Does the General Medical Council's 2020 guidance on consent advance on its 2008 guidance?

The General Medical Council renewed its guidance on consent in 2020. In this essay, I argue that the 2020 guidance does not advance on the earlier, 2008 guidance in regard to treatments that doctors are obliged to offer to patients. In both, doctors are instructed to not provide treatments that are not in the overall benefit, or clinical interests, of the patient; although, patients are absolutely entitled to decline treatment. As such, consent has two aspects, and different standards apply to each aspect. To explore this paradigm, I propose the reconceptualisation of consent as a person's freedom to achieve treatment, using Amartya Sen's approach. Sen explains that freedom has two aspects: process and opportunity. Accordingly, a patient's freedom to achieve treatment would comprise a process for the identification of proper treatment, followed by an opportunity for the patient to accept or decline this treatment. As per Sen, the opportunity aspect is to be assessed by the standard of public reason, whereas the standard for the process aspect is variable and contingent on the task at hand. I then use this reconceptualised view of consent to analyse case law. I show that senior judges have conceived the patient's opportunity to be encompassed in information, which is to be decided by public reason. On the other hand, the process aspect relies on the private reason of medical professionals. Given the nature of professionalism, this reliance is inescapable, and it is maintained in the case law that is cited in both guidances.

Integrity and rights to gender-affirming healthcare

Gender-affirming healthcare (GAH) interventions are medical or surgical interventions that aim to allow trans and non-binary people to better affirm their gender identity. It has been argued that rights to GAH must be grounded in either a right to be cured of or mitigate an illness-gender dysphoria-or in harm prevention, given the high rates of depression and suicide among trans and non-binary people. However, these grounds of a right to GAH conflict with the prevalent view among theorists, institutions and activists that trans and non-binary people do not have a mental illness and that one can be trans and entitled to GAH without being depressed or suicidal. This paper challenges the orthodoxy that a right to GAH must be grounded in either of these ways and instead argues for a right to GAH grounded in a right to live and act with integrity. The standard view, which this paper explains, is that our rights to live and act with integrity ground a right to religious accommodation in many cases such as a right to not be denied social security due to one's refusal to work a job on a holy day. This paper argues that if our rights to live and act with integrity can ground prima facie rights to religious accommodation, our rights to live and act with integrity ground prima facie rights to GAH.

Research bystanders, justice, and the state: Reframing the debate on third-party protections in health research

Research participants are afforded protections to ensure their rights and welfare are not unduly jeopardized by research activities. Yet people who do not meet the criteria for research participant status may likewise be impacted by research activities, and ethicists argue that protections should be afforded these "research bystanders." The standard rationale for extending protections to research bystanders contends that they are sufficiently like research participants that the ethical principles governing health research ought to extend to them. In this article we argue that this analogical reasoning is mistaken. Salient moral differences mean that research ethics frameworks are not fit for purpose. We defend the research bystander category by articulating a novel foundation for this new class of stakeholder. Focusing on bystanders directly impacted by publicly funded health research, we argue that bystanders are sometimes owed protections-but neither because of their similarity to research participants nor because research ethics principles should extend to them. Instead, we reframe the issue as a question of justice. Building on the work of Douglas MacKay, we argue that bystanders to publicly funded health research are owed protections as citizens of liberal states to whom the state owes duties of justice. The state has duties to protect the interests of citizens and to conduct health research. When the means by which the state fulfils the latter duty comes into conflict with the means by which it fulfils the former, the state must ensure that those impacted, including research bystanders, are afforded protections.

