In clinical trials involving experimental subjects who are also patients, what is supposed to become of the imperative to focus on the patient’s best interest? A second set of policy questions concerns patients who want to die. Are there limits to the imperative to let patients choose for themselves? Is commodification a threat to autonomy? When, if ever, do costs and benefits become decisively important? Can we know what to count as a cost-effective preparation for the next pandemic? When we put procedures in place to protect against abuse, is there any way to prevent such measures from becoming bureaucratic obstacles to accomplishing anything at all?

There is a growing movement within contemporary medical ethics to blur the boundaries between clinical medicine and clinical research. Some writers now argue that the research-practice distinction is outdated and the importance of distinguishing between research and medicine is no longer as pressing as it once was or seemed to be. Instead, we are now urged to view the health-care system as a dynamic “learning health-care system” in which research components are embedded within standard clinical care. This essay defends the ethical significance of the research-practice distinction while acknowledging the reality and usefulness of integrated health care. A key claim that this essay advances is that the principle of clinical equipoise, which has largely been rejected by research ethicists, can be reinterpreted and repurposed to help distinguish medical practices that call for more demanding forms of informed consent from those that do not.

As more jurisdictions permit a medically assisted death (MAiD)—and none of the jurisdictions that introduced MAiD has seen any serious attempts at reversing it—the focus of debate has turned to the question of what is a morally defensible access threshold for MAiD. This permits us to rethink the moral reasons for the legalization or decriminalization of assisted dying. Unlike what is assumed in many legislative frameworks, unbearable suffering caused by terminal illness is not what oftentimes motivates decisionally capable people to request MAiD. This matters when access thresholds are considered. The argument advanced in this essay is that because MAiD is less destructive to people’s relationships and less harmful than medically unsupervised suicide, access to medical assistance in dying should be open to anyone who is legally capacitated and who persistently requests such assistance.

Public health emergencies sometimes require the restriction of civil liberties through social distancing: lockdowns, quarantines, the closure of public spaces and institutions, and so on. Social distancing measures can decrease mortality and morbidity, but they also cause social and economic harm. Policymakers have to make trade-offs between “lives and livelihoods,” while introducing only minimally necessary restrictions on civil liberties. Traditionally, cost-benefit analysis has played a central role in formulating these trade-offs. Recently, however, some philosophers have argued that the trade-offs should instead be made on the basis of contractualist moral theory. In this essay, I argue against the use of contractualism for this purpose.

The public health crisis caused by the COVID-19 pandemic led to a rapid surge in activity in biomedical and social science. The pandemic created a need for new scientific knowledge specifically related to the new, emerging infectious agent and it quickly showed huge gaps in knowledge in relation to social and policy responses to pandemics. Governments all over the world accepted the COVID-19 pandemic as a significant public health crisis and went into crisis mode in order to end the crisis and mitigate its impacts. One area in which rapid policy changes occurred was in relation to research ethics. Research ethics systems and guidelines were changed in many countries. The COVID-19 crisis also led to a flurry of philosophical and bioethical work arguing that traditional research ethics rules and principles should be suspended, rethought, or abolished. This essay will analyze whether a public health crisis justifies changing research ethics principles and policies and, if so, what the scope of justified changes is.

The past five years have seen a dramatic increase in scholars working to supplement or challenge accounts of structural injustice. Almost without exception, scholars in this area assume that the move from personal responsibility to political or public responsibility will represent a net gain in justice, at least in modern liberal regimes. In this essay, I challenge this assumption and introduce the concept of “structural hobbling” as a parallel cause of injustice, but one whose origins derive from neutral state activities rather than from intentional bad faith or diffuse private action (as in structural injustice). Using health-care regulations as a lens, I offer two narratives of individuals navigating health-care regulations that demonstrate how seemingly neutral regulatory decisions create regressive hobbling effects. Structural hobbling challenges structural-injustice theorists to take more seriously the complex and often subtle ways in which apparently benevolent state activity can create downstream injustice, while adding complexity to existing narratives around public responsibility and what it demands.

Using the case of the Scientific Advisory Group for Emergencies in the United Kingdom as illustration, this essay offers a framework for understanding the role of narratives and competition among narratives in mediating the relationships between scientific advisers and policymakers during the COVID-19 pandemic. Throughout the pandemic, competing judgments about scientific independence and democratic accountability, about the risks of action and inaction, and about the appropriate balance of costs and benefits to society as a whole and to subgroups of the population were filtered through the narrative perspectives of different discourse coalitions. This narrativization of the process had both positive and negative effects. On the one hand, it provided common platforms for the integration of disparate types of knowledge relevant to policymaking. On the other hand, narratives provided platforms for rival coalitions in ongoing contests that left unresolved the central normative questions of distributional fairness and democratic accountability.

