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The use of artificial intelligence (AI) in healthcare comes with opportunities but also numerous challenges. A specific challenge that remains underexplored is the lack of clear and distinct definitions of the concepts used in and/or produced by these algorithms, and how their real world meaning is translated into machine language and vice versa, how their output is understood by the end user. This "semantic" black box adds to the "mathematical" black box present in many AI systems in which the underlying "reasoning" process is often opaque. In this way, whereas it is often claimed that the use of AI in medical applications will deliver "objective" information, the true relevance or meaning to the end-user is frequently obscured. This is highly problematic as AI devices are used not only for diagnostic and decision support by healthcare professionals, but also can be used to deliver information to patients, for example to create visual aids for use in shared decision-making. This paper provides an examination of the range and extent of this problem and its implications, on the basis of cases from the field of intensive care nephrology. We explore how the problematic terminology used in human communication about the detection, diagnosis, treatment, and prognosis of concepts of intensive care nephrology becomes a much more complicated affair when deployed in the form of algorithmic automation, with implications extending throughout clinical care, affecting norms and practices long considered fundamental to good clinical care.

Over the last decades, the face of health care has changed dramatically, with big improvements in what is technically feasible. However, there are indicators that the current approach to evaluating evidence in health care is not holistic and hence in the long run, health care will not be sustainable. New conceptual and normative frameworks for the evaluation of health care need to be developed and investigated. The current paper presents a novel framework of justifiable health care and explores how the use of artificial intelligence and big data can contribute to achieving the goals of this framework.

In 2002 with the passing of the Euthanasia Law, Belgium became one of the few countries worldwide to legalize euthanasia. In the 18 years since the passing of the law, much has changed. We argue that in Belgium a widening of the use of euthanasia is occurring and that this can be ethically and legally problematic. This is in part related to the fact that several legal requirements intended to operate as safeguards and procedural guarantees in reality often fail to operate as such. We focus on three kinds of safeguards or procedural guarantees: (1) the legally defined due care criteria for eligibility for euthanasia; (2) the consultation of a second (and sometimes third) physician; and (3) the reporting of euthanasia cases to the Federal Control and Evaluation Commission for Euthanasia. We will show how each of these three safeguards can exhibit shortcomings in theory and practice.

This article explores whether 'digital pills' that track medication intake should be used to enhance adherence. We concentrate on psychiatric conditions since these pose unique challenges. We analyze two public policies that potentially encourage the development of systems for remote monitoring of intake, namely the granting of patents and marketing authorization, and identify key stakeholders and their main interests so as to discuss whether these policies provide disproportionate benefits to some. The stakeholders identified are patients, system providers, drug manufacturers, insurers or healthcare systems, physicians, data users, and society at large. We discuss relevant industry reports, regulatory data, patent documents, and academic literature, and argue that there is concern that the drivers for these tracking systems are revenue and the monitoring of 'compliance' rather than 'adherence'. While accepting that the use of these systems can be justified in some circumstances, in our view these systems pose risks to patient autonomy, Shared Decision-Making, and privacy. We also find that policies on granting patents and marketing authorization overly favor the commercial actors and put patients' interests at risk. Accordingly, we propose that additional safeguards are required.

We express our sincere thanks to all those who submitted comments on our article and to the editors of AJOB for allowing us to comment in reply.Boggio and Ho’s (2018) comment is centered on the “hu...

