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There is a recognised association between professionalism lapses at medical school and later professional misconduct. Medical educators and regulators have increasingly called for professionalism lapses to be identified and addressed at medical school to prevent future problems. Many approaches to remediation have been reported; however, there is a lack of empirical or theoretical basis to many approaches and there are few reports of successful remediation models, particularly over the medium- and long-term. Indeed, in this research, medical schools in the United Kingdom identified that remediation of professionalism lapses is a resourceintensive process but outcomes are uncertain. One of the challenges of addressing unprofessional behaviour is the lack of a consistent definition of professionalism. Many existing definitions rely on an inequitable perception of a 'professional' doctor that has not evolved to reflect the diversity of the profession. With this in mind, 'unprofessional behaviour' may in fact represent diverse ways of being a medical student that do not align with out-dated professional norms and expectations. Increasingly, medical students are understood to learn professionalism through a process of identity development. Using a qualitative narrative methodology, this research explored the identities that 'unprofessional' students learn and perform. Analysis of narrative interviews identified common roles and characters within the stories that were told. Combining these findings with existing theoretical frames, particularly identity dissonance theory, a model was created that demonstrates a cycle of identity crisis that 'unprofessional' students seem to experience. Engagement with stakeholders further highlighted the problematic assumptions that limit the possibilities for remediation of professionalism lapses. The findings of this programme of research led to the creation of a proactive, strategic framework for remediation, founded in principles of equity and inclusion. This framework includes changes necessary in the environment of medical institutions to make space for diverse interpretations of professionalism; intensive faculty development, including the training of 'professional remediators'; and individual remediation through longitudinal coaching relationships. In conclusion, there is a clear mandate for approaching remediation more equitably in order to ensure the medical workforce of the future is equipped to care safely and professionally for patients.

The sharing of data and samples are increasingly promoted as crucial to the timely response to infectious disease outbreaks by bodies such as the World Health Organization. Data and sample sharing are often discussed as an ethical imperative that should occur in order to better understand diseases, and facilitate the development of timely innovations to respond to infectious diseases. However, data and sample sharing present a number of macro- and micro-level ethical considerations which need to be reconciled in practice. These include issues of consent, privacy, and the distribution of benefits. Furthermore, the urgent need to share and respond to infectious disease emergencies may also strain certain areas of best practice. Crucially, the perspectives of stakeholders involved in sharing data and samples in infectious disease contexts have not been well documented. This study aims to address the lack of emphasis on stakeholders’ views by foregrounding their perspectives and practical experiences of ethical issues and views on the role of ethics governance. To achieve these aims, I employed a qualitative methodology, including participant observation and semi-structured interviews to capture the experiences of 28 key stakeholders who were purposively sampled to represent a range of different roles and positions. The primary focus of this research was on gaining insights about sharing data and samples from low- and middle-income countries, given the disproportionate burden of infectious diseases in these settings. The findings, and subsequent analysis, illustrate that data and sample sharing in the infectious disease context take place within a complex moral world. The importance of sharing data, and the optimal use of samples, was underscored by interviewees in this study. However, the nature of the data, samples, disease and the modes of sharing were all reported to have particular ethical implications. A further finding is that sharing often takes place between a diverse set of individuals and organisations, who can be unfamiliar with one another and who at times have differing priorities, and make divergent arguments about how sharing ought to take place for it to be considered ethical. Outbreaks were noted to present particular challenges. Timeliness of data and sample sharing was considered ethically important in outbreak situations, but there were otherwise conflicting views on whether and how the urgent nature of the response ought to change practice. The pressures of an outbreak response also present practical limitations to meeting the usual requirements of good practice, such as obtaining informed consent. The findings show that aspects of practice that have ethical implications for data and sample sharing in the infectious disease context are insufficiently captured in current guidance documents.

The aim is to make a start on developing a comprehensive and integrated account of the adolescent transition, and to use this to articulate changes in adolescents’ relationships with their parents, and with institutions and the state. The thesis builds on existing work on the adolescent transition to offer an enriched map of the adolescent landscape. I argue that extant accounts over-simplify what is a highly complex period. I develop a gradualist multi-sphere model based on the many spheres of activity that open up to adolescents during the adolescent transition. Each sphere is associative and involves a range of responsibilities, powers, and rights. Negotiation of each sphere requires various skills, capacities, and knowledge, some of which are sphere-specific, others which are useful across several spheres of activity. Relationships are of central importance to understanding changes in adolescent status. To develop the relevant skills and competences needed to participate in each sphere requires practise and experience, and successful negotiation of new spheres requires familiarisation. Parents can facilitate the right kind of familiarisation and practise within spheres by mediating children’s relationships with institutions and organisations, but then must allow adolescents to negotiate these relationships when they are able to. Existing legislation reflects an underlying commitment to sphere-based gradualism. The sphere-model provides an integrated account of the adolescent transition that can make sense of gradual changes in status as adolescents mature at both an informal or social level, and at a more formal legislative level.

When we consent to something (e.g. a medical procedure, sex, a tattoo), we permit people to act in ways that would otherwise be legally or morally impermissible. However, in order for consent to be valid, certain conditions must be met. In this thesis, I discuss the condition that consent needs to be voluntary, I focus specifically on consent to medical procedures, and I argue that such consent is voluntary unless it is motivated by an influence that cannot be interpersonally justified. I call my view Interpersonal Consenter-Consentee Justification (ICCJ). ICCJ introduces the concept of interpersonal justification, known from the debate on contractualism, to the debate on consent and most clearly differs from other views in the literature by (i) focusing on the reasons or motivation for which a person consents, instead of mere causal links or counterfactuals, (ii) allowing the moral legitimacy and not just the strength of an influence to have a bearing on the voluntariness of consent, and (iii) making the behaviour of the person receiving consent (the consentee) central to its approach.

This thesis argues that bioethics emerged in the late 1960s and early 1970s not as a novel way to engage new technological or social ethical questions of life (bios), but rather as a late, post-Enlightenment secular phenomenon. In particular, bioethics seeks to adopt a methodology of theorizing on morality that is prominent in modern science, and this is a strategy that I contest by following Wittgenstein’s critique of scientific theorizing. Wittgenstein’s later exercises with language present a critical and clarifying way to identify the immanent and self-referential schema of principlism in bioethics. Additionally, I show how Wittgenstein’s approach to philosophy as a skillful and therapeutic activity rather than a cognitive content is informative for bioethics. Hence, I suggest that in pre-modern, traditional eras—or even in many contemporary non-Western global sectors—bioethics largely would be indistinct from religious and theological dogma and practices. I argue that the modern mind prioritizes material causality, leading to a moral techne that divides spirit from matter, vios from bios. Within such a schema, nature—and especially the medicalized human body—is managed, produced, and constructed. Furthermore, I argue that Wittgenstein gestures towards an ancient transcendent way beyond the modern division of vios and bios, and that a full vision of seeing life may be glimpsed through an apophatic epistemology that guides one towards an understanding of ethics itself as a form of apophatic and embodied knowledge.