Costa, cancer and coronavirus: contractualism as a guide to the ethics of lockdown

Lockdown measures in response to the COVID-19 pandemic involve placing huge burdens on some members of society for the sake of benefiting other members of society. How should we decide when these policies are permissible? Many writers propose we should address this question using cost-benefit analysis (CBA), a broadly consequentialist approach. We argue for an alternative non-consequentialist approach, grounded in contractualist moral theorising. The first section sets up key issues in the ethics of lockdown, and sketches the apparent appeal of addressing these problems in a CBA frame. The second section argues that CBA fundamentally distorts the normative landscape in two ways: first, in principle, it allows very many morally trivial preferences-say, for a coffee-might outweigh morally weighty life-and-death concerns; second, it is insensitive to the core moral distinction between victims and vectors of disease. The third section sketches our non-consequentialist alternative, grounded in Thomas Scanlon's contractualist moral theory. On this account, the ethics of self-defence implies a strong default presumption in favour of a highly restrictive, universal lockdown policy: we then ask whether there are alternatives to such a policy which are justifiable to all affected parties, paying particular attention to the complaints of those most burdened by policy. In the fourth section, we defend our contractualist approach against the charge that it is impractical or counterintuitive, noting that actual CBAs face similar, or worse, challenges.

Rawlsian justice in healthcare: a response to Cox and Fritz

Cox and Fritz state the central problem as the absence of a framework for healthcare policy decisions; but, they overlook the theoretical underpinnings of public law. In response, they propose a two-step procedure to guide fair decision-making. The first step relies on Thomas Scanlon's 'contractualism' for stakeholders to consider whether, or not, they could reasonably reject policy proposals made by others; then in the second step, John Rawls's principles of justice are applied to these proposals; a fair policy requires to pass both steps. I argue that Cox and Fritz misinterpret Rawls. His theory has two stages: first, public reason is used to generate principles of justice; second, public reason is used to interpret and apply these principles. The second stage requires that proposals are based on the principles of justice from the first stage, and these proposals have to be acceptable to reasonable persons. Thus, Rawls's theory does not need Scanlonian supplementation. Moreover, the application of Rawls's theory in Cox and Fritz's model is confusing. In any case, the problems with applying Rawlsian justice to healthcare can be located elsewhere. First, Rawls's theory would treat healthcare simply as a 'primary good' or resource. Social justice ought to, instead, consider healthcare as an opportunity, in the manner conceived by Amartya Sen. Second, Rawlsian justice rests, ultimately, on the conception of a reasonable person; until and unless the characteristics of reasonable stakeholders are clarified, any model of health justice will remain hostage to the unreasonable.

Responsibility and the recursion problem

A considerable literature has emerged around the idea of using 'personal responsibility' as an allocation criterion in healthcare distribution, where a person's being suitably responsible for their health needs may justify additional conditions on receiving healthcare, and perhaps even limiting access entirely, sometimes known as 'responsibilisation'. This discussion focuses most prominently, but not exclusively, on 'luck egalitarianism', the view that deviations from equality are justified only by suitably free choices. A superficially separate issue in distributive justice concerns the two-way relationship between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This paper outlines the degree to which this latter relationship between health and other social goods exacerbates an existing problem for proponents of responsibilisation (the 'harshness objection') in ways that standard responses to this objection cannot address. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. It ends by considering three possible solutions to this problem.

Pandemic prioritarianism

Prioritarianism pertains to the generic idea that it matters more to benefit people, the worse off they are, and while prioritarianism is not uncontroversial, it is considered a generally plausible and widely shared distributive principle often applied to healthcare prioritisation. In this paper, I identify social justice prioritarianism, severity prioritarianism and age-weighted prioritarianism as three different interpretations of the general prioritarian idea and discuss them in light of the effect of pandemic consequences on healthcare priority setting. On this analysis, the paper arrives at the following three conclusions: (1) that we have strong prioritarian reasons for special concern about the vulnerable and socially disadvantaged in reference to pandemic effects, (2) that severity of illness is an important factor in identifying the worse off in priority setting but that this must not over-ride the special priority to the socially disadvantaged and (3) that the maximisation rationale of the age-weighted view runs against the core prioritarian idea, and the age-weighted prioritarianism is thus unfitting as a prioritarian response to the COVID-19 case.

