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The question a judge has to ask in deciding whether or not life-sustaining treatment should be withdrawn is whether the continued treatment is lawful. It will be lawful if it is in the patient’s best interests. Identifying this question gives no guidance about how to approach the assessment of best interests. It merely identifies the judge’s job. The presumption in favour of the maintenance of life is part of the job that follows the identification of the question.The presumption is best regarded as a presumption of law. It has long been recognised as part of the way in which the English law discharges its obligations under Article 2 of the European Convention on Human Rights (the right to life). But even if it is a ‘mere’ evidential presumption it cannot, on the facts of most cases involving applications for the withdrawal of life-sustaining treatment from patients in prolonged disorders of consciousness, be rebutted.

This article explores the role of the physician in the Assisted Dying Bill, which is currently progressing through the House of Lords. The Supreme Court decision in Nicklinson and Others has alerted Parliament to the possibility that the current prohibition against assisted suicide may breach Article 8 of the European Convention in relation to the right to choose how to end one's life. In this article, the role of healthcare professionals in the proposed legalisation of physician-assisted suicide is examined, together with consideration of key ethical concerns over who might be permitted to access assisted dying. Whether the proposed law presents an ethically sound alternative to the current prohibition against assisting in suicide is not clear, but Parliament must now respond in order to address human rights issues and the call to legalise medically assisted suicide.

I first raised the idea of a smokers’ licence in a 2005 paper.1 In 20122 and again in an 18 min video in 2014,3 I elaborated on the rationale for it, described the practicalities in careful detail and anticipated potential objections to both the concept and its operation. LeGrande et al outlined far less elaborated models in 20074 and 2009,5 and Magnusson and Currow6 argued for a ‘no frills’ version in 2013, which focused on children not adults. I criticised this for some misconceptions but mainly because children's tobacco consumption represents 99.5% of all tobacco products would be hardly worth the lobbying effort necessary to see such a proposal argued publicly and eventually legislated. The 2012 paper2 has received a good deal of attention, with an Altmetric (http://www.altmetric.com) score of 193, 34 citations and 21 234 views as at 11 February 2016. Daniel Halliday's contribution8 to the discussion of the ethics of the concept of the smoker's licence is welcome. However, his conceptions contain many problems, which I now highlight. His paper is organised largely around the curious assumption that a smoker's licence should be considered ‘as a replacement for sales tax on tobacco products’ rather than as an additional component of broad, comprehensive tobacco control policy and practice. The main elements of such policy are well known and set out in the WHO's Framework Convention on Tobacco Control adopted by the World Health Assembly in May 2003 and now ratified by 180 nations.9 Comprehensive tobacco control consists of public awareness campaigns on the health risks of smoking, taxation designed to reduce consumption, bans on all forms of tobacco advertising and promotion, …

At the end of 2015, Northern Ireland's (NI) High Court of Justice ruled that NI abortion legislation breaches Article 8 of the European Convention on Human Rights—the right to respect for private and family life. The law breaches the Convention as it does not enable women to seek abortion for: At the time of writing, it was not known if NI's Department of Justice and Executive would appeal the decision or bring forward legislation to reflect the judgment. In November 2015, the High Court handed down a judgment in a case involving the recording of a do not attempt cardiopulmonary resuscitation (DNACPR) decision for a 28-year-old man who lacked capacity.2 The judgment has raised a number of interesting questions about when it would not be ‘practical and appropriate’ to ‘consult’ those close to the patient of a DNACPR decision, and what might be a ‘compelling obstacle’ to consultation. In the case, a DNACPR decision was made at 3:00 in the morning as the doctor believed that cardiopulmonary resuscitation (CPR) would have no chance of success. The doctor did not think there was imminent risk of a cardiopulmonary arrest but wished to avoid the possibility of nursing staff being obliged to attempt CPR. At the time the decision was made and documented, no one close to the patient was consulted or informed, instead “DNAR. Speak to family in the morning” was recorded. In the judgment, The Honourable Mr Justice Blake concluded that there had been a breach of section 4(7) duty to consult under the Mental Capacity Act 2005 (MCA) and there had been a violation of the procedural duty under …

Every infant has a right to bodily integrity. Removing healthy tissue from an infant is only permissible if there is an immediate medical indication. In the case of infant male circumcision there is no evidence of an immediate need to perform the procedure. As a German court recently held, any benefit to circumcision can be obtained by delaying the procedure until the male is old enough to give his own fully informed consent. With the option of delaying circumcision providing all of the purported benefits, circumcising an infant is an unnecessary violation of his bodily integrity as well as an ethically invalid form of medical violence. Parental proxy 'consent' for newborn circumcision is invalid. Male circumcision also violates four core human rights documents-the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the International Covenant on Civil and Political Rights, and the Convention Against Torture. Social norm theory predicts that once the circumcision rate falls below a critical value, the social norms that currently distort our perception of the practice will dissolve and rates will quickly fall.

