Ex-vivo tissue engineering is an emerging medical technology. Its aim is to regenerate tissues and organs and to restore them to full physiological activity. Some clinical trials with human tissue engineered products (HTEPs) have been conducted and others will follow. These trials not only have to confirm the therapeutic value of the HTEP, they also have to provide insight in its regenerative activity, its safety and long-term effects. The development of these trials is aggravated by the complexity of the tissue engineering process and product. This paper investigates how this complexity influences the ethical conduct of clinical trials with HTEPs. We focus on the value and validity of the trial, the risk-benefit ratio and the protection of the trial participant. We argue that trials with HTEPs need a robust methodology. The risk-benefit ratio of a new HTEP must be determined and compared with available efficacious therapies. This requires the identification and minimisation of risks associated with tissue engineering. Finally a process as complex as tissue engineering presents serious challenges for the informed consent process, and for the protection of the trial participant during and after the trial.

This article reports on moral problems that were raised by medical students as the basis for an ethical case-conference in an obstetrics and gynaecology clerkship. After introducing the issue of teaching clinical ethics, the method of our case-conference is explained. Next, the variety of topics and related moral problems are presented. The article continues with a discussion of three distinct and challenging aspects that characterise obstetrics and gynaecology as a domain for teaching clinical ethics. The conclusion puts forward three significant points our review raises.

The medical response to suicide is generally resuscitation, followed by attempts to maximise the patient's recovery. Care is generally withdrawn when it is futile and there is no hope for recovery. Suicidal patients who have completed an advance directive may complicate matters. Should medical providers not resuscitate a patient with an advance directive who has attempted to commit suicide? If stated wishes for care are ignored in the emergency setting, how should decisions be made over time in the event of a successful resuscitation resulting in the need for prolonged therapy counter to the wishes of the advance directive? What are the merits of the stated the wishes of suicidal patient? What if they were depressed at the time of the advance directive? This case highlights the need for consideration of these and other concerns in the care of patients who commit suicide and have an advance directive.

As an employee, a sports doctor has obligations to their employer, but also professional and widely accepted obligations of a doctor to the patient (in this case the individual team member). The conflict is evident when sports doctors are asked by an athlete to keep personal health information confidential from the coach and team management, and yet both doctor and athlete have employment contracts specifying that such information shall be shared. Recent research in New Zealand shows that despite the presence of an employment contract, there appears to be a wide range of behaviours among sports doctors when an athlete requests that information about them be kept from team management. Many seem willing to honour requests to keep health information about the athlete confidential, thereby being in breach of the employment contract, while others insist on informing team management against the wishes of the athlete. There are a number of potential solutions to this dilemma from forcing doctors to meet their contractual obligations, to limiting the expectations of the employment contract. This paper suggests that at times it may be appropriate to do both, making the position of the doctor clearer and supporting the ability of this group to resist pressure by coaches and management through having a robust code of ethics.

Some of the objections to life-extension stem from a concern with overpopulation. I will show that whether or not the overpopulation threat is realistic, arguments from overpopulation cannot ethically demand halting the quest for, nor access to, life-extension. The reason for this is that we have a right to life, which entitles us not to have meaningful life denied to us against our will and which does not allow discrimination solely on the grounds of age. If the threat of overpopulation creates a rights conflict between the right to come into existence, the right to reproduce, the right to more opportunities and space (if, indeed, these rights can be successfully defended), and the right to life, the latter ought to be given precedence.

The parents of some terminally ill children have reported that being asked to authorise removal of life-sustaining measures is akin to being requested to sign a "death warrant". This dilemma leaves families not only enduring the grief of losing a loved one, but also with feelings of ambivalence, anxiety and guilt. A straightforward method by which the parents of terminally ill children can entrust the role of healthcare surrogate to the treating physician is presented. The cornerstone of this paradigm is parental awareness that the physician will act in the child’s best interest, even if that means discontinuing life-sustaining measures. The goal is to mitigate parental guilt and fear of misperception, by self and others, of having given up on their child. From a moral standpoint this concept is an appealing option as it conforms to the four basic principles of medical ethics. While laws in the USA and several European nations prevent members of the medical team from taking on the responsibilities of healthcare surrogate for terminally ill patients, formal and informal precedence for this option already exists in France, The Netherlands, Norway, Sweden, Switzerland, and the Canadian province of Manitoba.