It is often morally important that you have a choice between two options in the sense that each option is available to you and you are not coerced into choosing one or the other. Even when you have a choice, though, the presence of time constraints and other noncoercive influences can prevent you from taking the time you need to make up your mind and really choose for yourself. How are we to understand this latter phenomenon? In this essay, I argue that while choosing for yourself seems, at first glance, to be an exercise in discovering your preferences, this is not the whole story. At least sometimes, choosing for yourself instead involves creating your preferences—and, in so doing, choosing what kind of person and valuer to be—through the exercise of what I call formative autonomy. I then explore some objections to this account and some implications for public health policy and clinical ethics. Throughout, I draw primarily on examples that involve choosing whether to continue or terminate a pregnancy and the regulations governing such choices.

This essay considers how the fact that some morally innocent person is nevertheless a threat to others can bear on the permissibility of health policies that harm some to protect others. Two types of innocent threats are distinguished. In the case of abortion, it is argued that even if the embryo/fetus were a person, abortion could be permissible to protect a woman’s life, health, or bodily autonomy. Whether there nevertheless should be time limits on abortions and what surprising form such limits might take are also considered. In the case of pandemics, it is suggested that discussions of health policies should, but often do not, distinguish morally between innocent threats and their potential victims as well as between providing benefits to people and preventing harms to them. The essay also examines discussions of pandemics by health professionals that make use of the trolley problem, the doctrine of double effect, and related philosophical distinctions.

This essay offers a framework for analyzing whether government may justifiably intervene to contain the spread of disease. Nonconsensual transmission of dangerous pathogens is an inherently violent act. This framework therefore justifies government public health activities for the same reasons and only to the same extent as other government activities. Government public health interventions are legitimate only to the extent they minimize the amount of violence in society. Violence-minimization is a more egalitarian and welfare-enhancing rule than, for example, a rule prescribing that government public health activities should minimize loss of life.

The ideological nature of public health is a problem for the profession. Ideological uniformity in the field of public health undermines scholars’ and officials’ legitimacy and compromises their ability effectively to prevent death and disease. I first provide some evidence that public health is ideological and then I argue that the ideology of public health is counterproductive. Additionally, public officials are also likely to violate people’s rights in trying to advance their ideology through public health policy. In light of these moral considerations against the ideological nature of public health, there are compelling reasons for people to resist the expanding scope of public health insofar as it consists in the further imposition of this counterproductive and harmful ideology. I therefore conclude that the profession would be more effective and just if public health officials and scholars focused more narrowly on improving health outcomes instead of promoting their broader ideological agenda through public health policy.

Thousands of people will suffer and die this year because we do not donate enough substances of human origin, including blood plasma. To solve this, some recommend that we allow commercial organizations to assist in collecting these and that we permit donor compensation as a tool to encourage donations. Many object to these proposals, including for semiotic or expressive reasons. But insofar as these objections rely on meanings and these meanings are social constructs, we can revise the meaning of these practices to avoid commodification. Revision may work in principle, but in practice some complain that changing meanings may be too difficult or practically infeasible. This essay attempts to show that this is not so in a wide range of cases and uses the case of commercial compensated blood plasma collection as an illustration. Getting people to conceive of this practice not as payment for blood plasma but as compensation for the time, effort, and inconvenience associated with the giving of plasma is practically feasible and preferable to prohibition.

It is widely believed that health policy should take care to ensure that persons are informed about the expected risks as well as the anticipated advantages of medical procedures. This is often justified by a concern for the moral value of personal autonomy, as it is widely believed that to the extent that a person makes decisions on the basis of false beliefs or ignorance her autonomy with respect to them is compromised. This essay argues against this widespread claim. A person’s autonomy with respect to her decisions will not be compromised by either ignorance or false beliefs. However, it does not follow that there is no reason to provide persons with the opportunity to have access to the available information relevant to their decisions concerning their medical treatment. The epistemic requirements for a person to give her consent to her treatment are more stringent than those that must be met for her to be autonomous with respect to her consent. Consent, not autonomy, can be undermined by ignorance or false belief. It is a concern for consent, not a concern for autonomy, that justifies providing people with information about their prospective medical procedures.