End-of-life decision-making in Canada: the report by the Royal Society of Canada expert panel on end-of-life decision-making.

This report on end-of-life decision-making in Canada was produced by an international expert panel and commissioned by the Royal Society of Canada. It consists of five chapters. Chapter 1 reviews what is known about end-of-life care and opinions about assisted dying in Canada. Chapter 2 reviews the legal status quo in Canada with regard to various forms of assisted death. Chapter 3 reviews ethical issues pertaining to assisted death. The analysis is grounded in core values central to Canada's constitutional order. Chapter 4 reviews the experiences had in a number of jurisdictions that have decriminalized or recently reviewed assisted dying in some shape or form. Chapter 5 provides recommendations with regard to the provision of palliative care in Canada, as well as recommendations for reform with respect to the various forms of assisted death covered in this document.

Making public health policy: what place for the alcohol-dependent?

Although public policy in general, and health policy in particular, can be powerful and effective tools in shaping a "healthy" environment for citizens, the influences and agendas that underpin them are often lacking in transparency. In the case of the alcohol-dependent, the critical importance of identifying strategies appropriate to their specific needs is often sidelined. This, it is argued, results in part from the influence of the alcohol industry on governments and on social conditions and in part from the ethical underpinnings of public health policy, which depends on maximising social benefits even at the expense of "hard to reach" groups. In addition, much of alcohol policy rests on the kind of' "healthy living" message that appeals to the otherwise healthy While not infantilising people who are dependent on alcohol, consideration must be given to the extent to which their ability to choose health is compromised by the nature of dependence itself.

Clinical ethics committees, due process and the right to a fair hearing.

The development of clinical ethics committees in the United Kingdom raises a number of important questions about the extent to which they are compatible with the normative values of due process. If committees are to be active in delivering ethics services, it is argued that attention to due process is important. Based on research outcomes, it seems that the chairs of the United Kingdom clinical ethics committees who responded are reasonably satisfied about the ability of their committees to make ethical decisions and slightly less confident about their ability to make legal decisions. If these committees are to make potentially far-reaching decisions (whether or not involving live consultations), it is argued here that they must pay attention to the rules associated with the legal concept of due process. Equally, evaluation of the clinical ethics committee's counterpart in the United States suggests that they may become increasingly authoritative, especially as their role becomes entrenched. This makes attention to due process even more important. However, it is also proposed that, when committees become concerned about due process, their ability to "do ethics" is constrained.

Motor memory preservation in aged monkeys mirrors that of aged humans on a similar task.

We studied long-term motor memory preservation in rhesus monkeys tested on a task similar to that employed in humans. First, motor speed and rate of motor decline was measured in 23 animals ranging from 4 to 26 years old. The task for the animals consisted of removing a food reward from a curved rod within the inner chamber of an automated panel. Young animals performed twice as fast as the aged animals. Second, young (n=6) and aged (n=10) animals were re-tested 1 year later on the same task with no intervening practice. We anticipated a decline in motor speed of 144 ms/year, instead the average performance time recorded during the repeat session improved significantly by 17% in the aged animals. This finding mirrors that of a longitudinal study conducted in humans using a similar test panel and supports that, while initial performance times of a novel motor task decline with age, motor memory traces are preserved over an extended time interval, even without continued practice. The data also support that the rhesus monkey could be used as a model to study the mechanisms by which long-term retention of motor memory occurs in aging.

The demise of UKXIRA and the regulation of solid-organ xenotransplantation in the UK.

The new regulations on xenotransplantation pay insufficient attention to the broad ethical (and legal) problems raised by this technique and that the abandonment of a national body with overall regulatory authority in this area is a mistake.

CLINICAL ETHICS COMMITTEES IN THE UNITED KINGDOM: TOWARDS EVALUATION.