Bedrijven kunnen medische gegevens halen uit verschillende bronnen: Facebook-berichten, aankopen met kredietkaart, inhoud van e-mails of recent bekeken video’s op YouTube. In principe houden deze gegevens geen verband met de gezondheidstoestand van de gebruiker. Kunstmatige intelligentie-instrumenten en “big data”-algoritmen kunnen betekenisloze informatie evenwel omzetten in gevoelige medische gegevens. Deze “emergent medical data” of “onverwachte medische gegevens” bieden mogelijke voordelen, zoals de opvolging van de verspreiding van een besmettelijke ziekte, de identificatie van mensen met een risico op suïcide of moord en drugmisbruik. De belangrijkste aantrekkingskracht voor organisaties van de toenemende beschikbaarheid van medische gegevens is de mogelijkheid tot gedragsgerichte “targeting” (ook “nudging” genoemd) en de optimalisatie van de klantprofilering en de marketing. Vaak gebeurt dit zonder expliciete instemming van de eigenaar van de gegevens. Algoritmen ontwikkeld op basis van niet-gevalideerde medische gegevens kunnen leiden tot minder nauwkeurige diagnostische en/of voorspellende instrumenten. Gebruikers moeten beseffen dat medisch relevante gegevens kunnen worden afgeleid van hun internetactiviteit. Bijzonder privacygevoelige persoonlijke gegevens komen in een grote gecentraliseerde databank terecht. Op het moment dat de “onverwachte medische gegevens” worden gegenereerd, moet de gegevensverwerker de gebruiker waarschuwen. Een opt-outverzoek moet mogelijk zijn. De op deze manier verzamelde informatie is niet beschermd door de “Algemene Verordening Gegevensbescherming” (AVG), ook gekend als de “General Data Protection Regulation” (GDPR). Deze wet trad in werking in mei 2018. De implementatie ervan verloopt moeizaam, waardoor de privacy en het zelfbeschikkingsrecht van de gebruiker onder druk komen te staan.

Digitalisering en artificiële intelligentie (AI) bieden mogelijkheden om de gezondheidszorg te optimaliseren. Vooral machine learning gebaseerd op neurale netwerktechnologie, waaronder deep learning of gebaseerd op beslisboomtechnologie, worden in die context naar voren geschoven. Succesvolle implementatie van dergelijke algoritmes vooronderstelt inzicht in hun architectuur en werking om ze te kunnen inzetten op de juiste plaats en met realistische verwachtingspatronen. Machine learning algoritmes zijn ideaal voor classificatie en prognosticatie, maar zijn contextgelimiteerd en bezitten geen (klinisch) gezond verstand. De kwaliteit van de datasets is sterk bepalend voor de performantie van de erop getrainde algoritmes. De datasets moeten voldoende representatief zijn om externe validiteit te hebben en mogen bestaande bias, zoals op basis van geslacht, niet versterken. Big data kunnen ook problemen rond privacy, aansprakelijkheid en beroepsgeheim genereren. Men mag ook de klassieke valkuilen niet uit het oog verliezen. Zo zal een lage pre-test probabiliteit aanleiding geven tot een groot aantal fout-positieven, zelfs bij een performant algoritme. Ten slotte zal AI problemen met een ethische dimensie, zoals bv. cut-offs voor triage, nooit kunnen oplossen. Deze paper wil belangrijke basisbegrippen aanreiken die de gebruiker nodig heeft om zinvol te kunnen omgaan met AI in de context van gezondheidszorg.

A wide variety of medications and neuromodulation techniques are being investigated to manage risk factors for deviant behavior. If certain neurointerventions can restore impaired moral decision-making and behavior in offenders, should the criminal justice system be permitted to use such neurointerventions and, if so, under which conditions? In this chapter, the authors argue that it can be ethical to offer neurointerventions to offenders as a condition of probation, parole, or sentence reduction, provided that the fulfillment of five minimal ethical conditions is verified on a case-by-case basis. The authors further argue that forcing neurointerventions as part of an offender’s sentence or as a postprison requirement is both ethically and practically problematic, with the possible exception of benign neurointerventions without side effects.

