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Many patients at the end of life require analgesia to relieve pain. Additionally, up to 1/5 of patients in the UK receive sedation for refractory symptoms at the end of life. The use of sedation in end-of-life care (EOLC) remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called \"terminal anaesthesia\", TA). However, the general public's views about sedation in EOLC are not known. We sought to investigate the general public's views to inform policy and practice in the UK. We performed two anonymous online surveys of members of the UK public, sampled to be representative for key demographic characteristics (n = 509). Participants were given a scenario of a hypothetical terminally ill patient with one week of life left. We sought views on the acceptability of providing titrated analgesia, gradual sedation, terminal anaesthesia, and euthanasia. We asked participants about the intentions of doctors, what risks of sedation would be acceptable, and the equivalence of terminal anaesthesia and euthanasia. Of the 509 total participants, 84% and 72% indicated that it is permissible to offer titrated analgesia and gradual sedation (respectively); 75% believed it is ethical to offer TA. Eighty-eight percent of participants indicated that they would like to have the option of TA available in their EOLC (compared with 79% for euthanasia); 64% indicated that they would potentially wish for TA at the end of life (52% for euthanasia). Two-thirds indicated that doctors should be allowed to make a dying patient completely unconscious. More than 50% of participants believed that TA and euthanasia were non-equivalent; a third believed they were. These novel findings demonstrate substantial support from the UK general public for the use of sedation and TA in EOLC. More discussion is needed about the range of options that should be offered for dying patients.

Purpose To critically analyze physician-related variability in end-of-life decision-making in intensive care. Methods An ethical analysis of factors contributing to physician-related variability in end-of-life decision-making. Results There is variability in decision-making about life support, both within and between intensive care units. Physician age, race, religion, attitude to risk, and personality factors have been associated with decisions to provide or limit life-sustaining treatment, though it is unclear how much these factors affect patient outcome. Inconsistency in decision-making appears worryingly arbitrary, and may mean that patients’ values are sometimes being ignored or overridden. However, physician influence on decisions may also sometimes be appropriate and unavoidable, particularly where patient values are unclear. Conclusions We argue that, although physician-related variability in end-of-life care can never be eliminated entirely, it is potentially ethically problematic. We outline four potential strategies for reducing the “roster lottery.”

Driverless cars are predicted to dramatically reduce collisions and casualties on the roads. However, there has been controversy about how they should be programmed to respond in the event of an unavoidable collision. Should they aim to save the most lives, prioritise the lives of pedestrians, or occupants of the vehicle? Some have argued that driverless cars should all be programmed to minimise total casualties. While this would appear to have wide international public support, previous work has also suggested regional variation and public reluctance to purchase driverless cars with such a mandated ethical setting. The possibility that algorithms designed to minimise collision fatalities would lead to reduced consumer uptake of driverless cars and thereby to higher overall road deaths, represents a potential “utility paradox”. To investigate this paradox further, we examined the views of the general public about driverless cars in two online surveys in the UK and Japan, examining the influence of choice of a “personal ethical setting” as well as of framing on hypothetical purchase decisions. The personal ethical setting would allow respondents to choose between a programme which would save the most lives, save occupants or save pedestrians. We found striking differences between UK and Japanese respondents. While a majority of UK respondents wished to buy driverless cars that prioritise the most lives or their family members’ lives, Japanese survey participants preferred to save pedestrians. We observed reduced willingness to purchase driverless cars with a mandated ethical setting (compared to offering choice) in both countries. It appears that the public values relevant to programming of driverless cars differ between UK and Japan. The highest uptake of driverless cars in both countries can be achieved by providing a personal ethical setting. Since uptake of driverless cars (rather than specific algorithm used) is potentially the biggest factor in reducing in traffic related accidents, providing some choice of ethical settings may be optimal for driverless cars according to a range of plausible ethical theories.

There is much debate about the use of immunity passports in the response to the COVID-19 pandemic. Some have argued that immunity passports are unethical and impractical, pointing to uncertainties relating to COVID-19 immunity, issues with testing, perverse incentives, doubtful economic benefits, privacy concerns, and the risk of discriminatory effects. We first review the scientific feasibility of immunity passports. Considerable hurdles remain, but increasing understanding of the neutralising antibody response to COVID-19 might make identifying members of the community at low risk of contracting and transmitting COVID-19 possible. We respond to the ethical arguments against immunity passports and give the positive ethical arguments. First, a strong presumption should be in favour of preserving people's free movement if at all feasible. Second, failing to recognise the reduced infection threat immune individuals pose risks punishing people for low-risk behaviour. Finally, further individual and social benefits are likely to accrue from allowing people to engage in free movement. Challenges relating to the implementation of immunity passports ought to be met with targeted solutions so as to maximise their benefit.

