Dominic Wilkinson | University of Oxford (original) (raw)

Books by Dominic Wilkinson

Research paper thumbnail of Challenges and Limits in Deciding with Children

Deciding With Children , 2024

Research paper thumbnail of Death or Disability? The 'Carmentis Machine' and decision-making for critically ill children

In ancient Rome parents would consult the priestess Carmentis shortly after birth to obtain proph... more In ancient Rome parents would consult the priestess Carmentis shortly after birth to obtain prophecies of the future of their newborn infant. Today, parents and doctors of critically ill children consult a different oracle. Neuroimaging provides a vision of the child's future, particularly of the nature and severity of any disability. Based on the results of brain scans and other tests doctors and parents face heart-breaking decisions about whether or not to continue intensive treatment or to allow the child to die.
Paediatrician and ethicist Dominic Wilkinson looks at the profound and contentious ethical issues facing those who work in intensive care caring for critically ill children and infants. When should infants or children be allowed to die? How accurate are predictions of future quality of life? How much say should parents have in these decisions? How should they deal with uncertainty about the future? He combines philosophy, medicine and science to shed light on current and future dilemmas.

Research paper thumbnail of Paediatric Handbook (7th Edition)

Papers by Dominic Wilkinson

Research paper thumbnail of Scaffolding Informed Consent

Journal of Medical Ethics, 2024

The principle of respecting patient autonomy underpins the concept and practice of informed conse... more The principle of respecting patient autonomy underpins the concept and practice of informed consent. Yet current approaches to consent often ignore the ways in which the exercise of autonomy is deeply epistemically dependent.
In this paper, we draw on philosophical descriptions of autonomy “scaffolding” and apply them to informed consent in medicine. We examine how this relates to other models of the doctor patient relationship and other theories (for example, the notion of relational autonomy). A focus on scaffolding autonomy reframes the justification for existing ways of supporting decisions. In other cases, it suggests a need to rethink how, when and where professionals obtain consent. It may highlight the benefit of technology for supporting decisions.
Finally, we consider the implications for some high-stakes decisions where autonomy is thought to be critical, for example termination of pregnancy. We argue that such decisions should not be free from all sources of influence – rather that they should be protected from undesired influence.

Research paper thumbnail of Parfitian Priority, Gene Therapy and Disability

Journal of Medicine and Philosophy, 2024

Gene therapies for severe genetic disease are often highly expensive. In deciding whether or when... more Gene therapies for severe genetic disease are often highly expensive. In deciding whether or when to provide them, one ethical consideration is the benefit of treatment, relative to cost. But a separate consideration is concern for medical need, and the desire to benefit those who are worse off. The latter is a prioritarian concern. But how should we apply prioritarianism to decisions about gene therapy, particularly since such treatments might affect which individuals come into existence?
That question is the main aim of this paper. I focus on a particular version of Prioritarianism articulated and defended by Derek Parfit. My primary aim is to explore how, if we were to adopt such an account, we should interpret and practically apply this in medical ethics. In doing so, I will assess how it fits with other elements of Parfit’s philosophy. I defend a new ‘time-relative’ version of priority.

Research paper thumbnail of Ethics Roundtable: Choice and Autonomy in Obstetrics

Journal of Medical Ethics , 2024

Decisions about how and where they deliver their baby are extremely important to pregnant women. ... more Decisions about how and where they deliver their baby are extremely important to pregnant women. There are very strong ethical norms that women’s autonomy should be respected, and that plans around birth should be personalized.

However, there appear to be profound challenges in practice to respecting women’s choices in pregnancy and in labour. Choices carry risks and consequences – to the woman and her child; also potentially to her caregivers and to other women.
What does it mean for women’s autonomy be respected in obstetrics? How should health professionals respond to refusals of treatment or to requests for care outside normal guidelines? What are the ethical limits to autonomy? In this clinical ethics roundtable, service users, midwives, obstetricians, philosophers and ethicists respond to two hypothetical cases drawn from real-life scenarios.

Research paper thumbnail of Augmenting research consent: Should large language models (LLMs) be used for informed consent to clinical research?

