This paper, presented as the 2019 Cambridge Quarterly Neuroethics Network Charcot Lecture, traces the nosology of disorders of consciousness in light of 2018 practice guidelines promulgated by the American Academy of Neurology, the American College of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research. By exploring the ancient origins of Jennett and Plum’s persistent vegetative state and subsequent refinements in the classification of disorders of consciousness—epitomized by the minimally conscious state, cognitive motor dissociation, and the recently described chronic vegetative state—the author argues that there is a counter-narrative to the one linking these conditions to the right to die. Instead, there is a more nuanced schema distinguishing futility from utility, informed by technical advances now able to identify covert consciousness contemplated by Jennett and Plum. Their prescience foreshadows recent developments in the disorders of consciousness literature yielding a layered legacy with implications for society’s normative and legal obligations to these patients.

Moralism in bioethics and elsewhere means going beyond accepted moral principles, either by exaggerating good ethical concerns, by applying them to areas where they do not belong, or simply by assuming anything else than concrete physical or mental harm as normative guides. This paper explores the conceptual background of moralism especially in the consequentialist tradition, presents cases of allegedly bad moralism in the light of this exploration, introduces six approaches to justice, and argues that these approaches question our prevailing views on the goodness and badness of moralism in its various forms.

Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking—including decisions about life-sustaining treatment—even though the prognostic value of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: (1) Surrogate decisionmakers may misinterpret results; (2) Results may create false hope about the prospects of recovery; (3) There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care.

Child sexual abuse is a global problem with significant emotional, psychological, and financial implications to victims, perpetrators, and society. Most child sexual abuse prevention programs target young children or those who have already engaged in abusive behavior, in order to prevent further offending. There are numerous secondary prevention programs targeting individuals at-risk of various health conditions in an effort to reduce the likelihood they will go on to experience a particular illness or disease. Considerable research exists regarding the risk factors for engaging in child sexual abuse and more specifically the factors contributing to reoffense. We argue that engaging in secondary prevention programs for people with pedophilia, in order to prevent child sexual abuse, is an ethically responsible and necessary practice. Secondary prevention programs with this focus are reviewed, along with the implications of mandatory reporting in doing this work.

During the previous years, voluntary moral bioenhancement (VMBE) has been contrasted to compulsory moral bioenhancement (CMBE). In this paper a third possible type of moral bioenhancement is discussed: genome editing for moral enhancement of the unborn that is neither voluntary nor compulsory, but involuntary. Involuntary moral bioenhancement (IMBE) might engineer people who will be more moral than they otherwise would have been. The possibilities of genome editing aimed at moral enhancement of our offspring is assessed. It is argued that genome editing might have the potential to engineer our offspring in three domains: to be more empathetic, to be less violently aggressive, and to have a higher potential for complex moral reflection. Genome editing is discussed in these three domains, and a proposal made that a combination of VMBE and IMBE might be the best option humans have to become better.

A country’s healthcare system—the protection and healing of some its weakest people, its sick and injured—could be considered to be one of the most definitive expressions of its national morality. In recent decades, Ireland has experienced profound cultural changes; from a mostly monocultural and religious society to a multi-ethnic one, where secular ideas predominate. Economically, it is largely neoliberal, with one of the world’s most open economies, and one of its lowest corporate tax rates; though there is also a welfare state. Its healthcare system has reflected these cultural changes. The system has evolved, gradually, from being run almost exclusively by religious groups, to becoming essentially secular in nature (though religious groups are still involved at the ownership level). Overall, the system is run according to the two competing secular ideologies which currently predominate; it is a two-tier system, with a mix of a neoliberally oriented (though government subsidized) private system, and a public system. The latter has been starved of resources in recent decades; so to achieve good, or at times adequate healthcare, it is almost essential to have private health insurance (which about half of the population have).