Psychological Examination of Political Philosophies: Interrelationship Among Citizenship, Justice, and Well-Being in Japan

This paper examines assumptions concerning the relationship between citizenship, justice, and well-being, based on representative political philosophies, including egoism, utilitarianism, libertarianism, liberalism, and communitarianism. A previous paper raised the possibility of an inter-disciplinary framework for collaboration between psychology and political philosophy. This study picks up that thread and attempts to actualize a collaborative research effort based on a framework grounded in positive political psychology. The first part of this study reflects on the methodology situated between empirical psychology and philosophy in reference to the debates caused by psychological and philosophical situationism. In response to its criticism against virtue ethics, the possibility of reconstructing it on empirical psychology has paradoxically emerged. Similarly, this study validates assumptions on political philosophies employing the psychological method concerning well-being. Accordingly, the central part examines the plausibility of the assumptions by empirical evidence obtained from two internet surveys (2020, N = 5000; 2021, N = 6885) in Japan. The relationships between citizenship, justice, and well-being are the most substantial in the communitarian assumption. The exploratory factor analysis of the two surveys illuminates that the correlations between citizenship, justice, and well-being (or political well-being) are substantial. This relationship denies the egoism assumption. Moreover, almost all correlations between the three are higher based on virtue-related indicators than hedonic ones. These findings are not in tune with the utilitarian assumption and are most congruent to the communitarian assumption. In addition, citizenship and justice correlate more with political well-being than overall well-being. As these are more directly associated with political well-being in the communitarian assumption, this result aligns with the assumption. Furthermore, the positive relationship between disparity elimination and well-being fits the liberal rather than the libertarian assumption. Nevertheless, the substantial correlation between ethical justice and well-being is higher by virtue-related indicators than hedonic indicators, suggesting distributive justice is associated with the ethical dimension. Again, this fits the communitarian assumption rather than the liberal assumption. Thus, philosophical psychology empirically verifies the interdependence of the three conceptions and the relative plausibility of the communitarian assumption. Moreover, as the relationship between the three is essential for political philosophies, the result increases the reliability of communitarianism.

A vaccine tax: ensuring a more equitable global vaccine distribution

While COVID-19 vaccines provide light at the end of the tunnel in a difficult time, they also bring forth the complex ethical issue of global vaccine distribution. The current unequal global distribution of vaccines is unjust towards the vulnerable living in low-income countries. A vaccine tax should be introduced to remedy this. Under such a scheme, a small fraction of the money spent by a country on vaccines for its own population would go into a fund, such as COVAX, dedicated to buying vaccines and distributing them to the world's poorest. A vaccine tax would provide a much-needed injection of funds to remedy the unequal distribution of vaccines. The tax allows for a distribution that, to a lesser degree, reflects the ability to pay and is superior to a donation-based model because it minimises the opportunity for free-riding.

Public justification and expert disagreement over non-pharmaceutical interventions for the COVID-19 pandemic

A wide range of non-pharmaceutical interventions (NPIs) have been introduced to stop or slow down the COVID-19 pandemic. Examples include school closures, environmental cleaning and disinfection, mask mandates, restrictions on freedom of assembly and lockdowns. These NPIs depend on coercion for their effectiveness, either directly or indirectly. A widely held view is that coercive policies need to be publicly justified-justified to each citizen-to be legitimate. Standardly, this is thought to entail that there is a scientific consensus on the factual propositions that are used to support the policies. In this paper, we argue that such a consensus has been lacking on the factual propositions justifying most NPIs. Consequently, they would on the standard view be illegitimate. This is regrettable since there are good reasons for granting the state the legitimate authority to enact NPIs under conditions of uncertainty. The upshot of our argument is that it is impossible to have both the standard interpretation of the permissibility of empirical claims in public justification and an effective pandemic response. We provide an alternative view that allows the state sufficient room for action while precluding the possibility of it acting without empirical support.

Should higher-income countries pay their citizens to move to foreign care homes?