Research Ethics, 2024

Artificial intelligence (AI) is transforming various aspects of clinical research, from augmentin... more Artificial intelligence (AI) is transforming various aspects of clinical research, from augmenting participant selection processes (Yuan et al., 2023) and automating clinical data analyses, (AlShehri et al., 2024) to assisting in academic writing. (HosseiniResnik and Holmes, 2023) Following recent advances in generative AI technology, exemplified by OpenAI’s ChatGPT, (Kung et al., 2023) researchers are now considering using such systems based on large language models (LLMs) to enhance the informed consent process in clinical research. (Savage et al., 2024) This follows similar proposals to use LLMs to improve consent-taking for medical procedures as part of standard patient care. (Allen et al., 2024)

While there is one previous study which claims to use an LLM to obtain consent from prospective participants for clinical research, (Savage et al., 2023) in fact this model is based on a rule-based system with fixed responses which does not utilise the full capabilities of generative AI to adapt dynamically to individual participant responses and concerns. Therefore, an actual prototype of an LLM for clinical research consent (CRC) is yet to be developed and trialled, though similar models have been proposed for patients’ consent in clinical practice. (Aydin et al., 2023)

Research paper thumbnail of A Wish to Die Trying to Live: Unwise or Incapacitous? The Case of University Hospitals Birmingham NHS Foundation Trust v 'ST'

Journal of Medical Ethics, 2024

The recent legal dispute about medical treatment for a 19-year-old patient (‘ST’, Sudiksha Thirum... more The recent legal dispute about medical treatment for a 19-year-old patient (‘ST’, Sudiksha Thirumalesh) in A NHS Trust v ST & Ors [2023] raised several challenging ethical issues. While Sudiksha’s case bears similarities to other high-profile cases in England and Wales, there are key differences. Crucially, Sudiksha herself was part of the disagreement. She was alert, communicative, and sought to advocate for herself. Furthermore, this case was framed in the courts as pivoting not on considerations of best interests but on a determination of decisional capacity. Sudiksha was deemed to lack capacity because she did not believe her doctors’ view of her prognosis.

While the legal questions in the case were central to a recent Court of Appeal decision (which overturned the original finding), in this commentary, we focus on the ethical questions therein. We start by describing Sukisha’s court case and the initial judgment. We then offer an ethical analysis of the relationship between false beliefs, values, and the “capacity” to make decisions, arguing for a need for particular care when judging patients to lack capacity based purely on “false and fixed beliefs”. After briefly noting the legal basis for the Appeal finding, we offer ethical implications for future cases. Although it appears that Sudiksha had decision-making capacity, this did not settle the ethical question of whether health professionals were obliged to continue treatment that they believed to have no prospect of success.

Research paper thumbnail of Recognising uncertainty: an integrated framework for palliative care in perinatal medicine

Archives of Disease in Childhood, 2024

In perinatal medicine the number of babies with life-limiting or life-threatening conditions is i... more In perinatal medicine the number of babies with life-limiting or life-threatening conditions is increasing and the benefits of providing palliative care with a holistic, interdisciplinary approach are well documented. It can be particularly challenging, however, to integrate palliative care into routine care where there exists uncertainty about a baby’s diagnosis or potential outcome.
This framework, developed collaboratively by the British Association of Perinatal Medicine (BAPM) and the Association of Paediatric Palliative Medicine (APPM), offers supportive guidance for all healthcare professionals working in perinatal medicine across antenatal and neonatal services. It explicitly acknowledges that palliative care is not just for babies who are dying are who will certainly die in early life; incorporating a palliative approach into antenatal and neonatal care for all babies with an uncertain outcome can be particularly valuable. The framework provides guidance on recognising babies who may benefit from palliative care and outlines the key elements of perinatal palliative care: holistic family support, empowering parents to be parents, parallel planning, symptom management and loss and bereavement care. It provides recommendations for the delivery of palliative care services, advocating for a unified approach that involves all members of the perinatal team, supported by specialist services as needed.
This framework calls for a shift in the philosophy and practice of perinatal care to integrate palliative care into the everyday and to recognise and embrace the challenge of uncertain prognosis.

Research paper thumbnail of Proportionality, wrongs and equipoise for natural immunity exemptions: response to commentators

Journal of Medical Ethics, Aug 4, 2022

We would like to thank each of the commentators on our feature article for their thoughtful engag... more We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about the need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies. Unfortunately, we lack the space to directly engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch's concern about the appropriate standard of proof in this context.

Research paper thumbnail of Consent GPT: Is It Ethical to Delegate Procedural Consent to Conversational AI?