In the United Kingdom there is a growing conviction that CECs have an important role to play in helping health care professionals address ethical dilemmas. For example, the Royal College of Physicians, the Nuffield Trust and the unofficial Clinical Ethics Network, which has received financial support from the Department of Health, commend the use of CECs in the UK. The growth of such committees has been influenced by the legal and policy support they have received in the United States. However, there is increasing concern about both the benefits and the quality of work produced by CECs. In addition, despite the rapid increase in the number of CECs in the UK, outside of the United States they remain under-researched and no formal mechanism exists to assess their performance. As a result we know little about the structure, function, impact and effectiveness of CECs. We are currently conducting a research project funded by the Wellcome Trust that seeks to interrogate the competing claims regarding the benefits and disbenefits of CECs. This initial account of our research provides a detailed analysis of theoretical issues that surround the development and use of CECs and points towards the questions that lie at the heart of the social science strand of our project.

HUMAN TISSUE LEGISLATION AND MEDICAL PRACTICE: A BENEFIT OR A BURDEN?

The scandals surrounding organ removal and retention throughout the United Kingdom provoked several Inquiries and ultimately led to law reform. Although the medical professions were well represented at the Inquiries, little was heard of the voices of those at the 'coal face'. In this scoping study, funded by the Wellcome Trust, we interviewed a number of doctors and others engaged in the uses of human tissue and organs to explore their hopes, concerns and fears about the role of the law in their practices. We found that those involved in transplantation were more aware of, and more actively involve with, the law, whereas others, such as pathologists, had less direct engagement with the law. Most of those we interviewed expressed the hope that law reform would provide much-needed clarity. Although some expressed concern that the law might be over-intrusive, most felt that the placing of authority firmly in the hands of the person him or her self to decide what should happen to their bodies was to be welcomed.

Permanent vegetative state: the legal position.

Medicine's diagnostic and therapeutic capacities raise increasingly complex ethical and legal issues for consideration. This is particularly so when the patient is in a permanent vegetative state. This article reviews the current legal position in the case of adults in permanent vegetative state (pVS), with particular attention to the devices used by courts in reaching decisions about whether or not to prolong assisted nutrition and hydration. The article further considers the impact of the Human Rights Act 1998, and argues that the current legal position is significantly, if not determinatively, based on clinical judgement, even where there is some doubt about whether or not the cases actually meet the terms of the Royal College of Physicians (RCP) diagnostic guidelines. In addition, the article asks whether or not the devices used by courts to permit withdrawing assisted nutrition and hydration from patients in pVS could be categorised as assisted death, and notes the (arguable) weakness of these devices as a basis for derogation from the sanctity of life principle.

Choosing children: intergenerational justice?

In this discussion, we argue that the concept of intergenerational justice, usually used in environmental matters, is applicable to reproductive decisions also. Additionally, we propose that this permits certain reproductive choices to be made prior to conception or during the pregnancy, and that these choices should not be confined to clinical concerns. In particular, we argue that consideration of the interests of future children should be viewed from the perspective of objective well-being. That being the case, decisions about the sex of future offspring can, in terms of intergenerational justice, be legitimate. We do not argue that every reproductive choice is legitimate; for example it would not be legitimate deliberately to choose characteristics that prevent future children from potentially successful participation in social life.

Sex selection: intergenerational justice or injustice?

Arguments surrounding the issue of sex selection focus on the potential, negative outcomes of permitting such choices. In this article, it is argued that--rather than being negative--sex selection (particularly for, but not confined to, family balancing reasons) can be a positive reflection of the reproductive liberties which have been won over the last century. It is accepted that this argument applies most clearly in cultures where there is no overt preference for one sex over another, but in those societies where this does not apply, it is equally unlikely that the concept of reproductive choice is valued. The article argues that permitting intending parents to choose the sex of their child--while likely to be a relatively rare event--is in line with the concept of intergenerational justice, in that it may serve not just the interests of intending parents but also those of the children to be born.

Post-mortem human reproduction: legal and other regulatory issues.

Increasingly women are seeking to establish pregnancies using sperm retrieved from their dead or dying partners. This raises a number of issues of a broad nature, but is also of significance in terms of the relationship between regulatory mechanisms and private choices. This article reviews this relationship with specific reference to the United Kingdom position, but also taking account of case law and regulation in Australia, particularly in the State of Victoria.