Collating the concepts of vulnerability through five regional perspectives on bioethics from the United States, Europe, Latin America, Africa, and Asia, this article proposes a means of integration between the different approaches in order to seek a theoretical and normative basis for the field of global bioethics. It argues that only through opening continuous, critical, and self-critical dialogue within the international bioethical community will it be possible to achieve a sufficiently global understanding of vulnerability that is capable of identifying the means needed for addressing the conditions that leave certain groups and individuals more susceptible to “wounding” than others.

In 2011, Frank Van Den Bleeken became the first detainee to request euthanasia under Belgium’s Euthanasia Act of 2002. This article investigates whether it would be lawful and morally permissible for a doctor to accede to this request. Though Van Den Bleeken has not been held accountable for the crimes he committed, he has been detained in an ordinary prison, without appropriate psychiatric care, for more than 30 years. It is first established that Van Den Bleeken’s euthanasia request plausibly meets the relevant conditions of the Euthanasia Act and that, consequently, a doctor could lawfully fulfill it. Next, it is argued that autonomy-based reasons for euthanizing him outweigh complicity-based reasons against doing so, and that, therefore, it is also morally permissible for a doctor to carry out the euthanasia request.

Separation of craniopagus twins is fraught by ethical issues. The surgery is high risk and may involve the sacrifice of one twin. We review surgical successes in separation of craniopagus twins and consider ethical and legal concepts affecting the decision to undertake such procedures. Our discussion considers how Gillett’s potentiality principle and the concept of moral permissibility may be used to arrive at fair and realistic decisions.

Recent neuroimaging research on disorders of consciousness provides direct evidence of covert consciousness otherwise not detected clinically in a subset of severely brain-injured patients. These findings have motivated strategic development of binary communication paradigms, from which researchers interpret voluntary modulations in brain activity to glean information about patients’ residual cognitive functions and emotions. The discovery of such responsiveness raises ethical and legal issues concerning the exercise of autonomy and capacity for decisionmaking on matters such as healthcare, involvement in research, and end of life. These advances have generated demands for access to the technology against a complex background of continued scientific advancement, questions about just allocation of healthcare resources, and unresolved legal issues. Interviews with professionals whose work is relevant to patients with disorders of consciousness reveal priorities concerning further basic research, legal and policy issues, and clinical considerations.

Use of the best-interests test as the legal standard to justify medical treatment (or its cessation) in respect to legally incompetent adults or minors has come under sustained critique over the years. “Best interests” has variously been alleged to be indeterminate as well as susceptible to majoritarian ideology and inherent bias. It has also been alleged to be inferior to rights-based approaches. Against the background of several particularly hard cases involving minors discussed by Gillett in a prior article in this journal, this article considers some of these critiques. It concludes that these critical accounts make significant contributions to enabling a more procedurally and substantively robust consideration of what might be in a child’s best interests. However, it is argued that none of these accounts alone provide a superior framework that would justify jettisoning the concept of best interests. Further, it is suggested that best interests still has an important role in achieving patient-centered decisionmaking in this context. It concludes by suggesting a taxonomy of considerations when determining best interests.

Closed-loop medical devices such as brain-computer interfaces are an emerging and rapidly advancing neurotechnology. The target patients for brain-computer interfaces (BCIs) are often severely paralyzed, and thus particularly vulnerable in terms of personal autonomy, decisionmaking capacity, and agency. Here we analyze the effects of closed-loop medical devices on the autonomy and accountability of both persons (as patients or research participants) and neurotechnological closed-loop medical systems. We show that although BCIs can strengthen patient autonomy by preserving or restoring communicative abilities and/or motor control, closed-loop devices may also create challenges for moral and legal accountability. We advocate the development of a comprehensive ethical and legal framework to address the challenges of emerging closed-loop neurotechnologies like BCIs and stress the centrality of informed consent and refusal as a means to foster accountability. We propose the creation of an international neuroethics task force with members from medical neuroscience, neuroengineering, computer science, medical law, and medical ethics, as well as representatives of patient advocacy groups and the public.

The Dutch Euthanasia Act seems to be set in stone. Since it took effect in 2002, it has not seen any significant amendments. Recent developments, however, indicate that a major component of the act—the review procedure—is due for revision. The review practice of the regional euthanasia review committees—responsible for applying and interpreting the law—now also extends to instances of euthanasia and assisted suicide for special categories of patients: psychiatric patients, patients with early-stage dementia, and patients whose suffering is derived from a combination of medical and existential causes. In this article, it is argued that a reconsideration of the review practice for these new cases is necessary primarily because review committees lack the legitimacy needed for the development of policies with such a large impact on society.