SSRN Electronic Journal

Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamenta... more Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamental part of safe and ethical clinical practice. Currently, it is routine for a significant part of the consent process to be delegated to members of the clinical team not performing the procedure (e.g. junior doctors). However, it is common for consent-taking delegates to lack sufficient time and clinical knowledge to adequately promote patient autonomy and informed decision-making. Such problems might be addressed in a number of ways. One possible solution to this clinical dilemma is through the use of conversational artificial intelligence (AI) using large language models (LLMs). There is considerable interest in the potential benefits of such models in medicine. For delegated procedural consent, LLM could improve patients’ access to the relevant procedural information and therefore enhance informed decision-making. In this paper, we first outline a hypothetical example of delegation of consent to LLMs prior to surgery. We then discuss existing clinical guidelines for consent delegation and some of the ways in which current practice may fail to meet the ethical purposes of informed consent. We outline and discuss the ethical implications of delegating consent to LLMs in medicine concluding that at least in certain clinical situations, the benefits of LLMs potentially far outweigh those of current practices.

Research paper thumbnail of Morally Relevant Patient Features in Ventilator Triage Survey

Research paper thumbnail of Ventilator Triage Decision-Making Survey

Research paper thumbnail of Personal ethical settings for driverless cars and the utility paradox: An ethical analysis of public attitudes in UK and Japan

PLOS ONE, Nov 15, 2022

Driverless cars are predicted to dramatically reduce collisions and casualties on the roads. Howe... more Driverless cars are predicted to dramatically reduce collisions and casualties on the roads. However, there has been controversy about how they should be programmed to respond in the event of an unavoidable collision. Should they aim to save the most lives, prioritise the lives of pedestrians, or occupants of the vehicle? Some have argued that driverless cars should all be programmed to minimise total casualties. While this would appear to have wide international public support, previous work has also suggested regional variation and public reluctance to purchase driverless cars with such a mandated ethical setting. The possibility that algorithms designed to minimise collision fatalities would lead to reduced consumer uptake of driverless cars and thereby to higher overall road deaths, represents a potential "utility paradox". To investigate this paradox further, we examined the views of the general public about driverless cars in two online surveys in the UK and Japan, examining the influence of choice of a "personal ethical setting" as well as of framing on hypothetical purchase decisions. The personal ethical setting would allow respondents to choose between a programme which would save the most lives, save occupants or save pedestrians. We found striking differences between UK and Japanese respondents. While a majority of UK respondents wished to buy driverless cars that prioritise the most lives or their family members' lives, Japanese survey participants preferred to save pedestrians. We observed reduced willingness to purchase driverless cars with a mandated ethical setting (compared to offering choice) in both countries. It appears that the public values relevant to programming of driverless cars differ between UK and Japan. The highest uptake of driverless cars in both countries can be achieved by providing a personal ethical setting. Since uptake of driverless cars (rather than specific algorithm used) is potentially the biggest factor in reducing in traffic related accidents, providing some choice of ethical settings may be optimal for driverless cars according to a range of plausible ethical theories.

Research paper thumbnail of Race and resource allocation: an online survey of US and UK adults’ attitudes toward COVID-19 ventilator and vaccine distribution

BMJ Open

ObjectiveThis study aimed to assess US/UK adults’ attitudes towards COVID-19 ventilator and vacci... more ObjectiveThis study aimed to assess US/UK adults’ attitudes towards COVID-19 ventilator and vaccine allocation.DesignOnline survey including US and UK adults, sampled to be representative for sex, age, race, household income and employment. A total of 2580 participated (women=1289, age range=18 to 85 years, Black American=114, BAME=138).InterventionsParticipants were asked to allocate ventilators or vaccines in scenarios involving individuals or groups with different medical risk and additional risk factors.ResultsParticipant race did not impact vaccine or ventilator allocation decisions in the USA, but did impact ventilator allocation attitudes in the UK (F(4,602)=6.95, p<0.001). When a racial minority or white patient had identical chances of survival, 14.8% allocated a ventilator to the minority patient (UK BAME participants: 24.4%) and 68.9% chose to toss a coin. When the racial minority patient had a 10% lower chance of survival, 12.4% participants allocated them the ventila...

Research paper thumbnail of Newborn resuscitation and support of transition of infants at birth

Notfall & Rettungsmedizin, Jun 2, 2021

Versorgung und Reanimation des Neugeborenen nach der Geburt Leitlinien des European Resuscitation... more Versorgung und Reanimation des Neugeborenen nach der Geburt Leitlinien des European Resuscitation Council 2021 Zusatzmaterial online Zusätzliche Informationen sind in der Online-Version dieses Artikels (

Research paper thumbnail of Individualised decision making: interpretation of risk for extremely preterm infants—a survey of UK neonatal professionals