The European Patent Office Enlarged Board of Appeal was asked in April 2019 to answer two questions regarding the exclusions from patentability under Art. 53 European Patent Convention (EPC), the dominant patent law in Europe. The first related to the manner in which EPC Articles should be interpreted, and the second to whether Art. 53 EPC excluded plants and animals that are the products of the excluded ?essentially biological processes.? Since product claims are infringed by all processes for making the product, the second question was important?if the products are patentable, the exclusion of the processes is rendered meaningless, something which cannot have been the intention of the legislators drafting the EPC. The questions are in case G-3/19 Peppers and the Enlarged Board of Appeal handed down its opinion on May 14, 2020. In this paper we examine the background to this case, the strength of the arguments presented, and the Enlarged Board's decision which we find to dangerously undermine the Article of the EPC, Art. 164 EPC, which requires changes to the principles of what can be patentable to be democratically agreed by the parliaments of the EPC member states rather than by an administrative body of government-appointees.

Eutanazja i wspomagane przez lekarza samobójstwo stanowią niezwykle szeroko dyskutowane zagadnienia, zwłaszcza w kontekście nieznośnego cierpienia psychicznego i emocjonalnego, których doświadczają osoby z zaburzeniami psychicznymi. W Belgii i Holandii prawo zezwala na przeprowadzenie procesu eutanazji/wspomaganego samobójstwa u osób chorych psychicznie od 2002 r. Celem niniejszego artykułu jest przegląd doświadczeń belgijskich i holenderskich oraz wątpliwości, które w ciągu ostatniej dekady pojawiły się w następstwie stosowania rzeczywistych procedur wspomaganego samobójstwa u pacjentów psychiatrycznych. Korzystając z dostępnych danych dotyczących stosowania eutanazji u osób chorych psychicznie, przedstawiono ich ilościową analizę. Ponadto zidentyfikowano różne wyzwania - etyczne, medyczno-psychiatryczne i prawne, które w coraz większym stopniu wpływają i warunkują zmianę postaw w środowiskach medycznych i psychiatrycznych wobec wspomaganego samobójstwa w populacji pacjentów psychiatrycznych.

In the context of debates on (forensic) psychiatry issues pertaining to moral dimensions of (forensic) psychiatric health care are frequently discussed. These debates invite reflection on the question whether forensic practitioners have a role in stimulating patients’ moral development and moral growth in the context of forensic psychiatric and psychological treatment and care. We conducted a qualitative study to examine to what extent forensic practitioners consider moral development and moral growth to be a part of their current professional practices and to what extent they think that stimulating moral development is a legitimate objective in the context of forensic psychiatric treatment. In addition, we asked how forensic practitioners balance pubic safety and risk management concerns with the interests and wellbeing of the individual patient. We conclude that: (i) elements of moral development and moral growth in forensic psychiatric care practices are to a certain extent inevitable and not necessarily questionable or undesirable; (ii) yet, as in similar debates these elements need to be made explicit in order to discuss the accompanying ethical challenges and boundaries. An open academic, professional and public debate on aspects of stimulating moral betterment within current practices is therefore desirable.

Advancements in the field of biotechnology have accelerated the development of drugs that are manufactured from cultures of living cells, commonly referred to as “biologics.” Due to the complexity of the production process, generic biologics are unlikely to be chemically identical to the reference product, and accordingly are referred to as “biosimilars.”Encouraging the development of biosimilars has been presented as the key solution to decrease prices and increase access to biologics, but the development and use of biosimilars continues to raise problems, none of which can easily be addressed. Developing a biosimilar requires considerable time and financial resources, and legitimate safety concerns necessitate elaborate clinical testing of biosimilars. As a consequence, the introduction of biosimilars onto the market has not resulted in significant price reductions, and concerns regarding the substitution and interchangeability of original biologics with biosimilars persist.This article will explain how the biologics production process distorts the trade-offs that traditionally guided both patent protection and regulatory exclusivities: disclosure as a key condition for benefiting from the corresponding monopoly position. Hence, we propose establishing a mechanism of mandatory deposit of the original biologic's cell line at the stage of the regulatory approval as the most effective remedy.

