clinicians, patients and relatives in discussing and navigating decisions around care at the end of life in line with the patient's wishes and preferences. Recommendations for future research are made and legal ramifications are discussed. [ABSTRACT FROM AUTHOR]

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. [ABSTRACT FROM AUTHOR]

This article clarifies how the freedom of thought as a human right can be understood and promoted as a right of mental health service users, especially people with psychotic disorder, by using Martha Nussbaum's capabilities approach and Fulford's and Fulford et al's values-based practice. According to Nussbaum, freedom of thought seems to primarily protect the capability to think, believe and feel. This capability can be promoted in the context of mental health services by values-based practice. The article points out that both Nussbaum's approach and values-based practice recognise that people's values differ. The idea of involving different actors and service users in mental healthcare is also common in both Nussbaum's approach and values-based practice. However, there are also differences in that values-based practice relies on a 'good process' in decision-making, whereas the capabilities approach is oriented towards a 'right outcome'. However, since process and outcome are linked with each other, these two approaches do not necessarily conflict despite this difference. The article suggests that absolute rights are possible within the two approaches. It also recognises that the capabilities approach, values-based practice and human rights approach lean on liberal values and thus can be combined at least in liberal societies. [ABSTRACT FROM AUTHOR]

In a recent paper in this journal, Jason Brennan correctly notes that libertarians struggle to justify a policy of compulsory vaccination. The most straightforward argument that justifies compulsory vaccination is that such a policy promotes welfare. But libertarians cannot make this argument because they claim that the state is justified only in protecting negative rights, not in promoting welfare. I consider two representative libertarian attempts to justify compulsory vaccination, and I argue that such arguments are unsuccessful. They either fail to show that the state is justified in implementing the policy or overgeneralise. I suggest that Brennan's solution is especially well motivated insofar as it addresses the shortcomings of these arguments. Brennan argues that we violate the rights of others by participating in an activity that imposes an unacceptable collective risk of harm. Going unvaccinated is an activity that imposes an unacceptable collective risk of harm, and thus amounts to a rights violation. So, the state can implement a policy of compulsory vaccination I object, however, that Brennan's delineation of acceptable and unacceptable risk implicitly rests on classical liberal rather than libertarian principles; he justifies compulsory vaccination on the grounds that it promotes welfare. I also object that Brennan's argument would entail significant departures from libertarian institutional arrangements. This leaves libertarians with a choice: they can develop new arguments to demonstrate that their position is compatible with compulsory vaccination, or they can accept that their view entails the impermissibility of compulsory vaccination, and argue that this is not an unpalatable implication of their view. [ABSTRACT FROM AUTHOR]

Unit 731, a biological warfare research organisation that operated under the authority of the Imperial Japanese Army in the 1930s and 1940s, conducted brutal experiments on thousands of unconsenting subjects. Because of the US interest in the data from these experiments, the perpetrators were not prosecuted and the atrocities are still relatively undiscussed. What counts as meaningful moral repair in this case-what should perpetrators and collaborator communities do decades later? We argue for three non-ideal but realistic forms of moral repair: (1) a national policy in Japan against human experimentation without appropriate informed and voluntary consent; (2) the establishment of a memorial to the victims of Unit 731; and (3) US disclosure about its use of Unit 731 data and an apology for failing to hold the perpetrators accountable. [ABSTRACT FROM AUTHOR]

It is argued that the current policy of the British Medical Association (BMA) on conscientious objection is not aligned with recent human rights developments. These grant a right to conscientious objection to doctors in many more circumstances than the very few recognised by the BMA. However, this wide-ranging right may be overridden if the refusal to accommodate the conscientious objection is proportionate. It is shown that it is very likely that it is lawful to refuse to accommodate conscientious objections that would result in discrimination of protected groups. It is still uncertain, however, in what particular circumstances the objection may be lawfully refused, if it poses risks to the health and safety of patients. The BMA's policy has not caught up with these human rights developments and ought to be changed. [ABSTRACT FROM AUTHOR]