Archives of Disease in Childhood - Fetal and Neonatal Edition, 2021

BackgroundThe British Association of Perinatal Medicine (BAPM) published a revised framework for ... more BackgroundThe British Association of Perinatal Medicine (BAPM) published a revised framework for perinatal management of extremely preterm infants (EPIs) in 2019. We aimed to assess UK neonatal professionals’ interpretation of elements of this framework, as well as the consistency of their estimates of outcome for EPIs.MethodsAn online survey gave participants five cases involving anticipated extremely preterm birth with different favourable and unfavourable risk factors. Respondents were asked to assign a risk category and management option using the BAPM framework and to estimate the chance of survival if the baby received active resuscitation and the chance of severe disability if they survived.ResultsRespondents were consistent in interpretation of risk categories. The majority would follow parental wishes about management. Management decisions did not always correspond with risk assessment, with less inclination to recommend palliative (comfort) care. There were wide estimates ...

Research paper thumbnail of Which features of patients are morally relevant in ventilator triage? A survey of the UK public

BMC Medical Ethics, 2022

BackgroundIn the early stages of the COVID-19 pandemic, many health systems, including those in t... more BackgroundIn the early stages of the COVID-19 pandemic, many health systems, including those in the UK, developed triage guidelines to manage severe shortages of ventilators. At present, there is an insufficient understanding of how the public views these guidelines, and little evidence on which features of a patient the public believe should and should not be considered in ventilator triage.MethodsTwo surveys were conducted with representative UK samples. In the first survey, 525 participants were asked in an open-ended format to provide features they thought should and should not be considered in allocating ventilators for COVID-19 patients when not enough ventilators are available. In the second survey, 505 participants were presented with 30 features identified from the first study, and were asked if these features should count in favour of a patient with the feature getting a ventilator, count against the patient, or neither. Statistical tests were conducted to determine if a f...

Research paper thumbnail of The unnaturalistic fallacy: COVID-19 vaccine mandates should not discriminate against natural immunity

Journal of Medical Ethics, 2022

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evid... more COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other...

Research paper thumbnail of Reply letter to: Intubation in neonatal resuscitation — Compelling necessity or incalculable risk?

Research paper thumbnail of Challenges and Limits in Deciding with Children

Deciding With Children , 2024

Research paper thumbnail of Death or Disability? The 'Carmentis Machine' and decision-making for critically ill children

In ancient Rome parents would consult the priestess Carmentis shortly after birth to obtain proph... more In ancient Rome parents would consult the priestess Carmentis shortly after birth to obtain prophecies of the future of their newborn infant. Today, parents and doctors of critically ill children consult a different oracle. Neuroimaging provides a vision of the child's future, particularly of the nature and severity of any disability. Based on the results of brain scans and other tests doctors and parents face heart-breaking decisions about whether or not to continue intensive treatment or to allow the child to die.
Paediatrician and ethicist Dominic Wilkinson looks at the profound and contentious ethical issues facing those who work in intensive care caring for critically ill children and infants. When should infants or children be allowed to die? How accurate are predictions of future quality of life? How much say should parents have in these decisions? How should they deal with uncertainty about the future? He combines philosophy, medicine and science to shed light on current and future dilemmas.

Research paper thumbnail of Paediatric Handbook (7th Edition)

Research paper thumbnail of Scaffolding Informed Consent

Journal of Medical Ethics, 2024

The principle of respecting patient autonomy underpins the concept and practice of informed conse... more The principle of respecting patient autonomy underpins the concept and practice of informed consent. Yet current approaches to consent often ignore the ways in which the exercise of autonomy is deeply epistemically dependent.
In this paper, we draw on philosophical descriptions of autonomy “scaffolding” and apply them to informed consent in medicine. We examine how this relates to other models of the doctor patient relationship and other theories (for example, the notion of relational autonomy). A focus on scaffolding autonomy reframes the justification for existing ways of supporting decisions. In other cases, it suggests a need to rethink how, when and where professionals obtain consent. It may highlight the benefit of technology for supporting decisions.
Finally, we consider the implications for some high-stakes decisions where autonomy is thought to be critical, for example termination of pregnancy. We argue that such decisions should not be free from all sources of influence – rather that they should be protected from undesired influence.