Purpose: To understand how clinical psychologists identify ethical issues. The specific aims were to describe the process of ethical sensitivity and examine how clinical psychologists identify a need to engage in ethical decision-making. Design: A qualitative design was adopted using Grounded Theory method. Findings: Twelve clinical psychologists participated in semi-structured interviews. A model of how participants identified ethical issues was developed. The three core categories were discomfort, conscious realisation of an ethical problem and the impact of context on the assessment of the situation. The service context, specifically the balance of service demands to resources resulted in either thinking space or restricted thinking. Thinking space enabled participants to attend to their discomfort, understand its cause and identify a clash with their values. This process of ethical sensitivity being facilitated led to a restored sense of coherence with participants' values. When the context restricted thinking this resulted in an ongoing emotional burden. Participants described this as unsustainable long-term and it had led several to changing jobs, reducing their hours or leaving the national healthcare service altogether to work for private providers or in independent private practice. Value: The paper details an empirically developed theory of clinical psychologists' ethical sensitivity. It describes the process experienced by practicing clinical psychologists when noticing potential ethical issues in their work practice. Limitations are discussed and practical recommendations made for mental health services, clinical psychologists and supervisors.

Within this thesis, I explore the concept of ‘moral distress’ in nursing using both theoretical and empirical methods. Using a feminist empirical bioethics methodology, I explore issues of voice, power, responsibility and relationships and the way in which these impact nurses’ experiences of moral distress. I present qualitative data from interviews with 21 critical care nurses in which they describe different moral events that caused them to feel the various emotions of ‘distress’. Using the empirical findings and tort law, I suggest causal criteria which explains the causal story between the moral event and distress, determining whether one’s distress ought to be regarded as moral distress. I argue for a broader conceptualisation of moral distress based upon the empirical findings and I provide normative reasons why we ought to accept this broader understanding. I argue that due to the complexity of clinical-ethical decision-making and prognostication that moral distress ought to be divorced from ‘knowledge of the right thing’, that this broader definition may encourage moral dialogue between healthcare professionals, and that to disregard these experiences as moral distress deprives these individuals of the tools to make sense of their own moral experiences. I construct a moral distress model which captures the definition of moral distress, the compounding factors that exacerbate/mitigate moral events, responses to moral distress and the interaction of moral distress to other related concepts. Finally, I provide recommendations for ways we can respond to moral distress in clinical practice and policy, and possible areas for further research.

The purpose of this paper is to go towards proving that the generalist ambitions championed in Medical Ethics discourse are both misguided and dangerous to that discourse's meaningfulness. It will be claimed that the generalist undertones which underscore the discourse are motivated by the looming threat of irrationalist accounts of moral reasoning. I first make attempts to show that generalism itself does not avoid this threat. I then aim to show that irrationalism, in turn, is predicated upon a particular and highly contestable conception of empirical epistemological ideas which are, post-analysis, simply unsustainable. I use the work of recent particularist contributors to philosophical debates regarding meaning to show - via a reading of Wittgenstein's later work - which this empiricist epistemology fails. I then defend this reading of Wittgenstein against others, by trying to show that there is enough in the accounts of theorists such as McDowell to suggest that it can rescue meaning in ethical utterances. Our discussion will take us through various areas of thought in claiming that a particularist account really does give the best explanation of moral reasoning. Epistemological, motivational, phenomenological and ontological concerns will all be assessed and contrasted with competing generalist claims. I also critically assess various particularist theorists' claims, making the case for a specific form of non-reductive ethics. This is cashed out by providing a commentary on the very recent debate regarding thick concepts. As the particularist position I advocate is largely found by way of adjudication between the pre-existing positions, I cannot make much claim of originality here. But by way of applying a thoroughly worked out particularist account to Medical Ethics - one which explains what motivates generalist accounts - I aim to elucidate in an important way how the generalist underscoring is not just incorrect, but also damaging to ethical debates in this domain; as well as providing a more thorough account of how we actually can improve Medical Ethics via first-order ethical reasoning. These last points give the thesis its unique interest.

This study explores the mental health nurse’s experience of ethical reasoning while overriding the choices of mental health service users within an acute mental health context. When working with service users in acute mental distress a mental health nurse’s clinical decisions will have a controlling element, which can lead to the service user’s freedoms being restricted. This power to restrict freedoms also known as coercion can be explicit, it follows the rule of law, and implicit; ways of controlling that are ‘hidden’. The ethical use of this power requires the nurse to be an effective ethical reasoner who understands both the explicit and implicit nature of this power. Coercive power, which is explicit, has been thoroughly explored; however, there is limited work exploring the use of this power within an ethical context and as a ‘real-time’ practice issue. In addition, there is little work exploring implicit power as a practice issue or as an ethical issue. To examine this knowledge gap this study adopts an interpretative phenomenological analysis (IPA) approach to engender an understanding of the mental health nurse’s personal meaning and experience of using both explicit and implicit coercive power. This approach affords the researcher the opportunity to tease out the personal ‘ethical’ meaning of the participants’ experiences by facilitating an in-depth and sensitive dialogue, which focuses on stimulating conscious ethical reflection. IPA is an idiographic mode of inquiry where sample purposiveness and analytical depth is more important than sample size. On this basis, six qualified mental health nurses were recruited who have used coercive strategies while nursing service users in acute mental distress. The semi-structured interviews were thematically and interpretively analysed, the five superordinate themes that were generated are; the nurse as a practitioner, their values, their practice, their use of coercion, and their ethics. In addition, the results of the study highlighted that coercive strategies are a key part of a mental health nurse’s daily practice both explicitly and implicitly. These strategies can be beneficent; however, this is dependent on the ethical reasoning ability of the nurse and the professional support they receive in practice. Being an effective ethical reasoner requires the nurse to acquire ‘good habits’, a basis for enabling the nurse to work through an ethical challenge in ‘quick time’. Furthermore, to enhance these good habits they also need to have an ‘ethical imagination’. Considering these points, this study recommends mental health nurses when using coercive power use a multi-faceted ethical reasoning approach. This approach should aim to create good ethical habits through continually rehearsing good responses to common practice issues. In addition, this approach should not neglect the need for the nurse to use their ethical imagination and to feel for an ethical solution where required. As a future area for research, this study recognises the skilled use of ethical imagination in the field of mental health nursing requires further exploration.

A particular methodological orientation has dominated bioethics. As such, certain values, concepts and approaches have been prioritised at the expense of other ways of doing bioethics. One such example is The Future of Human Nature (2003), a contribution to bioethical discourse by the world-renowned philosopher, Jürgen Habermas. The treatment it received, I believe, reflects the course bioethics has taken since its inception. The aim of this thesis is to expound a novel interpretation of The Future of Human Nature, and to articulate a comprehensive perspective on the ‘new genetics’ from Habermas’ wider body of work. A Habermasian perspective on the ‘new genetics’ builds upon recent efforts within bioethics, and outside the field, which take a broader view of emerging biotechnologies or issues of global significance. A hallmark of the characteristic thinking of these approaches is a reflexive and critical awareness of the tendencies of mainstream bioethics, and the social, economic and the political environment in which new biotechnologies are emerging, and policy and regulatory decisions are being taken. Whilst the primary aim of this thesis is to set forth a reformulation of The Future of Human Nature (2003) and develop a perspective on the ‘new genetics’ from Habermas’ wider body of thought, it also undertakes a reconstruction of bioconservatism – the school of thought to which The Future of Human Nature belongs. Regarding the debate on genetic enhancement and the ‘new genetics’ more generally, Kass (1985; 1997; 2002; 2003a; 2003b), Sandel (2007), Fukuyama (2002; 2004) and Habermas (2003) have been subject to criticisms which some feel strike a decisive blow to the bioconservative standpoint (Roache and Clark, 2009). A novel interpretation of their thought is advanced which marks a departure from a rigid opposition to genetic technologies, a reliance on intuition, the appeal to quasi-theological concepts, and a preoccupation with preserving what is natural. The motivation, however, for such a reformulation is not because these characteristic aspects of bioconservatism have been heavily criticised by bioliberals and posthumanists. Rather, a reading of Kass, Sandel, Fukuyama and Habermas which emphasises certain generally neglected – and entirely omitted from critical engagement – dimensions of their thought, furnishes a basis for a more pragmatic, robust, and, potentially, enduring counter-position to bioliberalism and posthumanism.