Australia has arguably led the developed world in implementing the most damaging and regressive measures aimed at deterring asylum seekers and refugees. The harms of this system have long been documented and only re-enforced more recently in a number of investigations that have detailed riots, violence and widespread physical and sexual abuse in offshore detention, with adults and children reported as victims.1 ,2 After time spent in an offshore processing centre on Nauru, Isaacs has emerged as a vocal critic of Australia's immigration detention policies. In his article,3 he argues that the mandatory and prolonged detention of asylum seekers and refugees is analogous to torture, drawing comparisons between Australian immigration detention and other notorious sites where torture has taken place. This provocative argument gives a new urgency for long overdue action. Similar concerns have also been raised by other former clinicians and academics (J-P Sanggaran and D Zion. Is Australia engaged in torturing asylum seekers? What this means for medical practise and legislation. Manuscript in preparation.) and follow from comments from the United Nations accusing Australia of systematically violating the international Convention Against Torture by detaining …

The acceptance of military directives violating medical ethics and international covenants encouraged by the demonisation of the enemy by the US president in 2002 has effectively removed the right of medical personnel to refuse participation in internationally proscribed actions Medicine and its traditional ethic of care is today a victim of the current conflict in Iraq and Afghanistan, its uniquely humanising mission rejected by US President George W Bush and his advisors. In denying the applicability of international agreements guaranteeing medicine’s ecumenical role in this conflict they have transformed medicine into just another weapon of tactical significance. The result, predictable in retrospect, has been to make military physicians and nurses complicit—actively or passively—in what Litton calls an “atrocity-producing situation”, resulting in detainee or prisoner abuse.1 From the first revelations of detainee torture in US detention camps (2004) to recent allegations of continued abuse (2006), the focus of international attention has shifted from the US prosecution of low ranking, non-commissioned military personnel to the context in which the atrocities they committed occurred. “No one up the chain of command has ever been held accountable for what is in these horrifying images,” Center for Constitutional Rights Director Bill Goodman said of recently published photographs of 2004 prisoner torture and abuse.2 “The situation in several areas violates international law and conventions on human rights and torture,” said the UN Special Rapporteur on Torture following a 2006 investigation.3 The denial of international law and convention involved the overt disavowal of covenants and conventions that for almost 150 years required medical personnel in the US military to act within the guidelines of a Hippocratic vision of medicine. To understand how fundamental this change has been requires a brief review of the history of medicine’s previously protected status and then a description of …

The International Bioethics Committee (IBC) of the United Nations Educational, Scientific and Cultural Organisation (UNESCO) is currently drafting a Universal Bioethics Declaration ("the declaration"). The content and even the name of the declaration has yet to be finalized, but it is expected to range widely over human and non-human bioethics. It appears likely to include many articles directly related to medical ethics. The declaration may well evolve, like the Universal Declaration of Human Rights, into a component of international customary law, or be the precursor to an International Convention on Bioethics. This article discusses whether this process will facilitate bioethics and, in particular, medical ethics, being subsumed by the normative system of international human rights.

According to a recent convention on human rights and biomedicine, coercive treatment of psychiatric patients may only be given if, without such treatment, serious harm is likely to result to the health of the patient; it must not be given in the interest of other people. In the present article a discussion is undertaken about the implication of this stipulation for the use of coercion in psychiatry in general and in forensic psychiatry in particular.

In Italy, consent for health treatment, aside from being an ethical and deontological obligation, constitutes an essential requirement for any medical treatment according to articles 13 and 32 of the National Constitution and also in accordance with the Council of Europe's 'Convention on Human Rights and Biomedicine'. An essential requirement for the validity of consent is that clear, exhaustive and adequate information be provided to the patient himself: the practice of informed consent is a communicative relationship in which the patient can express doubts, perplexities and clarification requests to the dentist. Furthermore, dental treatment has specific peculiarities: the relationship between dentistry and aesthetics, the concomitant presence of pathologies requiring different treatments, the elongated care process and the establishment of a trustworthy relationship and familiarity with the patient represent important aspects in the configuration of the dentist-patient relationship and in the process of acquiring informed consent. The dentist must offer correct information on diagnosis, prognosis, the therapeutic perspective and the likely consequences of therapy, alternative therapy and refusal of therapy, as well as eventual commitments for the period after treatment. Particular consideration must be given to minors and patients of unsound mind: the dentist's approach to these patients needs to be clear and appropriate to the person's age and understanding ability, even if the decisional power for sanitary treatment may be in the hands of a third person.