Faced with relatively old and ageing populations, a growing number of higher-income countries are struggling to provide affordable and decent care to their older citizens. This contribution proposes a new policy for dealing with this challenge. Under certain conditions, I argue that states should pay their citizens to move to foreign care homes in order to ease the pressure on domestic care institutions. This is the case if-but not necessarily only if-(1) a significant proportion of resident citizens do not currently have access to adequate aged and nursing care; (2) the care in the foreign care homes is not worse than the one that is available in domestic care homes; (3) sending states conduct regular checks to ascertain that the level of care abroad is not worse or delegate this task to reliable local monitoring bodies; (4) appropriate measures have been taken to ensure that this type of migration does not harm local residents; and (5) the public money spent on the payments is not better spent on other ways of easing the pressure on domestic care institutions. I end by defending the proposed payments against the objection that they create morally problematic inequalities by exerting greater pressure on members of lower socioeconomic classes to migrate than on their more affluent compatriots.

Disentangling the welfarism/extra-welfarism distinction: Towards a more fine-grained categorization

In health economics, the distinction between welfarism and extra-welfarism has been employed to discuss various epistemological and normative differences between health evaluation approaches. However, a clear consensus on the definition of either welfarism, extra-welfarism, or the differences between the two sets of approaches has not emerged. I propose an alternative set of distinctions that allows for a more fine-grained categorization of health evaluation approaches. This categorization focuses on five dimensions: (1) the maximand of an evaluation approach, (2) its sensitivity toward normative concerns that defy compensation, (3) its position on which groups of individuals or collective entities act as sources of values, (4) its sensitivity to changes of mind, and (5) the inclusion of process-external values.

Allocating scarce life-saving resources: the proper role of age

The COVID-19 pandemic has forced clinicians, policy-makers and the public to wrestle with stark choices about who should receive potentially life-saving interventions such as ventilators, ICU beds and dialysis machines if demand overwhelms capacity. Many allocation schemes face the question of whether to consider age. We offer two underdiscussed arguments for prioritising younger patients in allocation policies, which are grounded in prudence and fairness rather than purely in maximising benefits: prioritising one's younger self for lifesaving treatments is prudent from an individual perspective, and prioritising younger patients works to narrow health disparities by giving priority to patients at risk of dying earlier in life, who are more likely to be subject to systemic disadvantage. We then identify some confusions in recent arguments against considering age.

Solidarity is for other people: identifying derelictions of solidarity in responses to COVID-19

The role and importance of solidarity for effective health provision is the subject of lengthy and heated debate which has been thrown into even sharper relief by the COVID-19 pandemic. In various ways, and by various authorities we have all been asked, even instructed, to engage in solidarity with one another in order to collectively respond to the current crisis. Under normal circumstances, individuals can engage in solidarity with their compatriots in the context of public health provision in a number of ways, including paying taxes which fund welfare state initiatives, and avoiding others when ill. While there has been significant engagement in solidarity worldwide, there have also been high profile examples of refusals and failures to engage in solidarity, both by individual agents, and governments. In this paper I examine the consequence of these failures with reference to the actions of the current British government, which has failed to deliver an effective response to the crisis. This failure has effectively devolved responsibility for responding to the crisis to people who are simultaneously more vulnerable to infection, and less able to do anything about it. I argue that such responses represent mismanagement of a public health crisis, and a rejection of important democratic and egalitarian norms and values.

What does solidarity do for bioethics?

Bioethical work on solidarity has yielded an array of divergent conceptions. But what do these accounts add to normative bioethics? What is solidarity's distinctive social normative role? Prainsack and Buyx suggest that solidarity be understood as the 'putty' of justice. I argue here that the putty metaphor is deeply insightful and-when spelled out in detail-successfully explicates solidarity's social normative function. Unfortunately, Prainsack and Buyx's own account cannot play this role. I propose instead that the putty metaphor supports a conception of solidarity as equity. This proposal enables us to answer whether and when we should act in solidarity, and with whom, while also capturing the putty metaphor and hence answering a basic question: what is solidarity for?

