Recent reports from Canada have sparked debate about cases in which people with disabilities request assisted dying not primarily because of their medical conditions, but because of poverty, inadequate housing or insufficient care. Some argue that although such situations are tragic and unjust, such requests are autonomous and should be acceded to.In this paper, I instead argue that requests motivated by suffering that is caused by remediable social injustice for which the state is responsible should not be regarded as sufficiently voluntary. Hence, they do not fulfil the high standards for autonomy usually required in the context of assisted dying. Drawing on baseline theories of coercion, I show that proposals can be coercive when made by an agent who is simultaneously subjecting the recipient to ongoing injustice. I compare standard cases of such forms of coercion to the context of assisted dying, focusing on the role of the state as a collective agent. I argue that when the state unjustly fails to provide adequate resources to people with disabilities while simultaneously making the option of assisted dying available, this can create coercive pressure to choose assisted dying.To avoid creating such pressure, states that make assisted dying available should urgently ensure that people with disabilities have access to adequate resources and support. In addition, assessments of the voluntariness of individual requests should consider the potential influence of unjust social conditions.
There is substantial enthusiasm for a right to mental integrity in neuroethics-but less clarity on just what exactly that right would involve. A recent article by Jennifer Blumenthal-Barby and Peter Ubel presses a number of significant challenges to this notion-at least, that it is superfluous (since more familiar rights and wrongs already explain the relevant territory) and that it would demand too much (since we are not bound, in general, not to influence or interpret the minds of others). Responding to these objections can help us to see more clearly what is at stake in discussions about the right to mental integrity-and also what it would take to show that we should endorse rights like this, as a morally important set of considerations that deserve legal recognition. My claim will be that, as in the case of other integrity rights (bodily, territorial, data), mental integrity would have to involve the idea that a certain boundary must be protected in order to maintain the integration of an underlying system. This boundary, I argue, is not the same as the boundaries that define our rights regarding our bodies, selves or lives. Nor, I argue, need we understand any 'crossing' of it, without consent, as a mental trespass. I conclude by showing what it would take to fully specify the nature of the right to mental integrity, so understood, arguing that despite many difficulties such a right faces, we may well need it to account for the contours of mental morality.
Recently, the possibility of extending the so-called 14-Day Rule on human embryonic research has received increased attention, but many ethical, legal, scientific and logistical questions about doing so remain. When the 14-Day Rule was developed in 1979, human embryos could only be cultured for 3-5 days. Recently, embryos have been cultured for up to 13 or 14 days, which has the potential to provide important health benefits. Statements advocating extending the Rule have all stipulated that public engagement is essential. But crucial challenges arise, which have received relatively little attention, regarding specifically what and how to communicate about these controversial topics to policymakers, journalists and the public-what precisely to convey, how exactly such public discussions should occur, what content such communication should include, what obstacles may emerge and how best to respond to these barriers. Particular ethical, attitudinal, psychological, political, historical, educational and logistical obstacles emerge. Terms other than embryo 'destruction', for instance, may help. Empirical survey research is urgently needed to comprehend how policymakers and the public view and understand these issues and what educational approaches will be most effective. This paper examines challenges that emerge, suggests ways of addressing these and highlights needs for enhancing education, communication and literacy concerning relevant scientific and ethical issues. The enactment of ethically informed policy requires attention to not only what policies to pursue but how to communicate about these to stakeholders. Advocates for extensions of the Rule should recognise and begin to address these challenges as soon as possible.
The question we raise in this paper is whether the notion of patterns of practice is useful in clinical ethics. The first part of the paper presents the notion of patterns of practice, describing what it reflects (including important themes from the philosophy of practice) and how it might be used. Central to the idea is the concept of coherence, which is made up of internal and external aspects. In clinical practice, where any decision or action can be regarded as ethical in nature (which is often not recognised), patterns of practice must be both internally and externally coherent. Internal coherence is akin to casuistry, while external coherence reflects virtue ethics. A more tentative suggestion is that these notions link to the medieval concepts of conscientia and synderesis The second part of the paper, using fictional case vignettes, shows how these ideas are relevant to paediatric practice. The relevance is both explanatory and determinative; that is, patterns of practice help to explain quotidian ethical decision-making and determine what those decisions ought to be.
Ethical accounts of informed consent require that patients understand the risks, benefits and alternatives of a proposed intervention. Recent philosophical work has examined what content must be understood and how much understanding is sufficient, but a prior question remains unresolved: what kind of concept 'understanding' is in this context. In current institutional practice, understanding is treated as a private mental state produced by receiving information. On this reception model, the consent process is organised around information transfer, and understanding is presumed to follow from adequate disclosure. This article argues that the reception model rests on a grammatical confusion that Wittgenstein diagnoses in Philosophical Investigations §§148-155. Wittgenstein shows that 'understanding' is not a mental process or inner event but a capacity demonstrated in use: to say that someone understands is to say something about what they can do, not about what has occurred inside them. Applied to informed consent, this analysis reveals that the consent process as standardly practised verifies understanding using the wrong kind of evidence, collecting self-reports about an interior state rather than demonstrations of a capacity. The diagnosis explains an otherwise puzzling empirical pattern: readability-focused consent interventions produce inconsistent improvements in comprehension, while demonstration-based methods such as teach-back succeed more consistently. The article develops four implications for consent process design: evaluating adequacy by demonstrated comprehension rather than disclosure completeness; adopting teach-back as the standard approach to verification; redesigning consent forms for elicitation rather than readability alone; and narrowing the conceptual gap between ordinary consent and formal capacity assessment.