In this article, we discuss the ideas of Eric J. Cassell about the patient-professional relationship. We argue that his approach combines in an interesting way features from the literature on patient autonomy and paternalistic practices. We suggest that these seemingly paternalistic features of practicing medicine, which are widely either ignored or condemned in bioethical discussion, are of vital significance in medical practice. In the first sections of the article, we describe the main features of Cassell’s understanding of the sick person and his version of personalized medicine. We pay particular attention to his notion of information control and compare his ideas about conversation with patients to Hans-Georg Gadamer’s analysis of patient-professional dialogue. In the latter part of the article, we explore through a couple of examples the implications these ideas have for medical practice.

Human beings are sensorimotor coupled to the actual world and also attuned to the symbolic world of culture and the techniques of adaptation that culture provides. The self-image and self-shaping mediated by that mirror directly affects the neurocognitive structures that integrate human neural activity and reshape its processing capacities through top-down or autopoietic effects. Thus a crack’d mirror, which disrupts the processes of enactive self-configuration, can be disabling for an individual. That is exactly what happens in postcolonial or immigration contexts in which individuals’ cultural adaptations are marginalized and disconnected in diverse and often painful and disorienting ways. The crack’d mirror is therefore a powerful trope for neuroethics and helps us understand the social and moral pathologies of many indigenous and immigrant communities.

In bioethics, the concept of vulnerability is applied almost exclusively to research participants and patients. We turn the tables and apply the concept to nurses caring for anorexia nervosa (AN) sufferers. In doing so, and using results from a qualitative research study undertaken in the UK, we show that AN nurses face a significant probability of incurring identifiable harms (inauthentic relationships and nonreciprocal relationships). Some recommendations on how these harms can be avoided or mitigated are given, but further research is needed.

Managing a healthcare situation in accordance with the best interests of a child can be challenging for both parents and healthcare professionals. These challenges take different forms as the child grows and develops physically, emotionally, and cognitively. In this article I argue that a child’s best interests cannot be construed in terms of a narrow conception of human beings as isolated, self-contained biological organisms, in which “health” and “illness” are understood in terms of physiological function and dysfunction. Such an approach overlooks the wider context in which the child grows into and comes to dwell in the world, continually enacting her life within her community. The health of a child is intimately connected to the ways in which she is involved in the world, through active and rewarding engagement with significant others. That embeddedness implies that acting in her best interests calls for others to nurture and integrate her into a sustainable human community so that she is supported appropriately throughout all the contingencies and vagaries of life that impact on her health.

Dignity is one of the most controversial and yet commonly used terms in debates regarding end-of-life issues. The term “dignity” can take various meanings. For example, it can be used to denote the respect owed to an individual person, or to signify the intrinsic value of humankind as a whole. These two different understandings of dignity inevitably lead to different approaches to end-of-life decisionmaking.

This article explores the meaning of the term “dignity” in two European countries, England and France. Our analysis compares public debates and legislation on end-of-life-related issues in these two countries. We argue that in England dignity is most commonly understood as respect for individual autonomy, whereas in France dignity usually signifies respect for humanity as a whole. We demonstrate that the difference in the conceptualization of the term leads to different ethical, and hence legal and practical, approaches to end-of-life issues and vulnerable patients. Our particular focus is on (1) withdrawing/withholding life-sustaining treatment, (2) respect for patient preferences, and (3) assistance in dying.

Given the difference in the understanding of dignity, and the underlying philosophical approaches, it appears that there is still a long way to go before we can establish common guidelines on end-of-life decisions across Europe and beyond. However, clarifying the use of the term “dignity” in different discussions around Europe could hopefully facilitate this endeavor.

One of the topics that often comes up in ethical discussions of deep brain stimulation (DBS) is the question of what impact DBS has, or might have, on the patient’s self. This is often understood as a question of whether DBS poses a threat to personal identity, which is typically understood as having to do with psychological and/or narrative continuity over time. In this article, we argue that the discussion of whether DBS is a threat to continuity over time is too narrow. There are other questions concerning DBS and the self that are overlooked in discussions exclusively focusing on psychological and/or narrative continuity. For example, it is also important to investigate whether DBS might sometimes have a positive (e.g., a rehabilitating) effect on the patient’s self. To widen the discussion of DBS, so as to make it encompass a broader range of considerations that bear on DBS’s impact on the self, we identify six features of the commonly used concept of a person’s “true self.” We apply these six features to the relation between DBS and the self. And we end with a brief discussion of the role DBS might play in treating otherwise treatment-refractory anorexia nervosa. This further highlights the importance of discussing both continuity over time and the notion of the true self.