This edition of the journal includes, with an introduction and three commentaries, a recent joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing, on decisions relating to cardiopulmonary resuscitation (CPR).1 The statement was produced in response both to a professional need to decide when attempting CPR is and is not ethically appropriate, or indeed lawful (especially in the light of incorporation of the European Convention on Human Rights into UK law), and also to public concern that such decisions have not always been made in concordance with the wishes of patients or people close to them. The guidelines it sets out reflect a broad consensus of current medicolegal views in the UK, include a variety of helpful and practical recommendations, and can be seen, in many respects, as a model of their kind. As a model of actual decision making however, they raise some problems. Model helps us understand the reality they represent by simplifying it, but in the process of simplification, aspects of the reality represented which do not fit in with the model may be left out or downplayed. Three such aspects identified by our commentators concern patient autonomy, quality of life judgments, and the role of families in decision making. In his commentary, Robin Gill argues that while “many of us cherish” the right to be properly informed before decisions about our treatment are made, such information “may become a burden for others when they are at their most vulnerable”. Being told about CPR, with the implication that a “do not attempt resuscitation” (DNAR) order is at least possible, may provoke “angst about death” in these vulnerable patients. The guidelines state that a competent patient's wish not to discuss resuscitation should be respected. But they also state that …

The objective of this paper is to stimulate academic debate on embryo and fetal research from the perspective of the drafting of a protocol to the European Convention on Biomedicine. The Steering Committee on Bioethics of the Council of Europe was mandated to draw up such a protocol and for this purpose organised an important symposium on reproductive technologies and embryo research, in Strasbourg from the 16th to the 18th of December 1996.

Increasing globalisation and advances in artificial reproductive techniques have opened up a whole new range of possibilities for infertile couples across the globe. Inter-country gestational surrogacy with monetary remuneration is one of the products of medical tourism meeting in vitro fertilisation embryo transfer. Filled with potential, it has also been a hot topic of discussion in legal and bioethics spheres. Fears of exploitation and breach of autonomy have sprung from the current situation, where there is no international regulation of surrogacy agreements--only a web of conflicting national laws that generates loopholes and removes safeguards for both the surrogate and commissioning couple. This article argues the need for evidence-based international laws and regulations as the only way to resolve both the ethical and legal issues around commercial surrogacy. In addition, a Hague Convention on inter-country surrogacy agreements is proposed to resolve the muddled state of affairs and enable commercial surrogacy to demonstrate its full potential.

In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and coercion. The article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention. ispartof: Journal of medical ethics vol:34 issue:2 pages:73-76 ispartof: location:England status: published

Gauthier et al 1 contend that “suicide tourism can result in the amendment of existing laws”, and argue that this is “confirmed” by, inter alia, the example of the UK (by which they must mean England and Wales: The Suicide Act 1961 does not extend to Scotland). They rely entirely on the case of Purdy v DPP 2 to support this contention, saying: (1) that “the phenomenon of suicide tourism caused Debbie Purdy to bring about legal action to clarify the position regarding the prosecution of persons assisting in suicide” and (2) that the revision of the guidelines of the Director of Public Prosecutions (DPP) pertaining to the prosecution of assisted suicide which resulted from Purdy resulted in “an overall liberalisation of the prosecution practice in the UK following assistance in suicide”. (1) is wrong, while (2) is at best contentious, and probably wrong. The Purdy litigation sought to establish two things. First, that Article 8 of the European Convention on Human Rights extended to end-of-life decision-making (there being some doubt about this after Pretty v DPP 3 and Pretty v UK 4 …

This symposium discussed bioethics teaching, research and documentation and also research ethics committees. An international convention for the protection of the integrity of the human body was called for, as was a new European Committee on Ethics. 'The genetic impact' was a major preoccupation of the symposium.

Further discussion of the ongoing human cloning debate. In the late 1990s cloning was still the subject of passionate debate. While philosophers were crossing swords about the implications of the “Dolly technique” for the meaning of human identity, sweeping declarations were made by major international bodies such as the World Medical Association, UNESCO, and the World Health Organization that unanimously condemned human reproductive cloning as ethically unacceptable and/or contrary to human dignity. By now, the topic elicits a mere frown, sneer, sigh, or yawn from most bioethicists, depending on their temperament or mood. The same may hold true for those delegates at the United Nations who sat through many sessions that included the ominous agenda item entitled “international convention against reproductive cloning of human beings”. Human cloning became an issue at the United Nations when the item was introduced at the request of France and Germany in 2001. The two countries limited their proposal to reproductive cloning. This move, although aiming quite reasonably at the formulation of a minimal consensus among member states, got at least Germany into some trouble at home, as critical voices from different parts of the political spectrum argued that Germany should rather pursue a comprehensive ban on human cloning for any purpose, which would be more in accordance with its own national …

The growth of research ethics committees worldwide is now fairly rapid and new “markets” for research ethics are opening all the time. The market metaphor is appropriate, since a good deal of the impetus for research ethics review comes from the development of new pharmaceutical products, the globalisation of pharmaceutical research, development and marketing, and the internationalisation of regulatory standards for pharmaceutical R&D. The need for independent ethical review of research protocols by a committee drawing on a range of professional and lay expertise is established as a moral, a quality-management and a regulatory requirement in many jurisdictions, and internationally in the Declaration of Helsinki, the Council of Europe’s Biomedicine Convention, and the International Committee on Harmonisation’s Tripartite Guideline on Good Clinical Practice. Central and Eastern Europe have for many years been sites …