This two-tier system has led to significant concerns and occasional scandals; for example, patients dying while on waiting lists for public treatment, who could have been treated and possibly saved if they had health insurance. A purely ethical approach to healthcare—with the aim of healing the sick—has been mixed with competing motives, such as the desire for profit in the private sector, or for short term savings and box-ticking in the public system. Thus, good healthcare practice and best moral practice are being undermined by competing agendas.

In this article, I describe and reflect ethically on the Irish healthcare system, and how it has evolved to its current state. I also discuss how dysfunction in the healthcare system, leading to the death of a pregnant woman, Savita Halappanavar, was a major factor in a constitutional ban on abortion being overturned.

Disturbing cases continue to be published of patients declared brain dead who later were found to have a few intact brain functions. We address the reasons for the mismatch between the whole-brain criterion and brain death tests, and suggest solutions. Many of the cases result from diagnostic errors in brain death determination. Others probably result from a tiny amount of residual blood flow to the brain despite intracranial circulatory arrest. Strategies to lessen the mismatch include improving brain death determination training for physicians, mandating a test showing complete intracranial circulatory arrest, or revising the whole-brain criterion.

The advent of CRISPR-Cas9 technology has increased attention, and contention, regarding the use and regulation of genome editing technologies. Public discussions continue to give evidence of this debate falling back into the previous polarized positions of technological enthusiasts versus those who are more cautious in their approach. One response to this contentious relapse could be to view this promising and problematic new technology from a radically different perspective that embraces both the excitement of this technological advance and the prudence necessary to use it well. The thought of Teilhard de Chardin provides this desired perspective, and some insights that may help carry forward public discussions to achieve widely accepted uses and regulations.

In a recent article in this journal, Steve Clarke (2017) identifies two different bases for conscience-based refusals in healthcare: (1) all-things-considered moral judgments, and (2) the dictates of conscience. He argues that these two bases have distinct roles in justifying conscientious objection. However, accepting that there are these two bases, I argue that both are not able to justify conscientious objection. In particular, I argue that the second basis of the dictates of conscience cannot justify conscience-based refusal in a healthcare context. Even if someone objects in a healthcare context on the basis of the dictates of her conscience, and even if we can explain why she objects with reference to the dictates of her conscience, her objection will only be justified if she makes a judgment.

Aaron Ancell and Walter Sinnott-Armstrong (A&SA) propose a pragmatic approach to problems arising from conscientious objections in healthcare. Their primary focus is on private healthcare systems like that in the United States. A&SA defend three claims: (i) many conscientious objections in healthcare are morally permissible and should be lawful, (ii) conscientious objections that involve invidious discrimination are morally impermissible, but (iii) even invidiously-discriminatory conscientious objections should not always be unlawful, as there is a better way to protect patient rights. Pursuant to (iii), A&SA propose a framework that legally allows discriminatory conscientious objections, but that shifts the financial costs associated with such objections from patients to the clinics that employ doctors who discriminate against patients. Though their proposal is controversial, it has attractive features, and merits further discussion. In this paper, I remain neutral on the third claim A&SA advance in support of their proposal, but point out a problem with the two first claims. In the light of my criticisms, I propose to modify their proposal so that costs are shifted to clinics in a broader range of cases.

How should we regulate genome editing in the face of persistent substantive disagreement about the moral status of this technology and its applications? In this paper, we aim to contribute to resolving this question. We first present two diametrically opposed possible approaches to the regulation of genome editing. A first approach, which we refer to as “elitist,” is inspired by Joshua Greene’s work in moral psychology. It aims to derive at an abstract theoretical level what preferences people would have if they were committed to implementing public policies regulating genome editing in a context of ethical pluralism. The second approach, which we refer to as the democratic approach, defended by Francoise Baylis and Sheila Jasanoff et al., emphasizes the importance of including the public’s expressed attitudes in the regulation of genome editing. After pointing out a serious shortcoming with each of these approaches, we propose our own favored approach—the “enlightened democracy” approach—which attempts to combine the strengths of the elitist and democratic approaches while avoiding their weaknesses.