In a thought-provoking paper, Schuklenk and Smalling argue that no right to conscientious objection should be granted to medical professionals. First, they hold that it is impossible to assess either the truth of conscience-based claims or the sincerity of the objectors. Second, even a fettered right to conscientious refusal inevitably has adverse effects on the rights of patients. We argue that the main problem with their position is that it is not derived from a broader reflection on the meaning and implications of freedom of conscience and reasonable accommodation. We point out that they collapse two related but distinct questions, that is, the subjective conception of freedom of conscience and the sincerity test. We note that they do not successfully show that the standard norm according to which exemption claims should not impose undue hardship on others is unworkable. We suggest that the main reason why arguments such as no one is forced to be a medical professional are flawed is that public norms should not constrain citizens to choose between two of their basic rights unless it is necessary. In fine, Schuklenk and Smalling, who see conscience claims as arbitrary dislikes, sell freedom of conscience short and forego any attempts at balancing the competing rights involved. We maintain the authors neglect that most of legal reasoning is contextual and that the blanket restriction of healthcare professionals' freedom of conscience is disproportionate. [ABSTRACT FROM AUTHOR]

Must medical experiments with human subjects offer them a 'favourable risk-benefit ratio', that is, more expectation of benefit than harm or burden, if they are to be judged as ethically justified? Ethical justification is easier for experiments that do offer net benefit to subjects, but ethical justification is possible also for some experiments that do not. Basic science experiments with healthy volunteers and 'Phase I' drug trials that seek to determine tolerable dosage levels are routinely approved by ethical review committees; moreover, guidance they receive from government funding agencies specifically asks them to weigh risks to subjects against benefits to subjects and also benefits to those who may benefit from the knowledge gained in the experiment. If a puzzle remains, it is why there remains any assumption that research ethics requires a 'favourable risk-benefit ratio' for the individual research subject. [ABSTRACT FROM AUTHOR]

Professional providers of mental health services are motivated to help people, including, or especially, vulnerable people. We analyse the ethical implications of mental health providers accepting employment at detention centres that operate out of the normal regulatory structure of the modern state. Specifically, we examine tensions and moral harms experienced by providers at the Australian immigration detention centre on the island of Nauru. Australia has adopted indefinite offshore detention for asylum-seekers arriving by boat as part of a deterrence strategy that relies on making detainment conditions harsh. This has known deleterious mental health effects. As a token to fiduciary care obligations, Australia employs mental health professionals to work on Nauru. These providers are often motivated to make a positive difference for detainees' lives. We examine the overall impact of the providers' work with detainees and the implications of their presence. The strongest evidence supports that the small mitigation of harms offered by these providers does not outweigh the harms of supporting a system designed to perpetuate human suffering. For mental health professionals considering working in offshore detention, we offer specific topics to scrutinise and weigh prior to employment. Because optimising detainee's mental health is beyond the capacity of individual providers, we call for the organisations standardising and supporting mental health professionals to oppose employment of their associates in offshore detention. Lessons from this case study are generalisable to other jurisdictions to help inform organisations that licence and support mental health providers and individual providers considering work in similar settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

This paper questions an exclusively state-centred framing of global health justice and proposes a multilateral alternative. Using the distribution of COVID-19 vaccines to illustrate, we bring to light a broad range of global actors up and down the chain of vaccine development who contribute to global vaccine inequities. Section 1 (Background) presents an overview of moments in which diverse global actors, each with their own priorities and aims, shaped subsequent vaccine distribution. Section 2 (Collective action failures) characterises collective action failures at each phase of vaccine development that contributed to global vaccine disparities. It identifies as critical the task of establishing upstream strategies to coordinate collective action at multiple stages across a range of actors. Section 3 (A Multilateral model of global health governance) takes up this task, identifying a convergence of interests among a range of stakeholders and proposing ways to realise them. Appealing to a responsibility to protect (R2P), a doctrine developed in response to human rights atrocities during the 1990s, we show how to operationalise R2P through a principle of subsidiarity and present ethical arguments in support of this approach., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Much work in public health ethics is shaped by an 'autonomy first' view, which takes it to be axiomatic that it is difficult to justify state interference in the lives of competent adults unless the behaviours interfered with are compromised in terms of their autonomy, or would wrongfully infringe on the autonomy of others. However, such an approach is difficult to square with much of traditional public heath practice. Recent years have seen running battles between those who assume that an 'autonomy first' approach is basically sound (and so much the worse for public health practice) and those who assume that public health practice is basically sound (and so much the worse for the 'autonomy first' approach). This paper aims to reconcile in a normatively satisfying way what is best about the 'autonomy first' approach with what is best about a standard public health approach. It develops a positive case for state action to promote and protect health as a duty that is owed to each individual. According to this view, the state violates individuals' rights if it fails to take cost-effective and proportionate measures to remove health threats from the environment. It is thus a mistake to approach public health in the way that 'autonomy first' accounts do, as primarily a matter of individual entitlements versus the common good. Too little state intervention in the cause of improving population health can violate individuals' rights, just as too much can. [ABSTRACT FROM AUTHOR]