Research paper thumbnail of Parfitian Priority, Gene Therapy and Disability

Journal of Medicine and Philosophy, 2024

Gene therapies for severe genetic disease are often highly expensive. In deciding whether or when... more Gene therapies for severe genetic disease are often highly expensive. In deciding whether or when to provide them, one ethical consideration is the benefit of treatment, relative to cost. But a separate consideration is concern for medical need, and the desire to benefit those who are worse off. The latter is a prioritarian concern. But how should we apply prioritarianism to decisions about gene therapy, particularly since such treatments might affect which individuals come into existence?
That question is the main aim of this paper. I focus on a particular version of Prioritarianism articulated and defended by Derek Parfit. My primary aim is to explore how, if we were to adopt such an account, we should interpret and practically apply this in medical ethics. In doing so, I will assess how it fits with other elements of Parfit’s philosophy. I defend a new ‘time-relative’ version of priority.

Research paper thumbnail of Ethics Roundtable: Choice and Autonomy in Obstetrics

Journal of Medical Ethics , 2024

Decisions about how and where they deliver their baby are extremely important to pregnant women. ... more Decisions about how and where they deliver their baby are extremely important to pregnant women. There are very strong ethical norms that women’s autonomy should be respected, and that plans around birth should be personalized.

However, there appear to be profound challenges in practice to respecting women’s choices in pregnancy and in labour. Choices carry risks and consequences – to the woman and her child; also potentially to her caregivers and to other women.
What does it mean for women’s autonomy be respected in obstetrics? How should health professionals respond to refusals of treatment or to requests for care outside normal guidelines? What are the ethical limits to autonomy? In this clinical ethics roundtable, service users, midwives, obstetricians, philosophers and ethicists respond to two hypothetical cases drawn from real-life scenarios.

Research paper thumbnail of Augmenting research consent: Should large language models (LLMs) be used for informed consent to clinical research?

Research Ethics, 2024

Artificial intelligence (AI) is transforming various aspects of clinical research, from augmentin... more Artificial intelligence (AI) is transforming various aspects of clinical research, from augmenting participant selection processes (Yuan et al., 2023) and automating clinical data analyses, (AlShehri et al., 2024) to assisting in academic writing. (HosseiniResnik and Holmes, 2023) Following recent advances in generative AI technology, exemplified by OpenAI’s ChatGPT, (Kung et al., 2023) researchers are now considering using such systems based on large language models (LLMs) to enhance the informed consent process in clinical research. (Savage et al., 2024) This follows similar proposals to use LLMs to improve consent-taking for medical procedures as part of standard patient care. (Allen et al., 2024)

While there is one previous study which claims to use an LLM to obtain consent from prospective participants for clinical research, (Savage et al., 2023) in fact this model is based on a rule-based system with fixed responses which does not utilise the full capabilities of generative AI to adapt dynamically to individual participant responses and concerns. Therefore, an actual prototype of an LLM for clinical research consent (CRC) is yet to be developed and trialled, though similar models have been proposed for patients’ consent in clinical practice. (Aydin et al., 2023)

Research paper thumbnail of A Wish to Die Trying to Live: Unwise or Incapacitous? The Case of University Hospitals Birmingham NHS Foundation Trust v 'ST'

Journal of Medical Ethics, 2024

The recent legal dispute about medical treatment for a 19-year-old patient (‘ST’, Sudiksha Thirum... more The recent legal dispute about medical treatment for a 19-year-old patient (‘ST’, Sudiksha Thirumalesh) in A NHS Trust v ST & Ors [2023] raised several challenging ethical issues. While Sudiksha’s case bears similarities to other high-profile cases in England and Wales, there are key differences. Crucially, Sudiksha herself was part of the disagreement. She was alert, communicative, and sought to advocate for herself. Furthermore, this case was framed in the courts as pivoting not on considerations of best interests but on a determination of decisional capacity. Sudiksha was deemed to lack capacity because she did not believe her doctors’ view of her prognosis.

While the legal questions in the case were central to a recent Court of Appeal decision (which overturned the original finding), in this commentary, we focus on the ethical questions therein. We start by describing Sukisha’s court case and the initial judgment. We then offer an ethical analysis of the relationship between false beliefs, values, and the “capacity” to make decisions, arguing for a need for particular care when judging patients to lack capacity based purely on “false and fixed beliefs”. After briefly noting the legal basis for the Appeal finding, we offer ethical implications for future cases. Although it appears that Sudiksha had decision-making capacity, this did not settle the ethical question of whether health professionals were obliged to continue treatment that they believed to have no prospect of success.