The question of whether parents-to-be have a moral obligation to maximize the welfare of their future children before they are born has fuelled considerable debate and a multitude of contrasting opinions from within the philosophical, legal and medical academic literature over the last three decades. It is unsurprising that this burst of activity in the field has coincided with continuous and significant advances in the field of reproductive, perinatal and neonatal medicine. These advances perpetually re-set the bar as to what screening processes and therapies can be offered before birth to ensure that infants are born in the healthiest possible state. By extension, I argue, that our obligations towards the unborn should also change. Within this thesis I explore philosophical and legal theories relating to responsibilities held to the unborn child by those wishing to be parents but also the State. In doing so, I approach the available literature from a more clinical viewpoint. I argue that in future, when screening processes and in utero therapies are likely to be safer and more effective, the duty of future parents to bring to life the healthiest child possible will become more compelling. In my articles I employ a personhood view of the foetus and argue that eventual children can be harmed in the pre-personal stage. I carefully analyze what it means to be harmed and apply a comparative account of harm through the thesis in trying to answer the five main questions that permeate through the articles. I question whether parents-to-be have a moral obligation to engage with antenatal screening services, I do not limit the screening processes to genetics alone but include foetal anomaly and microbiological information acquired antenatally in the process. I also explore what the obligations of parents-to-be are, once a screening process reveals a certain problem or risk. I elaborate on what circumstances they may be obliged to act upon, in a way that treats or minimizes the risks posed to the foetus. I argue that even in the absence of a cure, antenatally acquired information can be vital for the welfare of the child and this should compel parents to engage with the services on offer. I also purport that if there is a cure the parents are obliged to uptake it, provided it is safe and with good clinical outcomes. Finally I question whether the State has a moral duty to increase uptake of such antenatal health programs and if so to what extent should it attempt to do so. By analyzing the moral limits of law I argue that impositions on individual liberties in the interest of the unborn may only be reasonable if our reproductive choices stand to significantly harm others. I argue that recent amendments in English and Welsh Law that prohibit the application of advanced reproductive technologies to select for disabled foetuses signify an important change in the way the State values the welfare of future children. I explore international legal cases that suggest that the foetus is increasingly afforded more legal protections and investigate possible ways in which we could objectively quantify harm caused antenatally in a manner that would help us decide if and when the State should intervene with reproductive choices of parents-to-be. Finally, I elaborate on the how State led medical paternalism can be stratified and what each stratum involves in terms of intervention. I put forth that the State ought to explore avenues of soft and moderate paternalism first but should stop short of hard paternalism for a number of reasons.

Recent developments in social neuroscience have stirred up increased interest within the bioethical debate (for a review see: Specker et al. 2014). Moral enhancement is a concept that directly embodies the idea of making brain science work for the social and moral good. In recent ethical discussions about biomedical means of moral enhancement, scholars have focused on so called ‘direct means of moral enhancement,’ discussing the ethical permissibility of modifying the emotional underpinnings of moral behaviour (Douglas, 2008; 2013; Persson and Savulescu, 2008; Savulescu and Persson, 2012). However, critics have argued that such modification only seems like moral enhancement, that behavioural modification is not ‘true’ moral enhancement, for the reason that it changes behaviours without making agents better moral agents. Critics have also noted that it can undermine freedom (e.g. Harris, 2011; see also: Douglas, 2014). This thesis addresses the ethical issues relating to enhancement. In the first part of this work I consider conceptual issues surrounding the concept of moral enhancement and argue that moral enhancement is plausible if we adjust our expectations to match those we have of cognitive enhancement. I examine the difference between pro-sociality and morality, and argue that an increase in empathy and reduction in anger cannot be seen as straightforward moral enhancements. The second part examines the objections related to moral disagreement, medicalization and narrative identity. The third part of this work focuses of the issues related to freedom and agency. I argue that voluntary direct emotion modulation, if embedded in appropriate reflection, is a prima facie desirable way of moral enhancement.

This thesis defends an individual's moral right to be aided in dying by a physician (that is, voluntary active euthanasia, or VAE), but departs significantly from the view in its favor generally accepted in the bioethics literature. The prevailing view appeals to both respect for an individual's autonomy and promotion of an individual's well-being as necessary conditions for a right to VAE, so as to justify the right only for those suffering grave illnesses and/or disabilities. The author argues that such a view is logically untenable; one or another aspect must be given up. Since invoking the premise that certain individuals would be better off dead necessarily relies on controversial assumptions about both the value of life and the nature and value of death, about which reasonable people disagree, it is the justification from an individual's best interest which must be excluded in a liberal society. The author endorses a self-determination justification for the right to VAE, but rejects understanding this in terms of respecting personal autonomy, instead making the case for a right to VAE grounded in self-ownership. The author's main conclusion is that the right to VAE is a general right applying to all competent adults, not only those suffering grave illnesses or disabilities, or those whose choice for VAE is an exercise of autonomy. Moreover, by analyzing the basis of physician authority over prescription medicine and how this can be justified to a society of self-owners, she maintains that individuals have not only the right to choose VAE without state interference, but also the right to be provided VAE by doctors. Nevertheless, both rights are compatible with reasonable limitations to protect both the interests of VAE seekers and the rights of others.

This thesis is a qualitative study of ethics education as experienced by general practitioners in mainland Britain. It draws upon interviews and documents as well as observations and reflections from encounters in the field. Ethics is conceived of as a kind of knowledge and ethics education is seen as involving translational processes shaped by various social forces and tensions. The data analysis is organised according to three concepts outlined by Bernstein: curriculum, pedagogy and evaluation. These broadly map to academia, education and practice,and the purposive sample reflects participants with involvements in these three domains. Ethnographic, phenomenological, and grounded theories are key influences on the method for selecting and organising the empirical data. The findings chapters look at the determination and production of the broad curriculum (chapter 4); the ‘transmission’, or the delivery and reception of, the curriculum (chapter 5); the assessment of ethics education (chapter 6); the ways in which ethical issues are identified and negotiated in practice (chapter 7); and key substantive issues that arise in practice – confidentiality, abortion, payment for performance and resource allocation – which enables an exploration of the negotiation of ethical issues in practice (chapters 8 and 9). The concluding chapter pulls the threads together. Societal forces and tensions are present when curricula are conceived, when knowledge and skills are taught and when GPs attempt to integrate learning into their daily practice. Having understood these forces and tensions better we can conceive better of how to make improvements to ethics education and assessment. The overall aim is to improve the reflexivity of ethics education. Many of ethical shortcomings of doctors have historically been linked to hidden curricula, features of practice and the practice environment that have been unseen or ignored by teachers or learners. Knowing more about these features and about the translational processes, that shape the experiences and enactments of GP ethics, provides the potential ability to adjust for their influence.