The inclusion of an investment chapter in the Comprehensive Economic and Trade Agreement (CETA) and the Transatlantic Trade and Investment Partnership (TTIP) has encountered significant opposition, especially in relation to Investor-State Dispute Settlement (ISDS). In this context, the EU has proposed several changes to the traditional procedures, including the creation of an investment court. The need to reform ISDS has long been recognised, but the key question remains: What is required for such a dispute settlement mechanism to have legitimate authority? Drawing from insights in legal theory and political philosophy, we examine what could be adequate criteria for the normative legitimacy of ISDS. We argue that ISDS can only be minimally legitimate if there are sufficient procedural safeguards to ensure fair access to the proceedings and equal consideration of their interest for all those affected by investment tribunals’ or courts’ decisions. Furthermore, we emphasize the need to look beyond what potential beneficial and adverse consequences of ISDS are, and explain that the appointment of the judges by the state parties and the reintroduction of some control of the state parties over dispute settlement outcomes are not sufficient to guarantee the normative legitimacy of ISDS.

In a target article (Feeney et al. 2018) in this Journal in 2018, for which we were two of the coauthors, we discussed the problematic nature of the patenting of foundational (bio)technological pro...

Background Notwithstanding fears of overly permissive approaches and related pleas to refuse euthanasia for psychological suffering, some Belgian hospitals have declared that such requests could be admissible. However, some of these hospitals have decided that such requests have to be managed and carried out outside their walls. Main text Ghent University Hospital has developed a written policy regarding requests for euthanasia for psychological suffering coming from patients from outside the hospital. The protocol stipulates several due care criteria that go beyond the requirements of the Belgian Euthanasia Law. For instance, the legally required first and second consulted physicians should all be psychiatrists and be affiliated with a psychiatry department of a Flemish university hospital. Moreover, euthanasia for psychological suffering can only be performed if the advices of these consulted physicians are positive. Importantly, preliminary reflection by the multidisciplinary Hospital Ethics Committee was introduced to discuss every request for euthanasia for psychological suffering coming from outside the hospital. Conclusion In this way, the protocol supports psychiatrists faced with the complexities of assessing such requests, improves the quality of euthanasia practice by ensuring transparency and uniformity, and offers patients specialised support and guidance during their euthanasia procedure. Nevertheless, some concerns still remain (e.g. relating to possible unrealistic patient expectations and to the absence of aftercare for the bereaved or for patients whose requests have been refused).

In 2012, a new and promising gene manipulation technique, CRISPR-Cas9, was announced that seems likely to be a foundational technique in health care and agriculture. However, patents have been granted. As with other technological developments, there are concerns of social justice regarding inequalities in access. Given the technologies' "foundational" nature and societal impact, it is vital for such concerns to be translated into workable recommendations for policymakers and legislators. Colin Farrelly has proposed a moral justification for the use of patents to speed up the arrival of technology by encouraging innovation and investment. While sympathetic to his argument, this article highlights a number of problems. By examining the role of patents in CRISPR and in two previous foundational technologies, we make some recommendations for realistic and workable guidelines for patenting and licensing.

Background Since Belgium legalised euthanasia, the number of performed euthanasia cases for psychological suffering in psychiatric patients has significantly increased, as well as the number of media reports on controversial cases. This has prompted several healthcare organisations and committees to develop policies on the management of these requests. Method Five recent initiatives that offer guidance on euthanasia requests by psychiatric patients in Flanders were analysed: the protocol of Ghent University Hospital and advisory texts of the Flemish Federation of Psychiatry, the Brothers of Charity, the Belgian Advisory Committee on Bioethics, and Zorgnet-Icuro. These were examined via critical point-by-point reflection, focusing on all legal due care criteria in order to identify: 1) proposed measures to operationalise the evaluation of the legal criteria; 2) suggestions of additional safeguards going beyond these criteria; and 3) remaining fields of tension. Results The initiatives are well in keeping with the legal requirements but are often more stringent. Additional safeguards that are formulated include the need for at least two positive advices from at least two psychiatrists; an a priori evaluation system; and a two-track approach, focusing simultaneously on the assessment of the patient's euthanasia request and on that person's continuing treatment. Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection. Conclusions All initiatives offer useful guidance for the management of euthanasia requests by psychiatric patients. By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses. Apart from the additional safeguards suggested, the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed. Shortcomings of the initiatives relate to the aftercare of patients whose euthanasia request is rejected, and to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal. Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.

