Regulation

Is Life-Sustaining Treatment Being Lawfully Withdrawn From Patients In Prolonged Disorders Of Consciousness? Nobody Seems To Know

By Charles Foster

From the time of the decision of the House of Lords in Airedale NHS Trust v Bland (1993) until the decision of the Supreme Court in An NHS Trust v Y (2018) (which I will refer to here as ‘Y”) it had been understood that the withdrawal of life-sustaining treatment (typically clinically assisted nutrition and hydration – ‘CANH’) from patients in a vegetative state should be endorsed by the court. Over the years, this practice had been extended to cover such withdrawals in Minimally Conscious States too.

In Y, the Supreme Court held that there was no requirement for court review or endorsement. Why? Continue reading

Ambient Intelligence

Written by Stephen Rainey

An excitingly futuristic world of seamless interaction with computers! A cybernetic environment that delivers what I want, when I want it! Or: A world of built on vampiric databases, fed on myopic accounts of movements and preferences, loosely related to persons. Each is a possibility given ubiquitous ambient intelligence. Continue reading

Lockdown Erodes Agency

By Charles Foster

A couple of lockdown conversations:

  1. The other day I met a friend in the street. We hadn’t seen one another for over a year. We mimed the hugs that we would have given in a saner age, and started to talk. ‘There’s nothing to tell you’, she said. ‘Nothing’s happened since we last saw you. And that’s just as well, because, as you’ll find, I’ve forgotten how to talk, how to relate, and how to read ordinary cues. We’ve not been out. We’ve not changed anything. I wonder if we’ve been changed?’
  1. Another friend. ‘Zoom’s great, isn’t it? You switch off your camera and your microphone, and the meeting just goes on perfectly happily without you. Everyone thinks you’re there. Your name’s up on their screen. But you are just getting on with your own business.’

And a lockdown fact: Lockdown has been great for book sales. 2020 saw an estimated rise of 5.2% in volume sales of print books in the UK compared with 2019 sales. This was the biggest annual rise since 2007: Continue reading

Cross-Post: The Moral Status of Human-Monkey Chimeras

Written by Julian Savulescu and Julian Koplin 

This article was first published on Pursuit. Read the original article.

The 1968 classic Planet of the Apes tells the story of the Earth after a nuclear war destroys human civilisation. When three astronauts return to our planet after a long space voyage, they discover that humans have lost the power of verbal communication and live much like apes currently do.

Meanwhile, non-human primates have evolved speech and other human-like abilities, and are now running the earth with little regard for human life.

The astronaut George Taylor, played by Charlton Heston, is rendered temporarily mute when he is shot in the throat and captured. In one scene he is brought before the Apes, as he appears more intelligent than other humans.

He regains the power of speech, and his first words are: Take your stinking paws off me, you damned dirty ape.”

Planet of the Apes may be fiction, but this month the world’s first human-monkey lifeforms were created by Juan Carlos Belmonte at the Salk Institute for Biological Studies in the US, using private funding. Professor Belmonte and his group injected stem cells from the skin of a human foetus into a monkey embryo.

This part-human lifeform is called a chimera.

If implanted into a monkey uterus, the chimera could theoretically develop into a live-born animal that has cells from both a monkey and a human.

While it has been possible to make chimeras for more than 20 years using a different technique that involves fusing the embryos of two animals together, this technique has not been used in humans. It has been used to create novel animals like the geep – a fusion of a sheep and goat embryo.

Professor Belmonte used a different technique– called “blastocyst complementation” – which is more refined. It enables greater control over the number of human cells in the chimera.

But why is this research being done?

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Ethics, iBlastoids, and Brain Organoids: Time to Revise Antiquated Laws and Processes

Written by Julian Savulescu
Oxford Uehiro Centre for Practical Ethics and Wellcome Centre for Ethics, University of Oxford
Biomedical Ethics Research Group, Murdoch Children’s Research Institute

Jose Polo and his team at Monash University have successfully reprogrammed human adult cells (fibroblasts – skin cells) to form “iBlastoids”. These are structures which are like early human embryos. Normally when a sperm enters an egg, it produces a new cell, which divides, and these cells divide until a blastocyst is formed in the first week, consisting of 200-300 cells. In normal embryonic development, this would implant in the uterus. However, iBlastoids can’t do this as they lack the normal membrane that surrounds the blastocyst. They cannot by themselves form a fetus or baby.