[...]we should also recognise that decisions about life-sustaining treatment for children are difficult, that disagreement in some cases is probably inevitable, and that there are no simple solutions.11 Funding: This research was funded in part, by the Wellcome Trust [203132/Z/16/Z] and by the Australian Research Council [DP190101597]. Competing interests: DW is a member of the Medical Ethics Committee of the British Medical Association, and the Ethics and Law Advisory Committee of the Royal College of Paediatrics and Child Health. 3 Linney M Hain RDW Wilkinson D. Achieving consensus advice for paediatricians and other health professionals: on prevention, recognition and management of conflict in paediatric practice.

Crowdfunding provides pharmaceutical companies with an opportunity to gain free promotion for their products and puts pressure on public funders by demonstrating the patients’ willingness to get treatment. When there is a realistic chance of crowdfunding success and clinical benefit for the child, clinicians have a vital role to play in supporting families’ crowdfunding efforts. LS has provided paid consultancy for Novartis Gene Therapy, Roche, and Biogen, and obtained funding from these companies for a newborn screening programme in Belgium.

Can metaphysics yield the consolations of philosophy? One possibility, defended by Derek Parfit, is that reflection on the nature of identity and time could diminish both fear of death and grief. In this paper, I assess the prospect of such consolation, focussing especially on attempts to console a grieving third party. A shift to a reductionist view of personal identity might mean that death is less threatening. However, there is some evidence to suggest that such a shift does not necessarily translate into less death anxiety. Moreover, applied to grief at loss of another, such a perspective may be misdirected. A temporally neutral perspective offers a theoretically powerful way of reducing the sense of loss at being separated in time from a loved one. However, it is unclear whether it is psychologically possible to achieve. Even if it were possible, it may not diminish the pain of separation. I identify a serious challenge to philosophical consolation for grief. The greater the consolation that is offered, the greater the risk of losing important attachments and the less it may be psychologically accessible.

Background ECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations. Methods An online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic. Results When initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, ( p  < 0.001). If a full unit were referred a good candidate for ECMO, participants were more likely during the pandemic to consider discontinuing ECMO from a current patient with low chance of survival (53% during pandemic vs. 33% prior p  = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%). Conclusions We found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic.

In Western countries, the ideal professional and ethical attributes of healthcare providers and the ideal patient-doctor relationship have been analysed in detail. Other cultures, however, may have different norms, arising in response to diverse healthcare needs, cultural values and offering alternative perspectives. In this paper, drawing a case study, we introduce the concept of Shinmi, used in Japan to describe a desirable approach to medical care. Shinmi means kind or cordial in Japanese. In the medical context, it refers to doctors treating patients with a degree of emotional closeness as if they were the doctors’ own family. We analyse the concept of Shinmi, drawing on virtue ethics. We distinguish two different elements to a Shinmi-na attitude. As illustrated in our example, excessive Shinmi can be problematic for patients and doctors. Furthermore, elements of Shinmi may conflict with existing Western values (for example, norms that encourage emotional detachment and discourage doctors’ treatment of family members). However, if pursued appropriately, we argue that a balanced Shinmi-na approach can be conducive to the goals of medicine. The concept of Shinmi may be valuable for medical students, in Japanese and potentially other health care systems, and help them to cultivate a virtuous approach to meeting the emotional needs of patients.

It may soon be possible to generate human organs inside of human-pig chimeras via a process called interspecies blastocyst complementation. This paper discusses what arguably the central ethical concern is raised by this potential source of transplantable organs: that farming human-pig chimeras for their organs risks perpetrating a serious moral wrong because the moral status of human-pig chimeras is uncertain, and potentially significant. Those who raise this concern usually take it to be unique to the creation of chimeric animals with ‘humanised’ brains. In this paper, we show how that the same style of argument can be used to critique current uses of non-chimeric pigs in agriculture. This reveals an important tension between two common moral views: that farming human-pig chimeras for their organs is ethically concerning, and that farming non-chimeric pigs for food or research is ethically benign. At least one of these views stands in need of revision.