A. M. Viens

The Cambridge textbook of bioethics

Medicine and health care generate many bioethical problems and dilemmas that are of great academic, professional and public interest. This comprehensive resource is designed as a succinct yet authoritative text and reference for clinicians, bioethicists, and advanced students seeking a better understanding of ethics problems in the clinical setting. Each chapter illustrates an ethical problem that might be encountered in everyday practice; defines the concepts at issue; examines their implications from the perspectives of ethics, law and policy; and then provides a practical resolution. There are 10 key sections presenting the most vital topics and clinically relevant areas of modern bioethics. International, interdisciplinary authorship and cross-cultural orientation ensure suitability for a worldwide audience. This book will assist all clinicians in making well-reasoned and defensible decisions by developing their awareness of ethical considerations and teaching the analytical skills to deal with them effectively.

The Ethical Significance of Antimicrobial Resistance

In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance (AMR), which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR.

Value judgment, harm, and religious liberty

Parents’ freedom to choose infant male circumcision is the correct policy Individuals and groups lobbying to have infant male circumcision prohibited or restricted often argue that the practice of routinely circumcising infants is unjustified. For instance, in this issue of the journal, John Hutson argues that it is virtually impossible to justify a policy in which the medical establishment should be able to embark on a “mass circumcision” campaign of 100% of the infant male population (with the exception, of course, where it would be contraindicated by the presence of an anatomical or physiological abnormality) [see page 238] .1 Indeed, I would be hard pressed to find anyone who could rationally disagree with this contention. However, this is because no one is currently arguing for the enactment of a policy that stipulates that all healthy male infants should be routinely circumcised (independent of parental choice). Arguments seeking to support a prohibition of “routine infant circumcision”, such as the one by Hutson, are arguing against a straw man—and a pitiful one at that.2 Such arguments only serve to misconstrue the debate and avoid engaging in the real and pressing issues concerning the legitimacy of the provision of this procedure. The questions that should be considered, and the ones which I shall be interested in discussing here, are what reasons are justifiable for allowing parents to choose to have their son circumcised? After well informed and careful deliberation should parents have the freedom to choose to have their son circumcised? These are the most relevant questions to be considered because there is a growing collection of citizens, medical practitioners, and lawyers who are currently lobbying for the practice of infant male circumcision to be outlawed—for example, there is a bioethicist who argues that the criminal law should be used …

Introduction to The Olivieri symposium

Adrian Viens, Guest Editor of this Olivieri symposium, and Julian Savulescu, the Editor of JME, set the scene for the symposium. In failing...[her] when she needed them most, it is now clear that some members of the University’s Faculty of Medicine heard her muffled cries of academic freedom from the back room, yet their response was to serve another round of drinks and turn the music up louder. With the bombshell revelations in the...affair, the plug may have been pulled on this business sponsored party, and hopefully a sober re-examination of the university’s neglected role and responsibility toward independent inquiry and academic freedom can begin.1 These guys don’t get one thing—we’re not going away. This isn’t a personal vendetta. This is something I want patients to be protected from when I’m dead, fifty years from now.2 [The Olivieri affair is] not a mystery novel, but instead the latest skulduggery at Toronto’s Hospital for Sick Children.1 The legal assaults which you have endured in your battle against the drug company, and in your battle against the medical establishment appear to have been fought with the type of uncommon bravery that is rarely seen. It is for this reason that our trustees have unanimously chosen to recognise you for this most prestigious award.3 [The Olivieri affair resulted from] a fundamental misreading of the issue as a mere contractual and scientific dispute...[it is] Canada’s worst academic and research scandal in decades...[Since 1998, Olivieri has been] demoted, then restored, then harassed. She has been smeared with allegations attacking her competence, integrity, sanity and personality....4 The Olivieri affair is one of the most important events to occur in research ethics. From its dominance in the Canadian and international news media, to changes in the governance of public health, academic medicine, …

Is Antimicrobial Resistance a Slowly Emerging Disaster

The problem of antimicrobial resistance is so dire that people are predicting that the era of antibiotics may be coming to an end, ushering in a ‘post-antibiotic’ era. A comprehensive policy response is therefore urgently needed. A part of this response will require framing the problem in such a way that adequately reflects its nature as well as encompassing an approach that has the best prospect of success. This paper considers framing the problem as a slowly emerging disaster, including its potential benefits and difficulties, from a conceptual and policy perspective.