The focus of this thesis is moral education. This study is important as it aims at solving a prevailing and increasing problem that is harming the medical profession of our times, namely, the fact that physicians are losing touch with the nature of their profession as a moral venture. This is evident from the numerous surveys done which report complaints from patients regarding physicians’ interpersonal and ethical skills. I argue in this thesis that modern day physicians experience moral erosion and that medicine is falling prey to deprofessionalization. This thesis focuses on the case of medicine in US-style universities in general and Lebanon in particular. Starting from the assumption of the ends of medicine as elaborated by Edmund Pellegrino, it asks what are the means that are most conducive to the attainment of these ends (or some of these ends)? The main conclusions are that curricular reforms must be made to ensure appropriate training of students of medicine and that the hidden curriculum is far too important to be ignored if changes are to take place and if moral erosion of physicians is to be avoided. In addition to curricular reforms, there is a need to work with veteran physicians who should serve as role models and mentors in an appropriate institutional culture, hence, there is a need for what I term a “post-flexnerian revolution”. In addition to teaching students the basic sciences and skills necessary for the making of a successful physician, medical schools ought to concentrate on attempting to produce graduates that are virtuous physicians, who will do the right thing even when no one is looking. If adequate training in virtue and goodness takes place, doing the right thing will become a second nature and the moral ends of medicine will be met.

Personal autonomy is often lauded as a key value in contemporary bioethics. In this thesis, I aim to provide a rationalist account of personal autonomy that avoids the philosophical flaws present in theories of autonomy that are often invoked in bioethics, and that can be usefully applied to contemporary bioethical issues. I claim that we can understand the concept of autonomy to incorporate two dimensions, which I term the 'reflective' and 'practical' dimensions of autonomy. I suggest that the reflective dimension pertains to the critical reflection that agents must carry out on their motivating desires, in order to be autonomous with respect to them. I begin by rejecting prominent desire-based and historical accounts of this dimension of autonomy, before going on to defend an account based upon a Parfitian analysis of rational desires. Following this analysis of the reflective dimension of autonomy, I argue that autonomy can also be understood to incorporate a practical dimension, pertaining to the agent's ability to act effectively in pursuit of their ends. I claim that recognising this dimension of autonomy more comprehensively reflects the way in which we use the concept of autonomy in bioethics, and makes salient the fact that agents carry out their rational deliberations in the light of their beliefs about what they are able to do. I go on to argue that this latter point means that my account of autonomy can offer a deeper explanation of why coercion undermines autonomy than other prominent accounts. Having considered the prudential value of autonomy in the light of this theoretical analysis, in the latter half of the thesis I apply my rationalist account of autonomy to a number of contemporary bioethical issues, including the use of human enhancement technologies, the nature of informed consent, and the doctor-patient relationship.

Drawing on the classification of expertise developed by Collins and Evans, this study explores the expertises held by members of NHS Research Ethics Committees (RECs) and how they differ from the ones described by the regulations. The study used Q methodology followed by ten semi-structured interviews with Lay and Expert REC members. The results show that committee members see themselves as part of a team, with individual members making different contributions to a collective task. Viewing REC members in this way allows their different expertises to be formally recognised and leads to the creation of two new membership categories, specialist and generalist, based on these expertises. Specialists have expertises such as statistics and pharmacy that are required by the current legislation and which would be present on recruitment. Generalists possess the other expertises needed by the committee but which not required by statute. These include the clinical expertises possessed by healthcare professionals and the other professional expertises – legal, academic, IT and so on – that are typically found amongst those currently classed as Lay members. All REC members, be they specialist or generalist, would also be trained in the ethical and regulatory expertises required to deliver an ethical review. Emphasising how all REC members, whether specialist or generalise, have expertises that contribute to the ethical review enables recruitment activities to focus on the skills needed by the committee rather than current concerns with population demographics. This provides a solution to many of the recruitment issues identified by participants. In particular, it enables the replacement of skills on a ‘like for like’ basis using clearly defined person specifications. Not only would such a process comply with the Nolan principles it be more likely to maintain the integrity and function of the committee regardless of personnel changes.

Particularism challenges the accepted idea of normative moral theory that morality can be reduced to a finite set of fundamental principles; it sees morality as quite capable of getting on without such principles. This thesis is concerned with asking what, if any, changes would be required in the practice of medical ethics if this is correct. It is proposed that current guidelines for professional clinicians and medical scientists constitute a “fleshed out” normative system which provides pro tanto rules for ethical practice. To investigate the implications of this in a particularist world, the idea of thin and thick moral concepts is extended to cover moral principles so that generalist professional guidance is seen as constituted of thick principles. This guidance aims to provide the required confidence for the doctor-patient relationship and in particular for the trust required between doctor and patient. Examples of the development of protocols for early phase clinical trials in cancer, and of resource allocation in a resource limited system are used to investigate the difference in decision making, and thus in the decisions themselves, between generalist and particularist professionals. In a generalist world trust is placed in the systems of trustworthiness (practice guidelines etc) and thus in the developers of such systems; in a particularist world moral decisions are made by the clinician and so trust is placed much more directly in that clinician. The implications of this analysis are that under particularism medical ethical training (initial and continuing) would focus more on the development of moral character of the various professionals and less of following guidelines. The complexity of modern medicine implies that such guidelines would still be required, but they would no longer represent pro tanto duties, but rather ceteris paribus advice.

Previous research has noted that members of research ethics committees are unclear about the extent of their roles. In this study, research amongst members of independent ethics committees (IECs) about how the ‘expert’ and ‘lay’ roles are understood and operationalized offers an explanation for this lack of clarity. IECs were selected for study because they have only addressed one type of research (Phase 1 ‘healthy volunteer’ studies) and this limited remit suggested that it would be in such committees that the member roles would have become most pronounced. Drawing on findings from the sociology of professions and employing a phenomenological approach to understanding, 20 semi-structured interviews with both expert and lay members of these committees revealed that a number of members were not only unclear about the roles, but unclear too whether they, or certain of their colleagues, were in which membership category. Notwithstanding this fact, and paradoxically, the ‘expert’ designation was seen as granting its members a privileged position on the committees. The expert member was seen to be either a medically qualified member or one tightly associated with the medical model. Such a repository of expertise being with the medical model privileges this model in ethics review such that other matters formally to be scrutinized by ethics committees become marginalised. Participant safety was the prime concern of the ethics review for IEC members. This relegated other matters including the adequacy of the insurance arrangements, the readability of the consent forms, the fairness of the inclusion criteria, and so forth, into areas of lesser concern. That this occurs though when the science, the safety and the methodology of the trials are already – separately - subject to an independent analysis by a body of experts, whose statutory role is to concern itself with these issues such that no trial may occur without their sanction, is of significance. IEC members were cognizant of this duplication of role but unable to resolve it. The situation could be accounted for as due to capture by the medical model and a cognitive dissonant process. Members’ training and education were found to have been neglected because under the medical professions’ gaze no other type of knowledge was considered necessary in ethics review. The study revealed that the medical profession’s dominance of such committees accounts for the members’ role uncertainty and as such allies itself to Freidson’s theory of professional dominance. If such a concept has been thought to be an obsolete one, this study suggests such a notion of the status of the theory is premature. The medical model’s status is implicitly accepted such that nothing else need be considered. The research calls for further studies to corroborate such findings in other research ethics settings and for a debate about what society wants its ethics committees to focus upon in their review.