They will be useful to study early human development and why so many embryos die soon after formation. They can be used to study mutations or the effect of toxins, perhaps developing treatments for infertility. So far, they have only been allowed to develop to the equivalent of a Day 11 Blastocyst. It is not clear whether they can produce the precursors to brain development:

“the developmental potential of iBlastoids as a model for primitive streak formation and gastrulation remains to be determined, and will require an international conversation on the applicability of the 14-day rule to iBlastoids.” (Excerpt from the team’s Nature article)

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Suspending The Astra-Zeneca Vaccine and The Ethics of Precaution

By Jonathan Pugh, Dominic Wilkinson, and Julian Savulescu

The authors are working on the UK Pandemic Ethics Accelerator project – @PandemicEthics_. This project was funded by the Arts and Humanities Research Council (AHRC) as part of UKRI’s Covid-19 funding.  All authors are affiliated to the University of Oxford.

 

Summary Points

  • Preliminary Reviews suggest that the number of thrombotic events in individuals who have received the Astra Zeneca vaccine is not greater than the number we would normally expect in this population.

 

  • It is crucial that we closely monitor these adverse events. The regulation of new medical interventions always requires us to manage uncertainty.

 

  • A precautionary approach to managing this uncertainty may be important for ensuring continued confidence in vaccination.

 

  • Regulators must weigh the potential risk suggested by these reports of adverse events following vaccination against the harm that suspension of the vaccine could have.
  • The harm of suspending the use of the Astra Zeneca vaccine depends on how many preventable deaths we can expect by suspending its use.

 

  • Amongst other things, this will depend on (i) how many people will be delayed in receiving a vaccine as a result (ii) the mortality risk of the people who would be prevented from receiving a vaccine, (iii) the prevalence of the virus at the time of the suspension, and (iv) the number of people who have received one dose of the Astra Zeneca vaccine, but not a second.

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Ethics Doesn’t Rule, OK?

By Charles Foster

Ethics and law are different. Or they should be.

Law has the power to coerce. That is a frightening power. There should be as little law as possible. But there should be more ethics than there is.

The boundary between the two domains is not absolute. Clinicians are probably more frightened of being struck off by the General Medical Council (GMC) (after an adjudication on their ethics by the Medical Practitioners’ Tribunal Service) than they are about an order by a civil court that compels their insurers to pay damages for clinical negligence. The exercise of the GMC’s statutory powers can be draconian: the existence of those powers, and the associated sanctions, is certainly coercive.

But although the boundary is sometimes blurred, it is still real. It is the job of the law to keep it from becoming dangerously permeable. In a recent case the law was caught napping. Continue reading

Cross-Post: Self-experimentation with vaccines

By Jonathan Pugh, Dominic Wilkinson and Julian Savulescu.

This is a crosspost from the Journal of Medical Ethics Blog.

This is an output of the UKRI Pandemic Ethics Accelerator project.

 

A group of citizen scientists has launched a non-profit, non-commercial organisation named ‘RaDVaC’, which aims to rapidly develop, produce, and self-administer an intranasally delivered COVID-19 vaccine. As an open source project, a white paper detailing RaDVaC’s vaccine rationale, design, materials, protocols, and testing is freely available online. This information can be used by others to manufacture and self-administer their own vaccines, using commercially available materials and equipment.

Self-experimentation in science is not new; indeed, the initial development of some vaccines depended on self-experimentation. Historically, self-experimentation has led to valuable discoveries. Barry Marshall famously shared the Nobel Prize in 2005 for his work on the role of the bacterium Helicobacter pylori, and its role in gastritis –this research involved a self-experiment in 1984 that involved Marshall drinking a prepared mixture containing the bacteria, causing him to develop acute gastritis. This research, which shocked his colleagues at the time, eventually led to a fundamental change in the understanding of gastric ulcers, and they are now routinely treated with antibiotics. Today, self-experimentation is having something of a renaissance in the so-called bio-hacking community. But is self-experimentation to develop and test vaccinations ethical in the present pandemic? In this post we outline two arguments that might be invoked to defend such self-experimentation, and suggest that they are each subject to significant limitations. Continue reading

Are Immunity Passports a Human Rights Issue?

