UK doctors' strikes 2023-2024: still justified in the interests of public health, even in time-critical outpatient contexts.

We respond to David Wilkinson's arguments against our view of the ethicality of doctors' strikes and our claim that the 2023-2024 UK doctors' strikes are morally permissible and arguably supererogatory.Wilkinson proposes that in specialist outpatient settings, striking doctors should help arrange their own cover to prevent disproportionate harm to patients and to abide by the principles of non-maleficence and fiduciary duty. This hasn't happened during the 2023-2024 UK doctors' strikes; therefore, in his view, these strikes are morally impermissible. We reject Wilkinson's proposal on the grounds that the risk of disproportionate harm is adequately mitigated by existing arrangements and his interpretations of non-maleficence and fiduciary duty are overly demanding.We agree with Wilkinson that strikes put particularly high pressure on covering doctors in chronically under resourced specialisms. But this doesn't justify calling off or depowering doctors' strikes because, without effective strikes, under-resourcing is likely to continue and, ultimately, cause even more harm.Wilkinson argues that doctors cannot justifiably strike in the interests of public health because they don't have a broad duty to public health. We think they do have such a duty; however, we argue that doctors can justifiably strike in the interest of public health whether they have such a duty or not.Finally, we defend our claim that doctors' strikes can be supererogatory from Wilkinson's objections that there may be no such thing as supererogatory action and that our view absurdly entails that strikes can be supererogatory despite placing unfair demands on others.

Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible.

In clinical ethics consultations, clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others. The reasoning process involves identifying and clarifying ethical values which are at stake or contested, and guiding clinicians, and sometimes patients and families, to think through ethically justifiable and available courses of action in clinical situations. There is, however, ongoing discussion about the various methods ethicists use to do this ethical deliberation work. In this paper, we make visible and accessible seven steps of facilitation used in the critical dialogue method of ethics consultation.We describe how the facilitation techniques serve two overall purposes. First, to identify ethically justified responses to ethical questions. Second, to assist participants to gain greater moral clarity, understanding and confidence to respond to ethical challenges as independent moral agents.By describing in detail facilitation steps for clinical ethics consultation, we aim to advance the scholarship of 'clinical ethics facilitation methods' and to demystify the ethical deliberation work undertaken by clinical ethicists.

Pass the tissue: restoring researcher access to legal human donations.

The sensitivity of human tissue and previous instances of misuse have, rightfully, led to the introduction of far-reaching oversight and regulatory mechanisms for accessing, storing and sharing samples. However, these restrictions, in tandem with more broad-based privacy regulations, have had the unintended consequence of obstructing legitimate requests for medical materials. This is of real detriment to ambitions for biomedical research, most notably the precision medicine agenda. As such, this paper makes the case for facilitating authorised researcher access to human tissue and associated data along practical medical ethics lines, detailing how liberating samples from unfit regulations, re-evaluating biobanks, diversifying considerations for donor benefit-risk, future proofing donor consent and flattening hierarchies of donation acceptability equate to a more cohesive and respectful means of managing biological samples and information than is achieved at present.

Reassessing 'good' medical practice and the climate crisis.

In August 2023, the General Medical Council released the latest update of Good Medical Practice, which sets out the standards of patient care and professional behaviour to be expected of UK doctors. These updated guidelines offer some environmental considerations that previous standards did not include. This paper explores these latest additions to Good Medical Practice through the healthcare ethics lens of non-maleficence, beneficence, justice and autonomy, alongside trust and physician well-being, to make the case that the latest updates to Good Medical Practice do not go far enough in specifying the duties for doctors in responding to climate and ecological emergencies to be seen as ethically justifiable.The paper argues that given the health implications of the climate crisis and the harms associated with high-emission healthcare, as well as the co-benefits of climate action on health, there must be a stronger commitment from the medical regulator to ensure the groundwork is set for doctors to learn, understand and advocate for the importance and urgency of practicing sustainable healthcare. The case for this is strengthened by also examining the importance of maintaining public trust in the medical profession as advocates for public health, along with the notable societal and generational injustices that continue to deepen as the climate emergency escalates.The paper concludes by arguing that doctors can and should be a part of writing a new chapter for health in the climate era, but our standards for practice need to offer a strengthened starting point of consensus for what is expected of the medical profession for that to come to fruition and raise questions as to what doctors can and should do when they have questions over their own regulators' commitment to maintaining public health in relation to the climate and ecological crisis.