This thesis addresses enhancement technologies and their ethical permissibility through a contextual, bottom up approach based on case studies. The first chapter presents various definitions of 'enhancement', arguments for and against, and discusses the therapy/enhancement distinction. The second chapter discusses applying genetic technologies from bendh to bedside, analysing: the objections to reprogenetics grounded in 'eugenics'; and, how pre-implantation genetic diagnosis (PGD) and other embryonic genetic screening techniques, as well as genetic tests sold online directly-to-the-consumer (DTC) to measure children's athletic potential raise a conflict between parental reproductive freedom and children's rights to an open future and capacity for self-determination. Chapter 3 turns to how genetic technologies are translated directly from the molecular medicine laboratory to "track & field," analysing: the scientific and regulatory context of gene enhancement, and on which basis it is classified as doping; how the International Olympic Committee and the International Association for Athletics Federation incorrectly consider hyperandrogenism an unfair advantage; and, the World Anti­ Doping Agency Code and its current revisions. Chapter 4 discusses enhancements in a democratic society, and addresses the neglected issue of justifying enhancement research (ER). I propose: a model in which cognitive enhancements, currently prescribed under a 'disease' model, could instead be prescribed under an 'enhancement' model; and, a possible justification for ER that translates the ethical criteria justifying clinical research to the enhancement context. I then consider possible changes society would need to implement to accommodate ER. The last chapter attempts to advance the discussion of enhancement by shifting the debate from ethics to policymaking, arguing for a deliberative democracy approach. Throughout, I adopt a casuistic approach to ethics, deploying tools from consequentialist, principled and virtue ethics. I try to break the stalemate between enhancement's proponents and opponents, and discuss the ethical permissibility of technologies in ways that could inform policymaking.

The collection, storage, export and use of human biological samples are important research practices in international collaborative research. However, the limitations of current ethical and regulatory frameworks to govern these research practices have resulted in inconsistencies in practice and a number of ethical concerns for researchers, research institutions and research ethics committees (RECs). The aim of this thesis was to contribute to an empirically-informed understanding of the ethical issues arising in the export, storage and future uses of human biological samples from sub-Saharan Africa (SSA). The thesis is based on an empirical bioethics project to examine stakeholders' perspectives of and responses to the ethical issues arising in these research practices. I employed a qualitative strategy of inquiry involving document review, observations, semi-structured interviews and focus group discussions with key stakeholders in Nairobi and Kilifi in Kenya and Navrongo and Accra in Ghana. The project suggests that the ethical issues arising from the use of human biological samples depends on the nature of interactions between key stakeholders in biomedical research. Despite the compelling reasons for sample export, storage and use, and the existence of structures governing these research practices, the stakeholders I interviewed expressed several practical ethical concerns. These relate to consent, cultural sensitivities around blood, local control of samples, power-relations, capacity building and trust-relationships. Drawing on these findings and existing literature, I argue that host research institutions bear the ultimate responsibility for the ethical conduct of research and should act as responsible stewards of research samples. I argue that it is important to refocus attention on important values in international research ethics such as trustworthiness to address the issues arising in practice. Recognising the limitations of current governance mechanisms and the uncertainties surrounding future uses of samples, I propose an entrustment framework to strengthen relationships between communities and host research institutions on one hand and between collaborating research institutions for research involving human biological samples in Africa. I also propose a set of 'points-to-consider' for research institutions, ethics committees and funding agencies.

This thesis offers a social theoretical development of Bourdieu' s habitus in order that it might be used to 'take education seriously'. It is conducted from within the later Wittgenstein's view of language and according to a Winchean methodology for 'doing social theory'. The context used for this theoretical exercise in UK medical education, particularly ethics education. The first aim of the thesis is to develop a more cognitive aspect to the habitus and to this end I draw on the idea of 'thinking dispositions.' I argue that 'thinking dispositions' should be considered the product of enculturation rather than socialisation and that former is implied by Bourdieu's construal of this latter process as a 'collective process of inculcation.' I then give a historical account of the development of medical education in the UK over the past 30-40 years making particular reference to the General Medical Councils document Tomorrow's Doctors (1993, revised 2003, 2009). Subsequentially I return to the more theoretical ground which is the central concern of this thesis and attempt to give more definition to the idea of a cognitive habitus through a consideration of the reflective practice and education of medical professionals, the concept of meta-cognition (drawn from science education research), and the idea of a cognitive apprenticeship emerging from socio-cultural learning theory, a branch of Vygotskian psychology. The final chapter returns to Bourdieuan grounds and considers the relationship between enculturation, a cognitive apprenticeship and the habitus. In the conclusion I consider some reflexive implications of my thesis for medical ethics education delivered as part of a medical education and for applied ethics considered as a branch of philosophy which seeks to extend its insights beyond its disciplinary borders as, for example, in medical ethics education.

To date research exploring the nature of ethical deliberations and decision making by healthcare teams has been largely ignored. However studying inter-professional approaches to ethical dilemmas may be valuable in offering insights into the processes of shared decision making and how such problems are addressed. Aim To investigate whether healthcare professionals working in teams embrace ethical and philosophical principles in their decisions. A secondary aim was to construct a model for ethical education informed by study data. Design A multi-methods approach comprising of a comprehensive review of the literature focus group interviews and a survey. Sample/participants A total of 112 healthcare personnel representing 15 disciplines were recruited from four large teaching hospitals within the Southwest region. Recruitment was through a lead consultant in each team who distributed invitations, participant information sheets (that outlined the study) and consent forms. Data collection Following ethical approval, 14 clinical teams were presented with profession specific vignettes and invited to engage in a facilitated discussion. Each team's interactions and decisions were tape recorded. Individuals also completed a modified version of the Decisional Conflict Scale (O'Connor 1995) to elicit their degree of comfort with decision making processes. Data analysis The transcripts from the 14 focus groups interactions were thematically analysed by employing Boyatzis (1998) model. Numerical data from the Decision Conflict questionnaire (DCQ) were entered into SPSS software for descriptive statistical analysis. Results The survey and the focus group data indicated that practitioners experienced varying degrees of conflict with the decision making process and displayed limited articulation and evidence of ethical principles that could be mapped to existing theories or methods. Participants did however employ strategies and shared expertise to overcome imposed restrictions through compromised solutions. The research identified eight key areas for consideration in the decision making process and these areas were developed to create a model for future ethics education and framing of ethical debate. The concept of restricted beneficence was also identified as being an over arching consideration in this area. The DCQ also highlighted that particular elements of the decision making process caused more concern but it highlighted that the team members opinions were valued and this supported the qualitative findings which identified evidence of a team ethos and value system. Conclusion The teams employed a very pragmatic approach to decision making within an environment that reflected the notion of restricted beneficence. It is suggested that the integration of such strategies ethical education this may result in a more practically relevant approach and enrich the quality of reflective debate in this area.