Written by Julian Savulescu

A shorter version of this post appears in The Telegraph

Imagine you are about to board a plane (remember that…) Authorities have reason to believe you are carrying a loaded gun. They are entitled to detain you. But they are obliged to investigate whether you have a gun. And if you are not carrying a gun, they are obliged to free you and allow you to board your plane. To continue to detain you without just cause would be false imprisonment.

Having COVID is like carrying a loaded gun that can accidentally go off at any time. The main ground for restricting people’s liberty is if they risk harming other people. This is the justification for quarantine, isolation, lockdown and other coercive measures in the pandemic. But if they are not a risk to other people, they should be free.

The ‘loaded gun’ analogy fails to acknowledge that most who are infected are significantly less harmed than gunshot victims: most recover swiftly and fully. However, in a pandemic, there is a second reason to restrict liberty: to decrease the number who fall ill and “save the NHS”. A person becoming ill not only threatens to harm others who become infected, but also increases the strain on the NHS themselves.

While research on immunity and transmission is ongoing, typically, immunity (natural or via a vaccine) both protects the individual from getting ill and reduces transmission to others. The Federal Drug Administration in the US has admitted as much. A recent study by Public Health England showed natural infection confers similar immunity vaccination (the SIREN study). There are also reasons to believe natural immunity might reduce transmission (by specific antibodies in the airways, called IgA).

An immunity passport would record a past infection (or presence of antibodies) or vaccination. It could be a bracelet, an app on the phone, or a certificate. An immunity passport would constitute evidence that a person was no longer a threat to herself or others. Because people have a human right of freedom of movement, they should be released from current lockdown if they are known not to be threats. There is no ethical basis to imprison people who are not a threat.

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The Libertarian Argument Is the Best Argument Against Immunity Passports. But is it good enough?

Written by Julian Savulescu and Alberto Giubilini

The government has reportedly flirted with the introduction of vaccination passports that would afford greater freedoms to people who have been vaccinated for COVID-19. However, the UK’s Minister for the Cabinet Office, Michael Gove, recently announced that vaccination passports are not currently under consideration in the UK. However, the issue may linger and businesses may introduce such requirements.

One of us (JS) defended immunity passports in the context of affording people with natural immunity greater freedom during lockdown, if immunity significantly reduces the risk of infecting others.

Vaccination passports–after vaccines have been made available–can be seen as a mild form of ‘mandatory vaccination’.  Proof of vaccination could be a requirement to, for example, access certain places (e.g. restaurants, hospitals, public transport, etc, depending on how restrictive we want the mandate to be) or engaging in certain social activities (e.g. mixing with people from different households) or enable health care or other care workers to not self-isolate if in contact with a person with COVID (there were 35 000 NHS workers in isolation at the peak of the pandemic because of contact). It is worth noting that this kind of measure has already been in place globally for a long time in a more selective way, e.g. in the US where, in most states, children cannot be enrolled in schools unless they are up to date with certain vaccinations. These are also a form of “vaccination passports”, which simply do not use that term. Yellow Fever Vaccination Certificates are required to travel to certain parts of the world where Yellow Fever is endemic.

The ethical ground for restriction of liberty is a person represents a threat of harm to others. That is, the grounds for lockdown, quarantine, isolation or mandating vaccination is to reduce the risk one person poses to another. However, if a person is no longer a threat to others, the justification for coercion evaporates. If either natural immunity or a vaccine prevents virus transmission to others (and this remains to be determined), the grounds for restricting liberty disappear. This is one argument for an immunity or vaccination passport – it proves you are not a threat to others.

Moreover, if we thought there were sufficient grounds for the drastic and long lasting restrictions of individual liberties entailed by lockdowns and isolation requirements, it is at least legitimate to ask whether there are also sufficient grounds for vaccination passports, given that the individual cost imposed – getting vaccinated – is likely to be much smaller than the cost entailed by those other measures (unless the risks of vaccines are significant).

However, the more effective a vaccine is, the greater the opportunity for individuals to protect themselves. A Libertarian could then argue that the risk of harming others is nullified. If you want to protect yourself, you can vaccinate yourself. If this is true, then a vaccine doesn’t need to give us herd immunity. We can take individual responsibility.

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