In 2014, the Belgian Euthanasia Law was amended so as to extend the possibility of obtaining euthanasia to minors who have the capacity for discernment. The amendment led to considerable debate among Belgian legal experts, health care professionals and ethicists, in large part due to concerns about the scope and assessment of the minors capacity for discernment, a concept first introduced in Belgian medical law by the amendment. This article offers a critical legal analysis of the concept of capacity for discernment and its implications for euthanasia practice in Belgium. We do so by focusing on a ruling of the Belgian Constitutional Court of 29 October 2015, where the concept figured prominently in the examination of the constitutionality of the amendment. This approach also allows us to shed light on the interpretation of several core aspects of the original 2002 Euthanasia Law and its 2014 amendment.

In 2017, regulatory approval was given in the US for a 'digital pill', a pill for which actual ingestion could be remotely monitored. The pill, Abilify Mycite is marketed by Otsuka but the monitoring system derives from Proteus Digital Health. In this paper, we focus on this digital pill and another equivalent system from AiCure which relies on facial recognition. Both systems not only remind the patient to take a pill but also verify the actual intake. In this process, patient-related data beyond the fact that the pill has been taken are also collected and sent to a remote computer system of the system-providing company and possibly to third parties.Although marketed as 'innovative', the introduction of such systems raises questions as to the limitation of patient autonomy, secondary uses of patient data, impact on the physician's liability, and artificial inflation of drug prices. Whereas incorrect medication taking can be problematic, it can be questioned whether remote intake-monitoring systems are, from an ethical, legal and social perspective, the ideal way to address this. In this paper, we will reflect on this question from the position of the different potential stakeholders involved.

Although climate change jeopardizes the fundamental human rights of current as well as future people, current actions and ambitions to tackle it are inadequate. There are two prominent explanations for this motivational gap in the climate ethics literature. The first maintains that our conventional moral judgement system is not well equipped to identify a complex problem such as climate change as an important moral problem. The second explanation refers to people’s reluctance to change their behaviour and the temptation to shirk responsibility. We argue that both factors are at play in the motivational gap and that they are complemented by crucial moral psychological insights regarding moral disengagement, which enables emitters to dissociate self-condemnation from harmful conduct. In this way, emitters are able to maintain their profligate, consumptive lifestyle, even though this conflicts with their moral standards with respect to climate change. We provide some illustrations of how strategies of moral disengagement are deployed in climate change and discuss the relationship between the explanations for the motivational gap and moral disengagement. On the basis of this explanatory framework, we submit that there are three pathways to tackle the motivational gap and moral disengagement in climate change: making climate change more salient to emitters and affirming their self-efficacy; reconsidering the self-interested motives that necessitate moral disengagement; and tackling moral disengagement directly.

Since the adoption of the WTO‐TRIPS Agreement in 1994, there has been significant controversy over the impact of pharmaceutical patent protection on the access to medicines in the developing world. In addition to the market exclusivity provided by patents, the pharmaceutical industry has also sought to further extend their monopolies by advocating the need for additional ‘regulatory’ protection for new medicines, known as data exclusivity. Data exclusivity limits the use of clinical trial data that need to be submitted to the regulatory authorities before a new drug can enter the market. For a specified period, generic competitors cannot apply for regulatory approval for equivalent drugs relying on the originator's data. As a consequence, data exclusivity lengthens the monopoly for the original drug, impairing the availability of generic drugs. This article illustrates how the pharmaceutical industry has convinced the US and the EU to impose data exclusivity on their trade partners, many of them developing countries. The key arguments formulated by the pharmaceutical industry in favor of adopting data exclusivity and their underlying ethical assumptions are described in this article, analyzed, and found to be unconvincing. Contrary to industry's arguments, it is unlikely that data exclusivity will promote innovation, especially in developing countries. Moreover, the industry's appeal to a property rights claim over clinical test data and the idea that data exclusivity can prevent the generic competitors from ‘free‐riding’ encounters some important problems: Neither legitimize excluding all others.