Reviewing past and present consent practices in unplanned obstetric interventions: an eye towards the future.

Many first-time mothers (primiparous) within UK National Health Service (NHS) settings require an obstetric intervention to deliver their babies safely. While the antepartum period allows time for conversations about consent for planned interventions, such as elective caesarean section, current practice is that, in emergencies, consent is addressed in the moments before the intervention takes place. This paper explores whether there are limitations on the validity of consent offered in time-pressured and emotionally charged circumstances, specifically concerning emergency obstetric interventions. Using the legal framework of the Mental Capacity Act, Montgomery v. Lanarkshire Health Board (2015) and McCulloch v Forth Valley Health Board (2023), we argue that while women have the capacity to consent during labour, their autonomy is best supported by providing more information about instrumental delivery (ID) during the antepartum period. This conclusion is supported by some national guidelines, including those developed by the Royal College of Obstetricians and Gynaecologists, but not all. Further, we examine the extent to which these principles are upheld in modern-day practice. Data suggest there is relatively little antepartum information provision regarding ID within NHS settings, and that primiparous women do not report a thorough understanding of ID before labour. Based on these results, and bearing in mind the pressures under which NHS obstetric services currently operate, we recommend further research into patient and clinician perceptions of the consent process for ID. Pending these results, we discuss possible modes of information delivery in future practice.

Understanding individualised genetic interventions as research-treatment hybrids.

Until recently, medicine has had little to offer most of the millions of patients suffering from rare and ultrarare genetic conditions. But the development in 2019 of Milasen, the first genetic intervention developed for and administered to a single patient suffering from an ultrarare genetic disorder, has offered hope to patients and families. In addition, Milasen raised a series of conceptual and ethical questions about how individualised genetic interventions should be developed, assessed for safety and efficacy and financially supported. The answers to these questions depend in large part on whether individualised therapies are understood as human subjects research or clinical innovation, different domains of biomedicine that are regulated by different modes of oversight, funding and professional norms. In this article, with development and administration of the drug Milasen as our case study, we argue that at least some individualised genetic therapies are not, as some have argued, either research or treatment. Instead, they are research-treatment hybrids, a category that has both epistemological and pragmatic repercussions for funding, ethics oversight and regulation.

COVID-19 and the vaccine tax: an egalitarian, market-based approach to the global vaccine inequality.

The global inequality in the distribution of vaccines is unjust. As countries scrambled to ensure enough vaccines, the world's poorest were left to fend for themselves, and the generosity meant to mitigate this through COVAX was not sufficiently forthcoming. In light of this, I proposed a vaccine tax, which obligates those willing and able to pay to protect their own population to contribute to protecting those residing in the world's low-income countries. Petrovic has offered an important critique of this proposal, questioning both the fairness and the efficiency of the tax. However, when properly specified, the vaccine tax is not vulnerable to these critiques.

Unjust organ markets and why it is irrelevant that selling a kidney is the best option.

An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique of the 'best option' argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one.

Total lockdown and fairness towards the sufferer: an egalitarian response to Savulescu and Cameron.

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.

No, pregnancy is not a disease.

Anna Smajdor and Joona Räsänen argue that we have good reason to classify pregnancy as a disease. They discuss five accounts of disease and argue that each account either implies that pregnancy is a disease or if it does not, it faces problems. This strategy allows Smajdor and Räsänen to avoid articulating their own account of disease. Consequently, they cannot establish that pregnancy is a disease, only that plausible accounts of disease suggest this. Some readers will dismiss Smajdor and Räsänen's claims as counterintuitive. By analogy, if a mathematical proof concludes '2+2=5', readers will know-without investigation-that an error occurred. Rather than dismiss Smajdor and Räsänen's work, however, the easiest way to undermine their argument is to describe at least one plausible account of disease that (1) excludes pregnancy and (2) avoids the problems they raise for it. This is our strategy. We focus on dysfunction accounts of disease. After outlining Smajdor and Räsänen's main arguments against dysfunction accounts, we explain why pregnancy is not a disease on these accounts. Next, we defend dysfunction accounts against the three problems that Smajdor and Räsänen raise. If successful, then contra Smajdor and Räsänen, at least one plausible account of disease does not imply that pregnancy is a disease. We suspect that defenders of other accounts can respond similarly. Yet, we note that insofar as dysfunction accounts align with the commonsense intuition that pregnancy is not a disease, this, all else being equal, seems like a point in their favour.