Long's argument that an intrinsic approach to the value of autonomy could allow an autonomy-based approach to assisted dying to avoid the expressivist objection fails because autonomy is not the only morally valuable goal, so moral values other than autonomy also require consideration in ethical decision-making about requests for assisted dying. Accepting requests for assisted dying because respecting patients' autonomy is considered more valuable than patients' lives still expresses value judgements about their lives. This can only be avoided by considering autonomy to be the only, or supreme, moral value, making all other moral considerations irrelevant, which faces a number of significant challenges. Furthermore, catalytic and intrinsic approaches to the value of autonomy are not incompatible or mutually exclusive, which can be explained by understanding autonomy to be valuable because it is necessary for human agency. Agency-based virtue ethics, understanding the virtues to be the traits which promote human agency in terms of the production and realisation of goals, explains this fundamental importance of autonomy and human agency to morality, as well as providing the virtues as a moral framework for understanding how the autonomous actions of human agents can be considered virtuous or vicious depending on whether they promote or hinder human agency.
Intravenous ketamine and intranasal esketamine have shown rapid effects in reversing suicidality and improving depressive symptoms. In countries that allow psychiatric euthanasia and/or assisted suicide (EAS), we argue that potentially effective treatments for suicidal ideation and behaviour, such as ketamine, should be required before allowing patients to access psychiatric EAS. Ketamine can both help clarify patients' decision-making capacity and serve as a reasonable therapeutic alternative when determining irremediability. For patients who refuse potentially effective treatments such as ketamine, oversight bodies should establish a formal process through which they can petition for review of their EAS request-protecting their legal right to die while guarding against potentially preventable death.
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.
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.
Braun has recently argued in this journal that an autonomy-based approach to assisted dying avoids the expressivist objection, namely that limiting access to assisted dying to those with irremediable suffering contains the implicit judgement that this suffering makes their life less worthy of living. Contrastingly, the autonomy-based approach would remove these beneficence-based constraints and allow assisted dying to be provided to anyone who requests it. In short, this provision would be shorn of any objective judgement and instead be provided according to the patient's subjective, autonomous preferences. Against this, Donaldson has argued that Braun's apparently autonomy-based approach does not escape the expressivist objection. Instead, because a doctor may acquiesce to or decline a request, their participation necessarily implies a judgement that a particular patient's assisted death is a good (or not bad) thing. This judgement by the doctor, like beneficence-based limits on eligibility, necessarily implies that the patient's life is less worthwhile. In this paper, I argue, contra Donaldson, that the autonomy-based approach advanced by Braun can still avoid the expressivist objection. Specifically, I argue that Donaldson implicitly adopts a particular conception of autonomy's value-the catalytic approach-which considers autonomy only in terms of the goals its exercise pursues. Here, I propose a plausible alternative-the intrinsic approach-which considers autonomy as valuable as its own end. This approach contends that a doctor can provide assisted suicide based on a commitment to respecting a patient's autonomy, without endorsing their assisted death as a worthwhile end.
The increasing use of online methods in qualitative research, alongside the growing availability of artificial intelligence tools, has raised concerns about whether researchers can be certain who they are speaking to. These concerns are often framed in terms of 'imposter' or 'fraudulent' participants, with proposed responses focusing on detection and verification. This paper argues that such framing mischaracterises the ethical landscape. It presumes that authenticity can be reliably established in contexts where uncertainty is often unavoidable, risks excluding participants whose circumstances or communication styles do not align with normative expectations and reshapes the research relationship in ways that amplify existing power asymmetries. Drawing on relational ethics, ethics of care and accounts of epistemic injustice, the paper proposes a reframing of these encounters as 'uncertain encounters'. It suggests that, rather than treating uncertainty solely as a threat to data integrity, it can be understood as a feature of contemporary qualitative research that requires careful ethical engagement. The paper develops a proportionate approach in which verification is guided by the potential consequences of inauthentic participation rather than being applied routinely. It argues that uncertain accounts may still hold analytic value, particularly in studies concerned with meanings, narratives and social imaginaries. The paper concludes by outlining practical and institutional implications, including the need for reflexive practice, collective deliberation and greater transparency in reporting.
Debates over how to allocate limited diagnostic resources have become increasingly pressing in attention-deficit/hyperactivity disorder (ADHD) services. In May 2025, the Coventry and Warwickshire Integrated Care Board temporarily paused National Health Service referrals for ADHD assessments for those over 25 years. The aim was to reduce long waiting times, particularly for children and young people, but the decision has raised controversy over potentially unfair treatment. In this paper, we focus on a distinction that has received limited attention outside emergency contexts: the difference between prioritising patients within a shared entitlement and suspending eligibility for a defined demographic. We examine this distinction through three normative frameworks: efficiency, temporal egalitarianism and whole-life egalitarianism, each of which captures a distinct moral dimension of age-based allocation, drawing on evidence from the Integrated Care Board's own impact assessment. We argue that although prioritising younger cohorts may be defensible under conditions of scarcity, suspending access for adults requires stronger justification than the claim that the policy is temporary. We conclude that on the available evidence, this requirement is not met. The ethical case for the decision, therefore, remains insufficiently established.