Examining the ethical underpinnings of universal basic income as a public health policy: prophylaxis, social engineering and 'good' lives

At a time of COVID-19 pandemic, universal basic income (UBI) has been presented as a potential public health 'upstream intervention'. Research indicates a possible impact on health by reducing poverty, fostering health-promoting behaviour and ameliorating biopsychosocial pathways to health. This novel case for UBI as a public health measure is starting to receive attention from a range of political positions and organisations. However, discussion of the ethical underpinnings of UBI as a public health policy is sparse. This is depriving policymakers of clear perspectives about the reasons for, restrictions to and potential for the policy's design and implementation. In this article, we note prospective pathways to impact on health in order to assess fit with Rawlsian, capabilities and perfectionist approaches to public health policy. We suggest that Raz' pluralist perfectionist approach may fit most comfortably with the prospective pathways to impact, which has implications for allocation of resources.

Integrating philosophy, policy and practice to create a just and fair health service

To practise 'fairly and justly' a clinician must balance the needs of both the many and the few: the individual patient in front of them, and the many unseen patients in the waiting room, and in the county. They must consider the immediate clinical needs of those in the present, and how their actions will impact on future patients. The good medical practice guidance 'Make the care of your patient your first concern' provides no guidance on how doctors should act when they care for multiple patients with conflicting needs. Moreover, conflicting needs extend far past simply those between different patients. At an organisational level, financial obligations must be balanced with clinical ones; the system must support those who work within it in a variety of roles; and, finally, in order for a healthcare service to be sustainable, the demands of current and future generations must be balanced.The central problem, we propose, is that there is no shared philosophical framework on which the provision of care or the development of health policy is based, nor is there a practical, fair and transparent process to ensure that the service is equipped to deal justly with new challenges as they emerge. Many philosophers have grappled with constructing a set of principles which would lead to a 'good' society which is just to different users; prominent among them is Rawls.Four important principles can be derived using a Rawlsian approach: equity of access, distributive justice, sustainability and openness. However, Rawls' approach is sometimes considered too abstract to be applied readily to policymaking; it does not provide clear guidance for how individuals working within existing institutions can enact the principles of justice. We therefore combine the principles derived from Rawls with Scanlonian contractualism: by demanding that decisions are made in a way which cannot be 'reasonably rejected' by different stakeholders (including 'trustees' for those who cannot represent themselves), we ensure that conflicting needs are considered robustly.We demonstrate how embedding this framework would ensure just policies and fair practice. We illustrate this by using examples of how it would help prevent injustice among different socioeconomic groups, prevent intergenerational injustice and prevent injustice in a crisis, for example, as we respond to new challenges such as COVID-19.Attempts to help individual doctors practise fairly and justly throughout their professional lives are best focused at an institutional or systemic level. We propose a practical framework: combining Scanlonian contractualism with a Rawlsian approach. Adopting this framework would equip the workforce and population to contribute to fair policymaking, and would ultimately result in a healthcare system whose practice and policies-at their core-were just.

Cancer Research UK'S obesity campaign in 2018 and 2019: effective health promotion or perpetuating the stigmatisation of obesity?

In 2018 and 2019 Cancer Research UK (CRUK) launched a controversial advertising campaign to inform the British public of obesity being a preventable cause of cancer. On each occasion the advertisements used were emotive and provoked frustration among the British public which was widely vocalised on social media. As well serving to educate the public of this association, the advertisements also had the secondary effect of acting as health promotion through social marketing, a form of advertising designed to influence behavioural changes. As CRUK delivered a public health message through its campaign, the advertisements should be held according to the ethical principles which underpin healthcare in the UK. This article evaluates whether the advertisements used by CRUK in 2018 and 2019 fulfilled the ethical principles of beneficence, autonomy, non-maleficence and justice. It is found that while providing an important message, the oversimplification of obesity as being the result of personal decisions ignored the complex aetiology and served to stigmatise the target demographic, potentially disengaging them from the message. Additionally, posting cancer as the consequence of obesity invokes feelings of fear due to its connotations of suffering and premature death. Based on available evidence, the use of fear in social marketing does not create sustained behavioural change. This essay recommends that CRUK discontinue its use of such strategies in its future social marketing endeavours.