Xenotransplantation centres on the potential of transgenic animal tissues for a range of transplant therapies in the treatment of human pathologies. This thesis focuses on the sociocultural and political aspects of this technology and takes account of its transgressive and hybrid nature and the way it destabilises the human/animal, science/politics boundary. Following a critical Public Understanding of Science (cPUS) approach, a qualitative dialogue on xenotransplantation was conducted with the lay publics in Ireland. This thesis presents their account of xenotransplantation 'politics' and focuses particular attention on the social cultural, moral and political dimensions shaping their perspectives. A moral economy around xenotransplantation was shown to be taking place, formed by prevailing concerns with human bodily ageing, illness and death and in a desire to reproduce human life and the enhancement of health. Promissory expectations were also directed at the potential of xenotransplantation to overcome the emotional challenges associated with human tissue exchange and in the provision of a more scientific and commercially driven transplant service. Anthropocentric relations with animals, transplantation politics and hope were all central elements driving the innovation pathway of mobilising consumer markets and animals as new forms of tissue capital. Within the emerging moral economy were also several sites of tension around the threat of human-animal transgression and hybridity, which exposed a more contested subjective investment in animal transplantation. This thesis presents the salient theoretical and professional debates around the transformations and their implications taking place in human bodily relations, health, human-animal relations and cultural transplant politics. RecOlmnendations for how these issues might be accounted for in future bio-ethical governance and policy debates are outlined, together with a consideration of how greater sustainability might be fostered in human transplantation. Some political recommendations are also directed at revitalising scientific governance in Ireland

Biobanks pose unique challenges to legal and bioethical frameworks, and raise many as yet unanswered questions, including how these collections of biological samples and information should be governed and for whose benefit. While some commentators have suggested that biobanks should be regulated through specific legislation, I focus on exploring alternative models of governance. I examine, in particular, the interrelationship between benefit-sharing and public engagement, arguing that public engagement is a benefit in itself, valuable both in its own right and as an essential component of good governance, and critically examine proposals for more direct 'representative‘ forms of participant involvement and 'power-sharing‘ arrangements in the biobanking context. Central to my arguments is the concept of the "common heritage", which has been invoked by UNESCO and HUGO in relation to the human genome. From its early beginnings in the law of the sea, this concept has been linked to notions of solidarity, reciprocity and equitable access and sharing. Applied in the context of biobanks, the "common heritage" highlights the value of genetic collections and research for the benefit of present and future generations. Viewed as a third generation human right, the "common heritage" also links to notions of citizenship, civic involvement in policy processes and, ultimately, to participatory or deliberative democracy. From this, I suggest that robust biobank governance mechanisms require not only effective benefit-sharing arrangements but that these must necessarily involve provision for effective public engagement. Drawing on democratic and business management theory, I argue for a 'stakeholder' model of governance. This model draws its basic ideology from communitarian philosophy and regards any organisation (whether it be a corporation or a charity) as a 'social entity', accountable to a broad range of stakeholders. It is my contention that a stakeholder model is the most appropriate model of governance for large-scale population biobanks, such as UK Biobank, which are designed for public benefit, to enhance the health of all, including future generations. In sum, it is a model through which the common interest vested in biobank research might materialise.

In England, medical, nursing and other healthcare professions are required by their codes of professional ethics to have a working knowledge of moral principles and to be able to apply them in practice. Little, if anything, is said explicitly by these professions about the virtues. However, much is said about the character of the doctor or the nurse, and their supposed ability to recognise moral issues in their professional work and make morally good decisions. Edmund Pellegrino has questioned the appropriateness of applying moral principles to medical practice in contemporary times without a firm foundation. He attempts to restore the moral foundation of the profession of medicine, by restricting an account of the good to the profession which he claims, unlike ethics in general, there can be agreement on norms. From this position, moral principles in medical ethics can be justified, agreed upon, and provide firm action guidance in practice, as well as provide an independent ground for medical virtues. I will claim that Pellegrino's concern about disagreement and a loss of norms in ethics in general is not resolved in the restricted field of professional medical ethics and that his understanding of principles and the link with virtue is confused. Then, using virtue terms Pellegrino himself thinks necessary for making good decisions in practice, I will show how a certain account of the virtues can provide a plausible account of how we can become good healthcare workers and so support Pellegrino's goal; though it will not support his confidence in supplying both clear, moral, and normative constraints in a code of professional medical ethics and firm decision-making in practice.

Biomedical ethics has been dominated for over three decades by the central principles of autonomy, beneficence, nonmaleficence, and justice. These form the pillars of the principles- based ethical framework developed and promoted by Tom Beauchamp and James Childress. Despite its dominance, this framework for bioethical thinking, discourse, and decision-making has been widely criticized by bioethicists from many belief traditions. Such criticism has often focused on its minimalist preoccupation with procedural clarity, its lack of moral content, and its inattentiveness to relational aspects of biomedical ethics. For Christian bioethicists, its lack of grounding in Scripture and in the relationship between God and humankind are particularly problematic. Some Christian ethicists have suggested that the biblical notion of covenant gives normative direction to medical relationships as well as extratemporal, presuppositional grounding for meaningful bioethical thinking and action. The biblical covenantal theme describes the relationship that God established with human beings at creation as one that is a common relational link for all human relationships. Just as God offered his gift of covenantal promise and binding relationship in return for obedience to him, human relationships can develop and flourish if modeled after such covenantal giving toward fellow human beings. A biblical covenantal ethic recontextualizes bioethical principles within the relationality inherent in medicine. Patient autonomy is transformed into birelational sensitivity and giving, beneficence becomes a principle of care as the core of medicine, the minimalist necessity for nonmaleficence disappears, and justice is grounded in the claim that every human being deserves selfless care as an image-bearer of God. This covenantal ethic can fulfill the search for covenantal relationships in medicine, providing deeper understanding of true beneficence by meeting the needs of other vulnerable human beings.