This paper deals with new pharmacological and technological developments in the manipulation and curtailment of our sleep needs. While humans have used various methods throughout history to lengthen diurnal wakefulness, recent advances have been achieved in manipulating the architecture of the brain states involved in sleep. The progress suggests that we will gradually become able to drastically manipulate our natural sleep-wake cycle. Our goal here is to promote discussion on the desirability and acceptability of enhancing our control over biological sleep, by illustrating various potential attendant ethical problems. We draw attention to the risks involved, possible conflicts of interests underlying the development of wake enhancement, and the potential impact on accountability for fatigue related errors.

On 9 May 2005, the Israeli Ministry of Health issued guidelines spelling out the conditions under which sex selection by preimplantation genetic diagnosis (PGD) for social purposes is to be permitted in Israel. This article first reviews the available medical methods for sex selection, the preference for children of a specific gender in various societies and the ethical controversies surrounding PGD for medical and social purposes in different countries. It focuses then on the question of whether procreative liberty or parental responsibility should be the centre of attention in this context. Finally, the article critically examines the new Israeli guidelines and their implications for the women undergoing the necessary medical treatments, for the children born as a result, for other members of the family and for society in general.

The recent case of German siblings Patrick Stübing (age 30 years) and his sister Susan Karolewski (age 22 years) has reignited debate over the criminalisation of sexual intercourse among consanguine descendants. The primary justification for criminalising incest is the purported increased risk of genetic disabilities among offspring, but is criminalising sexual intercourse an empirically sound and proportionate response to this increased risk? To answer this question we must consider the specifics of the harm in question (eg, is it a harm to the child or a societal harm) and the magnitude of the harms of the intervention. The example of incest law has important implications for liberal societies. If we can justify imprisoning consenting adults for choosing partners who will increase the risk of having children with disabilities, then we set a troubling precedent for all couples who may pass on genetic disorders to their children.

Chile has achieved great success in terms of growth and development. However, growing inequalities exist in relation to income and health status. The previous Chilean government began to reform the healthcare system with the aim of reducing health inequities. What is meant by "equity" in this context? What is the extent of the equity aimed for? A normative framework is required for public policy-makers to consider ideas about fairness in their decisions about healthcare reform. This paper aims to discuss the main features of the Chilean healthcare reform and their implications for such a normative framework.

This article discusses some ethical issues that can arise when researchers decide to increase the amount of payment offered to research subjects to boost enrollment. Would increasing the amount of payment be unfair to subjects who have already consented to participate in the study? This article considers how five different models of payment—the free market model, the wage payment model, the reimbursement model, the appreciation model, and the fair benefits model—would approach this issue. The article also considers several practical problems related to changing the amount of payment, including determining whether there is enough money in the budget to offer additional payments to subjects who have already enrolled, ascertaining how difficult it will be to re-contact subjects, and developing a plan of action for responding to subjects who find out they are receiving less money and demand an explanation.

After years of failure, in November 2007 primate embryonic stem cells were derived by somatic cellular nuclear transfer, also known as therapeutic cloning. The first embryo transfer for human reproductive cloning purposes was also attempted in 2006, albeit with negative results. These two events force us to think carefully about the possibility of human cloning which is now much closer to becoming a reality. In this paper we tackle this issue from two sides, first summarising what scientists have achieved so far, then discussing some of the ethical arguments in favour and against human cloning which are debated in the context of policy making and public consultation. Therapeutic cloning as a means to improve and save lives has uncontroversial moral value. As to human reproductive cloning, we consider and assess some common objections and failing to see them as conclusive. We do recognise, though, that there will be problems at the level of policy and regulation that might either impair the implementation of human reproductive cloning or make its accessibility restricted in a way that could become difficult to justify on moral grounds. We suggest using the time still available before human reproductive cloning is attempted successfully to create policies and institutions that can offer clear directives on its legitimate applications on the basis of solid arguments, coherent moral principles, and extensive public consultation.