MIP does not save the impairment argument against abortion: a reply to Blackshaw and Hendricks

Perry Hendricks' original 'impairment argument' against abortion relied on 'the impairment principle' (TIP): 'if it is immoral to impair an organism O to the nth degree, then, ceteris paribus, it is immoral to impair O to the n+1 degree.' Since death is a bigger impairment than fetal alcohol syndrome (FAS), Hendricks reasons that, by TIP, if causing FAS is immoral, then, ceteris paribus, abortion is immoral. Several authors have argued that this conclusion is uninteresting, since the ceteris paribus clause is not satisfied in actual cases of abortion: women have reasons for wanting abortions which do not apply to drinking during pregnancy, so all else is not equal, and the conclusion is irrelevant to the morality of actual abortions. In a recent article in this journal, Hendricks and Bruce Blackshaw try to evade this criticism by replacing TIP with the 'modified impairment principle' (MIP): 'if it is immoral to impair an organism O to the nth degree for reason R, then, provided R continues to hold (or is present), it is immoral to impair O to the n+1 degree.' MIP allows us to derive the ultima facie wrongness of abortion (not just its ceteris paribus wrongness) because MIP lacks a ceteris paribus clause. But I argue that this lack also renders MIP false: MIP faces counterexamples and implausibly produces genuine moral dilemmas. Since the moral principle on which it relies is false, the modified impairment argument fails. I close by considering what a principle would need to do for the impairment argument to succeed.

Age change, official age and fairness in health

In a recent JME article, Joona Räsänen makes the case for allowing legal age change. We identify three problems with his argument and, on that basis, propose an improved version thereof. Unfortunately, even the improved argument is vulnerable to the objection that chronological age is a better proxy for justice in health than both legal and what we shall call official age.

'Rethinking "Disease": a fresh diagnosis and a new philosophical treatment'

Despite several decades of debate, the concept of disease remains hotly contested. The debate is typically cast as one between naturalism and normativism, with a hybrid view that combines elements of each staked out in between. In light of a number of widely discussed problems with existing accounts, some theorists argue that the concept of disease is beyond repair and thus recommend eliminating it in a wide range of practical medical contexts. Any attempt to reframe the 'disease' discussion should answer the more basic sceptical challenge, and should include a meta-methodological critique guided by our pragmatic expectations of what the disease concept ought to do given that medical diagnosis is woven into a complex network of healthcare institutions. In this paper, we attempt such a reframing, arguing that while prevailing accounts do not suffer from the particular defects that prominent critics have identified, they do suffer from other deficits-and this leads us to propose an amended hybrid view that places objectivist approaches to disease on stronger theoretical footing, and satisfies the institutional-ethical desiderata of a concept of disease in human medicine. Nevertheless, we do not advocate a procrustean approach to 'disease'. Instead, we recommend disease concept pluralism between medical and biological sciences to allow the concept to serve the different epistemic and institutional goals of these respective disciplines.

What are considered 'good facts'?

In the January edition of the Journal of Medical Ethics, Fujita and Tabuchi (hereafter, Authors) responded that we misunderstood the 'facts' in our previous article. Our article's method was twofold. First, it appealed to normative analysis and publicly accessible materials, and second, it targeted a policy-making approach to public funding. We specifically did not focus on the Center for iPS Cell Research and Application or induced pluripotent stem stock projects. The Authors raised five criticisms, including transparency of our interpretation of public funding policy. We reply to these criticisms by clarifying facts, and demonstrating new data (facts), and asking the Authors what qualifies as a 'good fact' in medical ethics. We note that in some cases, it might be possible to examine to what extent facts are 'true', while in other cases, 'facts' are laden with 'values', which cannot be confirmed or falsified with observation alone. The level of 'good' implicit in a fact is a challenging issue that goes well beyond science and makes metaethical assumptions about the relationships between facts and values more broadly.