Research paper thumbnail of Recognising uncertainty: an integrated framework for palliative care in perinatal medicine

Archives of Disease in Childhood, 2024

In perinatal medicine the number of babies with life-limiting or life-threatening conditions is i... more In perinatal medicine the number of babies with life-limiting or life-threatening conditions is increasing and the benefits of providing palliative care with a holistic, interdisciplinary approach are well documented. It can be particularly challenging, however, to integrate palliative care into routine care where there exists uncertainty about a baby’s diagnosis or potential outcome.
This framework, developed collaboratively by the British Association of Perinatal Medicine (BAPM) and the Association of Paediatric Palliative Medicine (APPM), offers supportive guidance for all healthcare professionals working in perinatal medicine across antenatal and neonatal services. It explicitly acknowledges that palliative care is not just for babies who are dying are who will certainly die in early life; incorporating a palliative approach into antenatal and neonatal care for all babies with an uncertain outcome can be particularly valuable. The framework provides guidance on recognising babies who may benefit from palliative care and outlines the key elements of perinatal palliative care: holistic family support, empowering parents to be parents, parallel planning, symptom management and loss and bereavement care. It provides recommendations for the delivery of palliative care services, advocating for a unified approach that involves all members of the perinatal team, supported by specialist services as needed.
This framework calls for a shift in the philosophy and practice of perinatal care to integrate palliative care into the everyday and to recognise and embrace the challenge of uncertain prognosis.

Research paper thumbnail of Proportionality, wrongs and equipoise for natural immunity exemptions: response to commentators

Journal of Medical Ethics, Aug 4, 2022

We would like to thank each of the commentators on our feature article for their thoughtful engag... more We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about the need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies. Unfortunately, we lack the space to directly engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch's concern about the appropriate standard of proof in this context.

Research paper thumbnail of Consent GPT: Is It Ethical to Delegate Procedural Consent to Conversational AI?

SSRN Electronic Journal

Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamenta... more Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamental part of safe and ethical clinical practice. Currently, it is routine for a significant part of the consent process to be delegated to members of the clinical team not performing the procedure (e.g. junior doctors). However, it is common for consent-taking delegates to lack sufficient time and clinical knowledge to adequately promote patient autonomy and informed decision-making. Such problems might be addressed in a number of ways. One possible solution to this clinical dilemma is through the use of conversational artificial intelligence (AI) using large language models (LLMs). There is considerable interest in the potential benefits of such models in medicine. For delegated procedural consent, LLM could improve patients’ access to the relevant procedural information and therefore enhance informed decision-making. In this paper, we first outline a hypothetical example of delegation of consent to LLMs prior to surgery. We then discuss existing clinical guidelines for consent delegation and some of the ways in which current practice may fail to meet the ethical purposes of informed consent. We outline and discuss the ethical implications of delegating consent to LLMs in medicine concluding that at least in certain clinical situations, the benefits of LLMs potentially far outweigh those of current practices.

Research paper thumbnail of Morally Relevant Patient Features in Ventilator Triage Survey

Research paper thumbnail of Ventilator Triage Decision-Making Survey

Research paper thumbnail of Personal ethical settings for driverless cars and the utility paradox: An ethical analysis of public attitudes in UK and Japan

PLOS ONE, Nov 15, 2022

Driverless cars are predicted to dramatically reduce collisions and casualties on the roads. Howe... more Driverless cars are predicted to dramatically reduce collisions and casualties on the roads. However, there has been controversy about how they should be programmed to respond in the event of an unavoidable collision. Should they aim to save the most lives, prioritise the lives of pedestrians, or occupants of the vehicle? Some have argued that driverless cars should all be programmed to minimise total casualties. While this would appear to have wide international public support, previous work has also suggested regional variation and public reluctance to purchase driverless cars with such a mandated ethical setting. The possibility that algorithms designed to minimise collision fatalities would lead to reduced consumer uptake of driverless cars and thereby to higher overall road deaths, represents a potential "utility paradox". To investigate this paradox further, we examined the views of the general public about driverless cars in two online surveys in the UK and Japan, examining the influence of choice of a "personal ethical setting" as well as of framing on hypothetical purchase decisions. The personal ethical setting would allow respondents to choose between a programme which would save the most lives, save occupants or save pedestrians. We found striking differences between UK and Japanese respondents. While a majority of UK respondents wished to buy driverless cars that prioritise the most lives or their family members' lives, Japanese survey participants preferred to save pedestrians. We observed reduced willingness to purchase driverless cars with a mandated ethical setting (compared to offering choice) in both countries. It appears that the public values relevant to programming of driverless cars differ between UK and Japan. The highest uptake of driverless cars in both countries can be achieved by providing a personal ethical setting. Since uptake of driverless cars (rather than specific algorithm used) is potentially the biggest factor in reducing in traffic related accidents, providing some choice of ethical settings may be optimal for driverless cars according to a range of plausible ethical theories.