The “Ashley treatment” has provoked much debate and remains ethically controversial. Given that more children are being referred for such treatment, there remains a need to provide advice to clinicians and ethics committees regarding how to respond to such requests. This article contends that there is one particularly important gap in the existing literature about growth attenuation therapy (GAT) (one aspect of the Ashley treatment): the views of parents of children with profound cognitive impairment (PCI) remain significantly underrepresented. The article attempts to redress this balance by analyzing published accounts both from parents of children who have received GAT and from parents who oppose treatment. Using these accounts, important points are illuminated regarding how parents characterize benefits and harms, and their responsibilities as surrogate decisionmakers. This analysis could contribute to decisionmaking about future requests for GAT and might also have wider relevance to healthcare decisionmaking for children with PCI.

No single issue has dominated health practitioners’ ethical debates in 2014 in Australia, but a controversial decision on gene patenting and the media focus on “Dr. Death,” euthanasia campaigner Dr. Philip Nitschke, have given new life to these two familiar (and global) debates. Currently a dying with dignity bill, drafted by the Australian Green Party, is under examination. The Senate inquiry into the bill received more than 663 submissions, with 57% opposed and 43% in support of the bill, which has now been referred to a Senate committee. Will this be another of Australia’s failed attempts to legalize euthanasia? The trial of Dr. Nitschke begins on November 10, 2014.

Something strange has happened to the concept of dignity in bioethics. After a long period in which U.S. pragmatist and U.K. consequentialist philosophers have argued that the concept is useless and vacuous, and in which they have been reasonably successful in expunging it from mainstream English-language academic bioethics, dignity has suddenly become popular again in debates about the legalization of physician-assisted dying (PAD). And, even stranger, it is deployed not by conservatives but by liberals. In the debates about PAD, liberal proponents of legalization seem to accept without question that there is such a state or process as “death with dignity,” which is juxtaposed to “undignified dying.” It also seems to be accepted that both of these states can be fairly easily identified and that they carry great moral weight. This article provides an analysis of the current resurgence of “undignified” arguments and argues on the basis of that analysis (1) that a proper understanding of the concept of dignity shows that the previous reductive arguments against dignity are partially incomplete and therefore partially misguided and (2) that, despite dignity having meaning, the idea of an undignified death cannot carry the moral weight it is given by proponents of the legalization of PAD.

Severe congenital hydrocephalus manifests as accumulation of a large amount of excess fluid in the brain. It is a paradigmatic example of a condition in which diagnosis is relatively straightforward and long-term survival is usually associated with severe disability. It might be thought that, should parents agree, palliative care and limitation of treatment would be clearly permissible on the basis of the best interests of the infant. However, severe congenital hydrocephalus illustrates some of the neuroethical challenges in pediatrics. The permissibility of withholding or withdrawing treatment is limited by uncertainty in prognosis and the possibility of “palliative harm.” Conversely, although there are some situations in which treatment is contrary to the interests of the child, or unreasonable on the grounds of limited resources, acute surgical treatment of hydrocephalus rarely falls into that category.

This article examines ethical issues debated in Iceland concerning population genetic research, specifically methods of collecting biosamples and ways to return clinically relevant results to participants. Also discussed are scientific research in the health sector, a bill on surrogacy, and a policy on consent for organ donation.

On seeing promising results in a small number of patients, some researchers are conducting trials to determine whether deep brain stimulation (DBS) is an effective treatment for anorexia nervosa (AN). This article asks whether we should open enrollment in trials of DBS for AN to adolescents. Despite concerns about informed consent, parental consent, and unforeseeable psychological sequelae, the article concludes that the risks to anorexic adolescents associated with participation in trials of DBS are reasonable considering the substantial risks of not enrolling teens with AN in research on DBS. The seriousness of AN, its high incidence in teens, and serious shortfalls in the AN treatment literature point to the need for improved, evidence-based treatments for teens with AN. This unmet need generates an obligation on the part of researchers and physicians to promote and conduct research on AN in adolescents.

One of the widely recognized facts about human dignity is its vastly divergent applicability—from highly controversial issues in bioethics to broader topics in political philosophy. A group of theories that this article subsumes under the header “natural good theories” appears to be especially fitted for normatively multifaceted notions like dignity. However, the heavy normative weight the concept of dignity has to bear due to the central position it occupies within these theories creates its own difficulties. As is shown in a discussion of Martha Nussbaum’s capability conception of dignity, dignity appears to be unable to mirror the special normative relevance people want to assign to it in cases of great moral misconduct. The article provides a suggestion on how to solve this problem by means of paradigmatic cases that work as material constraints regarding the exact boundaries of dignity violations.