Obesity, equity and choice

Obesity is often considered a public health crisis in rich countries that might be alleviated by preventive regulations such as a sugar tax or limiting the density of fast food outlets. This paper evaluates these regulations from the point of view of equity. Obesity is in many countries correlated with socioeconomic status and some believe that preventive regulations would reduce inequity. The puzzle is this: how could policies that reduce the options of the badly off be more equitable? Suppose we distinguish: (1) the badly off have poor options from (2) the badly off are poor at choosing between their options (ie, have a choosing problem). If obesity is due to a poverty of options, it would be perverse to reduce them further. Some people in public health say that preventive regulations do not reduce options but, I shall argue, they are largely wrong. So the equity case for regulations depends on the worst off having a choosing problem. It also depends on their having a choosing problem that makes their choices against their interests. Perhaps they do. I ask, briefly, what the evidence has to say about whether the badly off choose against their interests. The evidence is thin but implies that introducing preventive regulations for the sake of equity would be at least premature.

Notes on substantance in orthodox theory: a reply to Badano

Gabriele Badano offers three criticisms of my challenge to the orthodox family of theories of legitimacy in bioethics. First, I assumed an 'oversimplified version of the orthodoxy'. Second, I failed to appreciate its domain of application. Third, I only addressed the ways in which orthodox theorists incorporate substance as an 'afterthought'-and, even then, only by rehashing Gopal Sreenivasan's argument. Here, I respond to each, taking up the first and third before ending with reflections on the second. The first underestimates the insight that criticism of the simplified version provides to that of the more complex relatives. The third misunderstands the relationship between my view and Sreenivasan's and neglects an entire argument of my paper. The second fails in light of these two, but raises interesting questions about how the method I suggest might be extended to other domains.

Ethical problems with ethnic matching in gamete donation

Assisted reproduction using donor gametes is a procedure that allows those who are unable to produce their own gametes to achieve gestational parenthood. Where conception is achieved using donor sperm, the child lacks a genetic link to the intended father. Where it is achieved using a donor egg, the child lacks a genetic link to the intended mother. To address this lack of genetic kinship, some fertility clinics engage in the practice of matching the ethnicity of the gamete donor to that of the recipient parent. The intended result is for the child to have the phenotypic characteristics of the recipient parents. This paper examines the philosophical and ethical problems raised by the policy of ethnic matching in gamete donation. I consider arguments for the provision of ethnic matching based on maximising physical resemblance and fostering ethnic identity development. I then consider an argument against ethnic matching based on the charge of racialism. I conclude that while the practice of ethnic matching in gamete donation could promote positive ethnic identity development in donor-conceived children from historically subjugated ethnic minorities, it also risks endorsing the problematic societal attitudes and assumptions regarding ethnicity that enabled such subjugation in the first place.

Substance in bureaucratic procedures for healthcare resource allocation: a reply to Smith

William Smith's recent article criticises the so-called orthodox approaches to the normative analysis of healthcare resource allocation, associated to the requirement that decision-makers should abide by strictly procedural principles of legitimacy defining a deliberative democratic process. Much of the appeal of Smith's argument goes down to his awareness of real-world processes and, in particular, to the large gap he identifies between well-led democratic deliberation and the messiness of the process through which the intuitively legitimate Affordable Care Act (ACA) was created. This reply aims to demonstrate that the ACA provides no counterexample to orthodox views, seizing this opportunity to explore the specific space that the procedural principles populating orthodox accounts are meant to regulate. Neither general questions of healthcare justice concerning, for example, universal access nor, relatedly, the activity of elected politicians falls within the natural scope of application of such principles, revealing a much more complex picture of the interactions between justice and legitimacy as well as substantive and procedural considerations than acknowledged by Smith. In the end, orthodox accounts of healthcare resource allocation turn out to provide a precious fund of theoretical resources for the normative study of administrators, which might be useful well beyond bioethics and health policy.

Libertarianism and collective action: is there a libertarian case for mandatory vaccination?