Research paper thumbnail of Race and resource allocation: an online survey of US and UK adults’ attitudes toward COVID-19 ventilator and vaccine distribution

BMJ Open

ObjectiveThis study aimed to assess US/UK adults’ attitudes towards COVID-19 ventilator and vacci... more ObjectiveThis study aimed to assess US/UK adults’ attitudes towards COVID-19 ventilator and vaccine allocation.DesignOnline survey including US and UK adults, sampled to be representative for sex, age, race, household income and employment. A total of 2580 participated (women=1289, age range=18 to 85 years, Black American=114, BAME=138).InterventionsParticipants were asked to allocate ventilators or vaccines in scenarios involving individuals or groups with different medical risk and additional risk factors.ResultsParticipant race did not impact vaccine or ventilator allocation decisions in the USA, but did impact ventilator allocation attitudes in the UK (F(4,602)=6.95, p<0.001). When a racial minority or white patient had identical chances of survival, 14.8% allocated a ventilator to the minority patient (UK BAME participants: 24.4%) and 68.9% chose to toss a coin. When the racial minority patient had a 10% lower chance of survival, 12.4% participants allocated them the ventila...

Research paper thumbnail of Newborn resuscitation and support of transition of infants at birth

Notfall & Rettungsmedizin, Jun 2, 2021

Versorgung und Reanimation des Neugeborenen nach der Geburt Leitlinien des European Resuscitation... more Versorgung und Reanimation des Neugeborenen nach der Geburt Leitlinien des European Resuscitation Council 2021 Zusatzmaterial online Zusätzliche Informationen sind in der Online-Version dieses Artikels (

Research paper thumbnail of Individualised decision making: interpretation of risk for extremely preterm infants—a survey of UK neonatal professionals

Archives of Disease in Childhood - Fetal and Neonatal Edition, 2021

BackgroundThe British Association of Perinatal Medicine (BAPM) published a revised framework for ... more BackgroundThe British Association of Perinatal Medicine (BAPM) published a revised framework for perinatal management of extremely preterm infants (EPIs) in 2019. We aimed to assess UK neonatal professionals’ interpretation of elements of this framework, as well as the consistency of their estimates of outcome for EPIs.MethodsAn online survey gave participants five cases involving anticipated extremely preterm birth with different favourable and unfavourable risk factors. Respondents were asked to assign a risk category and management option using the BAPM framework and to estimate the chance of survival if the baby received active resuscitation and the chance of severe disability if they survived.ResultsRespondents were consistent in interpretation of risk categories. The majority would follow parental wishes about management. Management decisions did not always correspond with risk assessment, with less inclination to recommend palliative (comfort) care. There were wide estimates ...

Research paper thumbnail of Which features of patients are morally relevant in ventilator triage? A survey of the UK public

BMC Medical Ethics, 2022

BackgroundIn the early stages of the COVID-19 pandemic, many health systems, including those in t... more BackgroundIn the early stages of the COVID-19 pandemic, many health systems, including those in the UK, developed triage guidelines to manage severe shortages of ventilators. At present, there is an insufficient understanding of how the public views these guidelines, and little evidence on which features of a patient the public believe should and should not be considered in ventilator triage.MethodsTwo surveys were conducted with representative UK samples. In the first survey, 525 participants were asked in an open-ended format to provide features they thought should and should not be considered in allocating ventilators for COVID-19 patients when not enough ventilators are available. In the second survey, 505 participants were presented with 30 features identified from the first study, and were asked if these features should count in favour of a patient with the feature getting a ventilator, count against the patient, or neither. Statistical tests were conducted to determine if a f...

Research paper thumbnail of The unnaturalistic fallacy: COVID-19 vaccine mandates should not discriminate against natural immunity

Journal of Medical Ethics, 2022

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evid... more COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other...

Research paper thumbnail of Reply letter to: Intubation in neonatal resuscitation — Compelling necessity or incalculable risk?