This study explores the complexities of implementing an interdisciplinary and intercultural medical ethics amongst Taiwanese doctors both in clinical and educational contexts. The purpose, theory, and strategy of doctors' teaching, learning, and practice of medical ethics are sophisticatedly constructed by interviewing 25 local stakeholders and analysing some relevant documents published worldwide. This constructivist qualitative research aims to generate practical insights into how to improve doctors' practice in a new pluralistic Taiwan nowadays. To achieve the aforementioned research aim, the purpose of why non-Western doctors must learn and exercise medical ethics beyond profession and tradition is first addressed. By delineating local doctors' cognitive bewilderment and situational vulnerability in face of the diversity of moral standpoints, a proposition emerges: doctors' learning of normative information is to equip and empower them to practise from a simplistic and rigid manner towards a holistic and sophisticated manner. To specify the meaning of doctors' holistic and sophisticated practice, six kinds of learning milestones of doctors' moral accomplishment are identified and then integrated as a whole within the notion of ethics as empowerment. I argue that by developing various kinds of knowledge, reasoning, skill, competency, habituation, and attributes, doctors can balance between the global and the local, the ideal and the practical, the thinking and the doing. However, such theoretical framework is not proposed for direct generalisation, but for demonstrating the richness of doctors' learning In ethics. To further translate the aforementioned sophisticated learning model into a teaching strategy, I first concentrate on the issues of doctors' power, knowledge, and role. I then argue that doctors' power can be self-limiting by inspiring them with moral philosophy so that a reflective ethical understanding can be gained. I also argue that doctors' knowledge can be holistic by equipping them with academic reasoning capacity. I finally argue that doctors' role can be communal by empowering them with explicit professional duties so that their commitment to patients' welfare can be fulfilled. My thesis offers an alternative perspective, which I argue is practical and holistic, for local practitioners, teachers, and policy-makers to embrace the arising global, multi-disciplinary, and reasoning-based medical ethics.

This study challenges the primacy of consent in the history of human experimentation and argues that privileging the cultural frameworks adds nuance to our understanding of the construction of the volunteer in the period 1945 to 1970. Historians and bio-ethicists have argued that medical ethics codes have marked out the parameters of using people as subjects in medical scientific research and that the consent of the subjects was fundamental to their status as volunteers. However, the temporality of the creation of medical ethics codes means that they need to be understood within their historical context. That medical ethics codes arose from a specific historical context rather than a concerted and conscious determination to safeguard the well-being of subjects needs to be acknowledged. The British context of human experimentation is under-researched and there has been even less focus on the cultural frameworks within which experiments took place. This study demonstrates, through a close analysis of the Medical Research Council's Common Cold Research Unit (CCRU) and the government's military research facility, the Chemical Defence Experimental Establishment, Porton Down (Porton), that the `volunteer' in human experiments was a subjective entity whose identity was specific to the institution which recruited and made use of the subject. By examining representations of volunteers in the British press, the rhetoric of the government's collectivist agenda becomes evident and this fed into the institutional construction of the volunteer at the CCRU. In contrast, discussions between Porton scientists, staff members, and government officials demonstrate that the use of military personnel in secret chemical warfare experiments was far more complex. Conflicting interests of the military, the government and the scientific imperative affected how the military volunteer was perceived.

This project is an investigation of the issue of human biomedical enhancement, taking human growth hormone as a case study. Growth hormone is mainly used to increase the adult height of short children, and is also employed illicitly as an anti-ageing treatment. Both these applications are viewed by bioethicists as going beyond the scope of therapeutic medicine by enhancing normal human traits rather than treating diseases and as such are considered ethically suspect. This project adopts a comparative and retrospective stance, examining the socio-historical development of human growth hormone in the US, where much of the impetus for enhancement uses has originated, and also in the UK where the potential for enhancement uses of pharmaceuticals and other medical technologies is a growing concern. This project combines a social constructivist approach to bodies and disease categories with science and technology studies theory on the emergence and shaping of new (medical) technologies. Research focuses on the development of growth hormone as a medical technology and the construction of the diagnostic categories that define the illness it is employed to treat. A combination of archive material and contemporary interview data is used to investigate and identify factors that shape the way some applications of hGH have come to be viewed as legitimate, accepted practices while others remain unstable and controversial. Enhancement suggests an inappropriate use of biomedicine, but in the case of growth hormone at least, the determination of medical need and entitlement is shown to be more than a matter of instrumental measurements. It is a contingent and socially shaped procedure that is applied in heterogeneous ways at different sites in the networks of healthcare provision. This technique provides a different model for thinking about those biomedical practices labelled as enhancement, which does not share the limitations of that framing.

The sequencing of the entire human genome has opened up unprecedented possibilities for healthcare, but also ethical and social dilemmas about how these can be achieved, particularly in developing countries. This thesis examines two of the several international responses these dilemmas have spawned: the suite of declarations on genetics and bioethics adopted between 1997 and 2005 by the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the Global Genomics Initiative proposed by the Toronto Joint Centre for Bioethics (TJCB). Through these initiatives, UNESCO and TJCB hope to promote the ethical governance of genetic and biomedical research, which is often conducted on an international basis. The thesis draws on interview, documentary and observational data, collected in Kenya and South Africa and from UNESCO, to assess the actual and potential efficacy of these two governance mechanisms, in terms of protecting individual research participants and reducing inequalities of health between North and South. It analyses the negotiation and subsequent implementation of the UNESCO declarations at international and national levels and the plans to date for the Global Genomics Initiative. Using as a conceptual framework particular branches of international relations theory concerned with global governance-namely regime theory, networked governance and cosmopolitan democracy-the thesis finds that determining where the balance of power between different actors should lie and, moreover, how this balance can be achieved is complex and difficult in international decision-making fora. Furthermore, the effective implementation of any regulations, policies or programmes there decided upon requires co-ordination among different sectors and organisations, across international and national levels. The thesis concludes that the UNESCO declarations on genetics and bioethics might provide a means to effect such a system of governance, if supported by networks of stakeholders both within and between states, perhaps through the proposed GGI.

In this thesis I examine the medical concept of informed consent and the philosophical concept of autonomy in conjunction with the relationship between them. This examination is complicated because autonomy can refer to decisions or persons. Further autonomy may have instrumental or intrinsic value. These differences mean autonomy may be respected in different ways. This examination is further complicated because whilst a vast wealth of medical literature exists on informed consent and mentions autonomy, very little of this literature does more than mention autonomy. As a result of my examination I argue for the following. Firstly I argue the form of autonomy underlying informed consent should be personal autonomy and to respect autonomy means accepting autonomous decisions. Secondly I show in certain contexts a surrogate decision maker cannot make a decision on behalf of an incompetent patient that would be generally agreed to be in his best interests. I will argue in such contexts a patient’s decision should always be accepted as the concept of competence becomes detached from the concept of informed consent. Thirdly I show a patient may make an autonomous decision based only on understanding the purpose of the procedure he is consenting to. I will argue it follows a patient should not be required to understand details of the nature of the procedure he is consenting to for his consent to be accepted. Fourthly I argue an autonomous decision must be one an agent identifies with and has some persistence. I will show these conditions are satisfied by an autonomous agent’s absence of restlessness to change his decision Lastly I argue informed consent decisions should be linked to a patient’s ability to understand the risk involved in his decision and not directly linked to the degree of risk involved in his decision.

The introduction of the new Glasgow medical curriculum provided an opportunity for evaluation of ethics education in the context of a modern curriculum.  The constraints imposed prevented a comprehensive evaluation of ethics teaching in the new curriculum.  Its focus had to be narrowed. This thesis builds on a dissertation submitted for a MMEd Degree at Dundee University, which covered the evaluation of ethics education in the first year of the new curriculum and produced the first three papers in the series being presented. It was decided to perform both process and outcome evaluation in year 1, where the largest proportion of formal curricular ethics sessions takes place.  Outcome evaluation continued throughout the curriculum.  The aims of the first year process evaluation were: 1) To judge the value of the curricular experiences provided for students in terms of: a) Acceptability to both students and tutors.  b) Feasibility.  c) Relevance of material to aims of teaching. 2) To judge the effectiveness of clinical tutors as facilitators of learning. The aim of the outcome evaluation was to test the following hypotheses: 1.  Small group ethics teaching, in the first year of an integrated medical curriculum, will have a positive impact on students’ potential behaviour when facing ethical dilemmas. 2.  The effect will be greater than that produced by a discrete lecture and large group teaching based course early in a traditional curriculum. 3.  Students’ performance will be adversely affected as they progress through the medical curriculum. 4.  The effect will be less pronounced in students undertaking the modern curriculum compared to those undertaking the traditional curriculum.