Reform of the coroner system: a potential public health failure

The Coroners and Justice Act (2009) represents the latest in a long series of legislative and policy measures aimed at reforming the coroner system. Unfortunately, the Act represents a continued failure to recognize that the legal orientation of the coroner system threatens its capability to contribute to adequate cause-specific disease surveillance and, in doing so, to fulfil its proper role in a public health system.

Infection Control Measures and Debts of Gratitude

Health care workers (HCWs) returning home from Ebolainfected regions are subject to various infection control measures (ICMs), including investigative, diagnostic, and liberty-restricting measures. Public health laws justifying the use of ICMs, such as quarantine, have been invoked in recent cases involving HCWs returning home from areas affected by Ebola, such as for Maine nurse Kaci Hickox. Upon her return to the United States, Hickox was issued with a 21-day quarantine order by the Maine Department of Health and Human Services (Temporary order 2014), which she successfully challenged in court. In the final court order on the matter, Judge LaVerdiere acknowledged that while protecting others from harm can serve as a justification for the use of quarantine in such cases, the fact that Hickox had been asymptomatic, and hence unlikely to infect others with Ebola, rendered such measures illegitimate (Order pending hearing 2014). This was an instance where, as Steven Miles (2015) notes in his article, “a government motivated by antiscience, irrational fear, or politics attempts to abuse public health laws to infringe on civil liberties” (18). Instead, the court held that the proportionate response would be for Hickox to comply with direct active monitoring (DAM), which provides public health authorities with the ability to conduct the requisite surveillance activities in a way that would not violate her civil rights. Interestingly, in his order, Judge LaVerdiere claimed that “we owe her and all professionals who give themselves [to fighting Ebola] a debt of gratitude” (Order pending hearing 2014, 3). On what basis and in what ways does one exactly discharge a debt of gratitude in the case of Hickox and other professionals who are fighting Ebola? There are many facets to both questions, but we argue that making progress on them depends on distinguishing between two senses of gratitude and understanding how each sense impacts the legitimacy of using ICMs.

Addiction, Responsibility and Moral Psychology

neuroscience can tell us. If scientists are seen as complicit in provoking unrealistic expectations and if they fail to speak out against misuses of their work, the public may become skeptical or antagonistic towards addiction neurobiological research. Hence, while we share the optimism about the benefits of new treatments and social policies that may emerge from the neuroscience of addiction, these hopes must be tempered by a greater appreciation of possible misuses and misunderstandings. Scientists must be realistic about the way in which they report their research; to moderate their optimism and enthusiasm about new treatments by recognition of past failures of “cures” of addiction (e.g., disulfiram, naltrexone, ultra-rapid opioid detoxification treatment). Addiction neurobiologists cannot evade responsibility for the uses made of their research once it is in the public domain by remaining silent. We need more addiction neuroscientists such as Steven Hyman who understand the limits of their research and are therefore well placed to reduce the likelihood of inappropriate uses, by clarifying what neuroscience cannot say, the limits of how it should be used, where there is uncertainty, and where we should proceed with caution. Above all, we need neuroscientists who are prepared to speak out when their work is used to the detriment of those who are drug addicted. REFERENCES Charland, L. C. 2002. Cynthia’s dilemma: Consenting to heroin prescription. American Journal of Bioethics 2(2): 37–47.

Death investigation systems and disease surveillance

Medico-legal death investigation systems have the potential to play an important role in disease surveillance. While these systems are in place to serve a public function, the degree to which they are independent of central government can vary depending on jurisdiction. How these systems use this independence may present problems for public health initiatives, as it allows death investigators to decline to participate in government-led surveillance regardless of how critical the studies may be to public health and safety. A recent illustration of this problem in the UK is examined, as well as general lessons for removing impediments to death investigation systems participating in public health research.

Interdependence, Human Rights and Global Health Law

The connection between health and human rights continues to play a prominent role within global health law. In particular, a number of theorists rely on the claim that there is a relation of interdependence between health and human rights. The nature and extent of this relation, however, is rarely defined, developed or defended in a conceptually robust way. This paper seeks to explore the source, scope and strength of this putative relation and what role it might play in developing a global health law framework.