Research paper thumbnail of Ethical and practical questions in satisfying the human right to unconsciousness at the end of life: a reply

Anaesthesia, 2021

The correspondence offers two different perspectives related to our article [1] on general anaest... more The correspondence offers two different perspectives related to our article [1] on general anaesthesia at the end of life (GAEL). Morfey's thoughtful analysis and conclusion [2], that anaesthetists should engage more with the ethical dimensions of inducing unconsciousness, is consistent with the message of our article. Morfey touches upon the complex philosophical question of the difference between death and unconsciousness at the end of life [3]. A full discussion would require more space than is available here; however, it suffices to note that anaesthesia in dying patients is conceptually distinct from death (since the former is in theory reversible, while the latter is not). It is also legally distinct, since no jurisdictions in the world have adopted a 'higher brain' standard of death. The main concern of Iliff et al. [4] is that general anaesthesia could have the 'double effect' of hastening dying and is therefore akin to physicianassisted suicide or euthanasia. As we explained, it is unhelpful and misleading to conflate the two. French law elegantly makes that distinction, where euthanasia is illegal but unconsciousness at end of life is enshrined as a human right. Apart from the fundamental intent being different, we cited several studies confirming that life was not foreshortened when general anaesthesia at the end of life was employed [5]. Even if, in a particular case, careful induction of anaesthesia nevertheless caused cardiorespiratory depression then this is no different from the double effect of using high dose opioid for pain relief in the dying.

Research paper thumbnail of General anaesthesia does not inevitably result in apnoea or require ventilatory support

Anaesthesia, 2021

General anaesthesia does not inevitably result in apnoea or require ventilatory support We thank ... more General anaesthesia does not inevitably result in apnoea or require ventilatory support We thank Yip et al. [1] for their interest in our manuscript [2]. We had, of course, stressed how anaesthesia is a continuum from sedation [3]. We note that Yip et al. stress the close link between the state of 'general anaesthesia' on the one hand and need for 'respiratory support' on the other. The way they present their argument implies that one cannot achieve general anaesthesia without need for respiratory support.

Research paper thumbnail of British laypeople’s attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life

PLOS ONE, 2021

Background Many patients at the end of life require analgesia to relieve pain. Additionally, up t... more Background Many patients at the end of life require analgesia to relieve pain. Additionally, up to 1/5 of patients in the UK receive sedation for refractory symptoms at the end of life. The use of sedation in end-of-life care (EOLC) remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called “terminal anaesthesia”, TA). However, the general public’s views about sedation in EOLC are not known. We sought to investigate the general public’s views to inform policy and practice in the UK. Methods We performed two anonymous online surveys of members of the UK public, sampled to be representative for key demographic characteristics (n = 509). Participants were given a scenario of a hypothetical terminally ill patient with one week of life left. We sought views on the acceptability of providing titrated analgesia, gradual sedation, terminal anaesthesia, an...

Research paper thumbnail of Intensive Care Clinicians’ Perspectives on Ethical Challenges Raised by Rapid Genomic Testing for Critically Ill Infants

Children, 2023

Rapid genomic testing (rGT) enables genomic information to be available in a matter of hours, all... more Rapid genomic testing (rGT) enables genomic information to be available in a matter of hours, allowing it to be used in time-critical settings, such as intensive care units. Although rGT has been shown to improve diagnostic rates in a cost-effective manner, it raises ethical questions around a range of different areas, including obtaining consent and clinical decision making. While some research has examined the perspectives of parents and genetics health professionals, the attitudes of intensive care clinicians remain under explored. To address this gap, we administered an online survey to English-speaking neonatal/paediatric intensivists in Europe, Australasia, and North America. We posed two ethical scenarios: one relating to obtaining consent from the parents and the second assessing decision-making regarding provision of life-sustaining treatments. Descriptive statistics were used to analyse the data. We received 40 responses from 12 countries. 50-75% of intensivists felt explicit parental consent was necessary for rGT. 68-95% felt that a diagnosis from rGT should affect the provision of life-sustaining care. Results were mediated by intensivists’ level of experience. Our findings show divergent attitudes toward ethical issues generated by rGT among intensivists, and suggest the need for guidance regarding ethical decision making for rGT.

Research paper thumbnail of The publication symmetry test: a simple editorial heuristic to combat publication bias

Journal of Clinical and Translational Research, 2017

Premier academic journals—that is, the journals in which many researchers must publish their work... more Premier academic journals—that is, the journals in which many researchers must publish their work in order to maintain or advance their careers—have historically tended to reject papers reporting “negative” or null findings, including those derived from “failed” attempts to replicate prior results [1–3]. This tendency was likely due to three main factors. First, the limited space available for publishing articles when journals were printed exclusively on paper. Second, the prestige-related desire of “top” journals to publish new and exciting find- ings—i.e., “discoveries” (often taken to imply a demonstration that something “works,” as opposed to “fails to work”). And third, the difficulty posed by negative findings in terms of how they should be interpreted: do they suggest that there is no effect of interest to be found, or rather that the experiment, whether in its design or execution, was simply inadequate to show the effect even though it is real [4–6]?