Terminal illness and the prospect of a painful and protracted dying process created new medical realities for Western culture in recent decades. Patients challenged traditional medical canons against medical killing by requesting changes in laws to allow physician assistance with suicide (PAS). This challenge occurred within a broader cultural context where core principles of medical common morality (beneficence, patient autonomy, and justice) were questioned. A new study of medical killing is warranted because ethical changes are occurring in current issues surrounding doctors and patients (for example, humanism and autonomy, rights, justice, and the morality of medical killing). Furthermore PAS proponents argue that sometimes there is a moral obligation for beneficent medicine to allay suffering; that is, a doctor must kill or assist his patient's suicide. This thesis explores the possible influence that John Stuart Mill's hedonistic-utilitarianism (HU) exerts on one aspect of medical killing, the philosophy and practice of PAS. This study clarifies certain features of the PAS debate and demonstrates weaknesses inherent in HU that impact adversely on medical canons and doctor-patient relationships (DPR). Six features within the PAS debate are examined for HU influence. Chapter 1 delineates how Mill's key utilitarian pleasure-is-happiness (PH) theme interacts with the topic of PAS in contemporary medico-cultural discussions. Chapter 2 surveys some epochal events in the development of rights, justice, and medical killing, while chapter 3 surveys similarly autonomy, physician paternalism, and sanctity of life (SL)~all in relationship to PAS. The final chapter isolates key HU weaknesses found in PAS arguments and offers moral concerns regarding the utilisation of HU claims to justify changing traditional medical canons to endorse PAS. The thesis contributes to the ongoing medical-ethical dialogue about medical killing by exploring the historical and ethical points crucial to future discussions of medical killing.

Illness creates a range of negative emotions in patients including vulnerability, powerlessness and dependence on others for help. The nursing literature is saturated with debate about a 'therapeutic' nurse-patient relationship. However, despite the current agenda regarding patient-centred care, literature concerning the development of good interpersonal responses and the view that a satisfactory nursing ethics should focus on persons and character traits rather than actions, nursing ethics is dominated by the traditional obligation, act-centred theories such as consequentialism and deontology. I critically examine these theories and the role of duty-based notions in both general ethics and nursing practice. Because of well-established flaws, I conclude that obligation-based moral theories are incomplete and inadequate for nursing practice. Instead, the moral virtues and virtue ethics provide a plausible and viable alternative for nursing practice. I develop an account of a virtue-based helping relationship and a virtue-based approach to nursing. The latter is characterized by three features: (1) exercising the moral virtues such as compassion and courage, (2) using judgment and (3) using moral wisdom - moral perception, sensitivity and imagination. Merits and problems of this approach are examined. Following Macintyre, I conceive nursing as a practice; nurses who exercise the virtues and seek the internal goods help to sustain the practice of nursing and thus prevent the marginalization of the virtues. The strong (action-guiding) practice based version of virtue ethics proposed is context-dependent, particularist and relational. Several areas for future philosophical inquiry and empirical nursing research are suggested to develop this account yet further.

The patent law morality criterion has become the focus of much attention as the central means of questioning the social implementation of modern applications of biotechnology. In consequence, the precise nature of this legal provision has become the source of much speculation and contention. This thesis assesses the meaning of the provision and whether the morality criterion represents a clear, reliable and valid mechanism for examining human and animal biotechnology within a patent law context. It also considers alternative approaches to regulating morality through this legal provision and whether they can be operated by the European and UK patent systems justifiably and transparently in comparison with present practice. This thesis contends that biotechnology is capable of being regulated, meeting all of the requirements placed upon public decision-making, but that it must adopt an amended form to that currently practised by the European Patent Office. While the 'morality' criterion currently prescribes the point at which the assessment occurs, the facets of the innovation which are assessed, that the evidence considered cannot be limited solely to legislation and arguably that morality cannot have any boundaries to proscribe the analysis, it omits the essential parameters for making a moral assessment. Consequently, this thesis identifies that an 'abhorrence' standard, utilising a 'rebuttable presumption' methodology and the widest range of evidential sources, in some instances extending to public opinion polls/surveys, would lend important validity to current practice as well as meeting the needs of regulating biotechnology through patent law.

This thesis emerged from a long-standing interest in healthcare ethics and professional education and is the result of conceptual and literature-based research. It began with: a nagging doubt about the possibility of teaching professional ethics; with an interest in the gap between what is known and what is done; with an awareness that the A grade ethics student is not necessarily the exemplary nurse or doctor in practice; and with an idea that virtue ethics might be the answer. Two central and related issues are addressed: (1) ethical values and perspectives which are necessary components of healthcare ethics and (2) the implications of, and strategies for, promoting these ethical values and perspectives in the education of health professionals. Changes within healthcare and in society urge an ongoing consideration and reevaluation of ethical values in healthcare and professional education. Contemporary approaches to health professional ethics have, for the most part, focused on duty, consequences, principles and, more recently, on rights. Such obligation-based approaches are primarily concerned with action and the cognitive realm with too little regard for the emotions and character. It will be argued that virtue ethics, which focuses on the character of the professional, goes some way towards correcting the rationalist and externalist bias of predominant approaches to healthcare ethics. A wide array of ethical values, have been described and discussed as characterising healthcare ethics. One of the most well-known perspectives is that of Beauchamp and Childress (2001) who elucidate four biomedical ethical values, what they call principles, of autonomy, beneficence, non-maleficence and justice. Beauchamp and Childress identify but elaborate little on the virtue correlates of these principles: respectfulness, benevolence, non-malevolence and justice. In this thesis, the virtue of respectfulness will be developed. It will be argued that respectfulness and selfrespectfulness are necessary healthcare values. Respectfulness is considered both initself and as respect-for: in relation to dignity and autonomy. Respectfulness also goes some way to reinforcing and encompassing other values: if the dignity and autonomy of people are respected they will be benefited rather than harmed and they will be treated fairly. Whilst self-respectfulness and respectfulness are necessary health professional virtues, they are not sufficient. Two further necessary virtues will be discussed in relation to the health professions: courage and practical wisdom. The more holistic approach to ethics proposed in this thesis requires attention to: technical-rational ('hard, high ground') and professional artistry ('swampy lowlands') perspectives on healthcare; to 'whole person' and common human experience perspectives; to rationality and the emotions; to action or conduct and character; to obligations and virtues; and to empirical and theoretical ethics. These aspects should be considered in professional education. It is argued that the development of ethical competence is the overall purpose of professional ethics education. The model of ethical competence proposed comprises: ethical knowing; ethical seeing; ethical reflection; ethical doing; and ethical being A draft curriculum is suggested regarding how ethical competeiice might be promoted.