In an earlier paper entitled Harm is all you need?, I used an analysis of English law to claim that the harm threshold was an unsuitable mediator of the best interests test when deciding if parental decisions should be overruled. In this paper I respond to a number of commentaries of that paper, and extend my discussion to consider the claim that the harm threshold gives appropriate normative weight to the interests of parents. While I accept that parents have some rights over their children, I argue these are dependent on parents' duties to benefit their children. While many such benefits are understood pluralistically, and are thus within parents' ambit to decide, I claim that health benefits are ordinally different, because they play a foundational role in the flourishing of an individual. In the light of this, clinicians have the moral authority to override parental refusals, although in some cases abstaining from exercising this authority may be a pragmatic way to maintain parental engagement and ensure our ability to benefit the child in future. [ABSTRACT FROM AUTHOR]

A growing number of bioethics papers endorse the harm threshold when judging whether to override parental decisions. Among other claims, these papers argue that the harm threshold is easily understood by lay and professional audiences and correctly conforms to societal expectations of parents in regard to their children. English law contains a harm threshold which mediates the use of the best interests test in cases where a child may be removed from her parents. Using Diekema's seminal paper as an example, this paper explores the proposed workings of the harm threshold. I use examples from the practical use of the harm threshold in English law to argue that the harm threshold is an inadequate answer to the indeterminacy of the best interests test. I detail two criticisms: First, the harm standard has evaluative overtones and judges are loath to employ it where parental behaviour is misguided but they wish to treat parents sympathetically. Thus, by focusing only on 'substandard' parenting, harm is problematic where the parental attempts to benefit their child are misguided or wrong, such as in disputes about withdrawal of medical treatment. Second, when harm is used in genuine dilemmas, court judgments offer different answers to similar cases. This level of indeterminacy suggests that, in practice, the operation of the harm threshold would be indistinguishable from best interests. Since indeterminacy appears to be the greatest problem in elucidating what is best, bioethicists should concentrate on discovering the values that inform best interests. [ABSTRACT FROM AUTHOR]

This paper is about the moral status of those human beings who have profound intellectual disabilities (PIDs). We hold the common sense view that they have equal status to 'normal' human beings, and a higher status than any non-human animal. On the standard account of moral status, this view cannot be sustained. In this paper, we ask whether, in order to be justified in continuing to hold our view, we are obliged to offer an alternative account that does sustain it? Our answer is that we are not. [ABSTRACT FROM AUTHOR]

Almost any medicine can be purchased online from abroad. Many high-income countries permit individuals to import medicines for their personal use. However, those who import medicines face the risk of purchasing poor-quality products that may not work, or that may even harm them. Many people are willing to accept this risk for the opportunity to purchase more affordable medicines. This is especially true of individuals from low socioeconomic backgrounds who already struggle to afford the medicines they need if they are not subsidised by insurers or if copayments are high. As medicine prices and out-of-pocket healthcare spending continue to climb, the online marketplace provides an important alternative for individuals in high-income countries to source medicines. In this article, I argue that doctors have a responsibility to help patients access medicines online and I propose a framework that can be used to facilitate responsible personal importation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

This article explores the role of the physician in the Assisted Dying Bill, which is currently progressing through the House of Lords. The Supreme Court decision in Nicklinson and Others has alerted Parliament to the possibility that the current prohibition against assisted suicide may breach Article 8 of the European Convention in relation to the right to choose how to end one's life. In this article, the role of healthcare professionals in the proposed legalisation of physician-assisted suicide is examined, together with consideration of key ethical concerns over who might be permitted to access assisted dying. Whether the proposed law presents an ethically sound alternative to the current prohibition against assisting in suicide is not clear, but Parliament must now respond in order to address human rights issues and the call to legalise medically assisted suicide. [ABSTRACT FROM AUTHOR]