Current guidelines on investigators' responsibilities to communicate research results to study participants may differ on (1) whether investigators should proactively re-contact participants, (2) the type of results to be offered, (3) the need for clinical relevance before disclosure, and (4) the stage of research at which results should be offered. Lack of consistency on these issues, however, does not undermine investigators' obligation to offer to disclose research results: an obligation rooted firmly in the principle of respect for research participants.

Extreme rates of premature death prior to the advent of modern medicine, very low rates of premature death in First World nations with low rates of prayer, and the least flawed of a large series of clinical trials indicate that remote prayer is not efficacious in treating illness. Mass contamination of sample cohorts renders such clinical studies inherently ineffectual. The required supernatural and paranormal mechanisms render them implausible. The possibility that the latter are not benign, and the potentially adverse psychological impact of certain protocols, renders these medical trials unethical. Resources should no longer be wasted on medical efforts to detect the supernatural and paranormal.

In Ian Brassington’s article in a previous issue of this journal, he argues that suicide for the purpose of avoiding suffering is not, as Kant has contended, contrary to the moral law. Brassington’s objections are not cogent because they rely upon the exegetically incorrect premise that according to Kant the priceless value of personhood is in the noumenal world that we have no perception of. On the basis of Kant’s normative, metaphysical and epistemological theory, I argue, contrary to Brassington, that according to Kant personhood’s moral value is explicitly in the sensible, phenomenal realm. While I argue that suicide solely to avoid suffering is immoral, I show that Kant’s normative system allows some acts of suicide to be morally permissible. In the course of the discussion of the value of humanity’s rationality and the immorality of suicide, I will discuss the broader modern medical ethical implications of Kant’s arguments, such as the moral impermissibility of using rationality depriving drugs, such as ketamine, solely to avoid pain.

Increasing geographical mobility and international travel augment the ease and speed by which infectious diseases can spread across large distances. It is therefore incumbent upon each state to ensure that immunisation programmes are effective and that herd immunity is achieved. Across Europe, a range of immunisation policies exist: compulsion, the offer of financial incentives to parents or healthcare professionals, social and professional pressure, or simply the dissemination of clear information and advice. Until recently, immunisation against particular communicable diseases was compulsory in Italy. The Italian National Vaccination Plan (NVP) (2005–7) paved the way for regions to suspend the sanctions associated with compulsory vaccinations for children when certain criteria are met—for example when immunisation coverage is high and when effective monitoring/surveillance systems are in place—and thus marked a milestone in the move from compulsory to voluntary immunisation. The forthcoming NVP for 2008–10 confirms the liberal approach to vaccination in Italy as it entrusts to the regions responsibility for the achievement and maintenance of herd immunity. This paper reviews the arguments for and against compulsory and voluntary immunisation in relation to the Italian NVP (2005–7) and in the context of the diverse immunisation policies that exist across Europe. It concludes with cautious support for the NVP and an associated shift from compulsory to voluntary immunisation in Italy, and draws similarities between issues concerning regional variation in immunisation policy in Italy and national variation in immunisation policy across Europe and beyond.

Informed consent needs to be practised within a culture of openness if it is to enhance public trust in medical procedures around death. Openness should entail patients not just receiving information from doctors, but also having the right to see certain medical procedures. This article proposes in particular that it would be desirable for the public to be allowed to attend an autopsy of a person they do not know. Evidence from the UK, where members of the public may go backstage to witness the process of cremation, the other technical process in which dead bodies are violently but legitimately assaulted, suggests benefits from a policy of openness. When a family consents to cremation in Britain, their consent is only minimally informed, but the system has nothing to hide, and trust is high. This suggests that the opportunity for lay people also to witness certain medical procedures might do more to restore public trust in medical procedures around death than a narrow interpretation of informed consent in which information is controlled by the profession.