Although emissions trading is embraced as a means to curb carbon emissions and to incentivize the use of renewable energy, it is also heavily contested on ethical grounds. We will assess the main fundamental objections and possible counterarguments. Although we sympathize with some of these arguments, we argue that they are unpersuasive when an emissions trading system is well designed: emissions should be accounted ‘upstream,’ on the production rather than the consumer level. Moreover, allowances should be auctioned, and regulatory measures (such as an escalating tax on additional allowances) could instigate the right kind of behavior towards the environment.

Rapid advances in microarray and sequencing technologies are making genotyping and genome sequencing more affordable and readily available. There is an expectation that genomic sequencing technologies improve personalized diagnosis and personalized drug therapy. Concurrently, provision of direct-to-consumer genetic testing by commercial providers has enabled individuals’ direct access to their genomic data. The expanded availability of genomic data is perceived as influencing the relationship between the various parties involved including healthcare professionals, researchers, patients, individuals, families, industry, and government. This results in a need to revisit their roles and responsibilities. In a 1-day agenda-setting meeting organized by the COST Action IS1303 “Citizen’s Health through public-private Initiatives: Public health, Market and Ethical perspectives,” participants discussed the main challenges associated with the expanded availability of genomic information, with a specific focus on public-private partnerships, and provided an outline from which to discuss in detail the identified challenges. This paper summarizes the points raised at this meeting in five main parts and highlights the key cross-cutting themes. In light of the increasing availability of genomic information, it is expected that this paper will provide timely direction for future research and policy making in this area. Funding Deborah Mascalzoni is supported under Grant Agreement number 305444. Álvaro Mendes is supported by the FCT—The Portuguese Foundation for Science and Technology under postdoctoral grant SFRH/BPD/88647/2012. Isabelle Budin-Ljøsne receives support from the National Research and Innovation Platform for Personalized Cancer Medicine funded by The Research Council of Norway (NFR BIOTEK2021/ES495029) and Biobank Norway funded by The Research Council of Norway—grant number 245464. Heidi Carmen Howard is partly supported by supported by the Swedish Foundation for Humanities and Social Science under grant M13-0260:1), the Biobanking and Molecular Resource Infrastructure of Sweden (BBMRI.se) and the BBMRI-ERIC. Brígida Riso is supported by the Portuguese Foundation for Science and Technology (FCT) under the PhD grant SFRH/BD/100779/2014. Heidi Beate Bentzen receives support from the project Legal Regulation of Information Processing relating to Personalized Cancer Medicine funded by The Research Council of Norway BIOTEK2021/238999.

Data exclusivity is a temporary exclusive user right on the clinical data that need to be submitted to the regulatory authorities to prove that a new drug is safe and effective. For the pharmaceutical industry, data exclusivity is an important addition to the patent system, as data exclusivity will de facto delay the market entry of generic drugs until after the exclusive user rights on the clinical data have expired. In order to assess the normative legitimacy of the industry’s demand to include minimum standards for data exclusivity in international agreements, this chapter evaluates the three justifications that have frequently been advanced, depicting data exclusivity as (1) an essential policy tool to promote innovation, (2) a mechanism to prevent the generic industry from ‘free-riding,’ and (3) a legal instrument to protect the industry’s property rights in clinical data.