In his paper 'A libertarian case for mandatory vaccination', Jason Brennan argues that even libertarians, who are very averse to coercive measures, should support mandatory vaccination to combat the harmful disease outbreaks that can be caused by non-vaccination. He argues that libertarians should accept the clean hands principle, which would justify mandatory vaccination. The principle states that there is a (sometimes enforceable) moral obligation not to participate in collectively harmful activities. Once libertarians accept the principle, they will be compelled to support mandatory vaccination. In my paper, I argue that the cases Brennan uses to justify this principle are disanalogous to the case of non-vaccination and that they are not compelling to libertarians. The cases Brennan offers can be explained by a libertarian using the individual sufficiency principle: which states that if an individual's action is sufficient to cause harm, then there is a (sometimes enforceable) moral obligation not to carry out that action. I argue that this principle is more appropriate to Brennan's examples, and more appealing to the libertarian, than the clean hands principle. In order to get libertarians to accept the clean hands principle, I present a modified version of one of Brennan's cases that is analogous to the case of non-vaccination. Using this case, I argue that whether the clean hands principle will justify mandatory vaccination is dependent on whether the herd immunity rate in a given population is approaching a threshold after which a collective risk of harm will be imposed onto others.

Against lifetime QALY prioritarianism

Lifetime quality-adjusted life-year (QALY) prioritarianism has recently been defended as a reasonable specification of the prioritarian view that benefits to the worse off should be given priority in health-related priority setting. This paper argues against this view with reference to how it relies on implausible assumptions. By referring to lifetime QALY as the basis for judgments about who is worse off lifetime QALY prioritarianism relies on assumptions of strict additivity, atomism and intertemporal separability of sublifetime attributes. These assumptions entail that a health state at some period in time contributes with the same amount to how well off someone is regardless of intrapersonal and interpersonal distributions of health states. The paper argues that this is implausible and that prioritarians should take both intrapersonal and interpersonal distributions of goods into account when they establish who is worse off. They should therefore not accept that lifetime QALY is a reasonable ground for ascribing priority and reject lifetime QALY prioritarianism.

Bioethics and multiculturalism: nuancing the discussion

In his recent analysis of multiculturalism, Tom Beauchamp has argued that those who implement multicultural reasoning in their arguments against common morality theories, such as his own, have failed to understand that multiculturalism is neither a form of moral pluralism nor ethical relativism but is rather a universalistic moral theory in its own right. Beauchamp's position is indeed on the right track in that multiculturalists do not consider themselves ethical relativists. Yet, Beauchamp tends to miss the mark when he argues that multiculturalism is in effect a school of thought that endorses a form of moral universalism that is akin to his own vision of a common morality. As a supporter of multiculturalism, I would like to discuss some aspects of Beauchamp's comments on multiculturalism and clarify what a multicultural account of public bioethics might look like. Ultimately, multiculturalism is purported as a means of managing diversity in the public arena and should not be thought of as endorsing either a version of moral relativism or a universal morality. By simultaneously refraining from the promotion of a comprehensive common moral system while it attempts to avoid a collapse into relativism, multiculturalism can serve as the ethico-political framework in which diverse moralities can be managed and in which opportunities for ethical dialogue, debate and deliberation on the prospects of common bioethical norms are made possible.

Response: Freedom from Pain as a Rawlsian Primary Good

In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels' developments of John Rawls' theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value of efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors' argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods.

Medical Need, Equality, and Uncertainty

Many hold that distributing healthcare according to medical need is a requirement of equality. Most egalitarians believe, however, that people ought to be equal on the whole, by some overall measure of well-being or life-prospects; it would be a massive coincidence if distributing healthcare according to medical need turned out to be an effective way of promoting equality overall. I argue that distributing healthcare according to medical need is important for reducing individuals' uncertainty surrounding their future medical needs. In other words, distributing healthcare according to medical need is a natural feature of healthcare insurance; it is about indemnity, not equality.

Rawlsian Justice and Palliative Care

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.