Rationale, aims and objectives Continuous sedation at the end of life is an end-of-life practice that has gained considerable attention in the international literature. Nevertheless, significant confusion persists, even on how to label or define the practice. Several different terms and definitions exist, and these are often non-neutral and indicative of one's normative position on sedation at the end of life. This is problematic for two reasons. First, the use of such value-laden terms or definitions of continuous sedation may make it difficult, if not impossible, to agree on the facts surrounding continuous sedation. Second, including normative criteria in a definition can lead one to make disguised circular or tautological statements. Methods This paper identifies commonly used terms and definitions and demonstrates how particular elements present in these are value-laden and can influence the ethical evaluation of continuous sedation at the end of life. Results Two commonly used terms, ‘palliative sedation’ and ‘terminal sedation’, have been strongly criticized. We propose to use another, more descriptive term, namely ‘continuous sedation at the end of life’. As regards the different definitions of sedation, some are general, but most contain very specific elements, thereby clearly limiting the number of cases that are covered by the definition. Some definitions of sedation include the intention one should (not) have, the possible indications for the practice, and the type of patients the practice should be reserved for. Conclusion Including value-laden elements in the very definition of a clinical practice runs the risk of pre-empting a proper normative debate about the practice. We explain why this is the case and why it is problematic, and we propose an alternative, descriptive, definition that seeks to avoid these problems.

Although transplant professionals have initially been reluctant to perform transplants after public solicitation of organs from living donors, nowadays these transplants are increasingly being performed and reported. After clarifying the existing terminology, we elaborate an operational definition of public solicitation that is consistent with the Ethical, Legal, and Psychosocial Aspects of Transplantation classification for living organ donation. Our aim is to critically assess this phenomenon, from a legal, moral, and practical perspective, and to offer some recommendations. From a legal point of view, we analyze the current situation in the Europe and the United States. From a moral perspective, we evaluate the various arguments used in the literature, both in favor and against. Finally, we offer a set of recommendations aimed at maximizing the organ donor pool while safeguarding the interests of potential living donors.

An 'Information Centre' has recently been established by law which has the power to collect, collate and provide access to the medical information for all patients treated by the National Health Service in England, whether in hospitals or by General Practitioners. This so-called 'care.data' scheme has given rise to major and ongoing controversies. We will sketch the background of the scheme and look at the responses it has elicited from citizens and medical professionals. In Autumn 2013, NHS England set up a care.data website where citizens could record their concerns regarding the collection of health-related data by the Information Centre. We have reviewed all the comments on this website up until June 2015. We have also analysed the readers' comments on the coverage of the care.data scheme in one of the main national UK newspapers. When discussing the responses of citizens, we will make a distinction between the problems that citizens detect and the solutions they propose. The solutions that are being perceived as the most relevant ones can be summarized as follows: citizens wish to further the common good without being manipulated into doing it, while at the same time being safeguarded against various abuses. The issue of trust turns out to figure prominently. Our analysis of reactions to the scheme in no way pretends to be exhaustive, yet it provides various relevant insights into the concerns identified by citizens as well as medical professionals. These concerns, moreover, have a more general relevance in relation to other contexts of medical data-mining as well as biobank research. Our analysis also offers important pointers as to how those concerns might be addressed. ispartof: Medicine, Health Care and Philosophy vol:19 issue:2 pages:177-190 ispartof: location:Netherlands status: published

The capabilities approach of Amartya Sen and Martha Nussbaum has become an influential viewpoint for addressing issues of social justice and human development. It has not yet, however, given adequate theoretical consideration to the requirements of environmental sustainability. Sen has focussed on the instrumental importance of human development for achieving sustainability, but has failed to consider the limits of this account, especially with respect to consumption-reduction. Nussbaum has criticised constraining material consumption for its paternalistic prescription of one particular conception of the good life, without considering it as an imperative of justice. We discuss two possible extensions of the capabilities approach. First, the concept of capability ceilings contains several attractive elements, but it also suffers from some shortcomings. Therefore, second, we advocate constraining people's combinations of functionings in accordance with a personal budget which consists of a fair share of environmental resources.