This journal aspires to a global vision of bioethics. It has a distinct editorial category of “Global Bioethics,” and its editorial team and board are globally engaged in both their vision and their lives. However, the Journal of Bioethical Inquiry is published by a global multi-national company, of European origin, and its editorial processes are firmly lodged in the western logical-positive tradition and peer review structures. Scrutiny of its publication and rejection record shows that most papers come from Australasia, North America, and Europe, and no doubt many authors from other regions, cultures, and traditions, would say they are under-represented. There are language barriers for sure and big differences in approach and writing styles. We do need to publish papers that have global interest and open up novel concepts, tell new stories, or describe innovative ways of analyzing ethical issues. In other words, papers that have some generalizable value to settings other than that of the authors in question. It is also clear that countries around the world are at different stages of development in their regulation and societal consideration of the conduct of science and health service delivery. They do this by attempting to implement core values and procedures of the global (but predominantly western) bioethics cannon but also by exploring their own political, religious, and philosophical traditions, and both these paths are represented in our short symposium in this issue, in Latin American, Middle Eastern, and Islamic settings.

We live in an increasingly complex world: family relationships are changing, technology is making inroads into medical treatment, and what was once seemingly impossible is, at times, now possible. The law often struggles to keep up with medical advances and shifting boundaries of relationships as they give rise to legal questions of increasing complexity, but in the absence of specific regulatory frameworks, courts are called upon to apply well-established principles to new issues as they come before them. This is not a problem unique to our era; imagine the days when cars first took to the roads, planes to the sky, sounds were transmitted through radio, or handheld recording devices were introduced. Humanity and technology are constantly evolving, and systems of regulation must also adapt and evolve. The two decisions considered here provide practical examples of how well-established legal tests can be applied to new challenges and fill apparent regulatory gaps so that clarity can be found. Whilst the law is often “in the rear and limping a little” (Mt Isa Mines Ltd v Pusey (1970) 125 CLR 383), it can provide answers to new problems, such as: Is a sperm donor a father and how can a doctor provide information about the unknown (and unknowable) risks of innovative medical treatment?

This issue of the Journal of Bioethical Inquiry (JBI), dedicated to a cross-cultural symposium gathering articles from different countries, is fully consistent with the journal’s mission. JBI is not just an academic journal; it aims at fostering a community of bioethics scholars and practitioners from multiple disciplines and all corners of the world. The four papers included in this volume represent three different and contrasted geographical areas: the Middle East, Latin America and South Asia (specifically the Malayan Archipelago). The bioethical literature from the Middle East remains quite scarce, although a few countries (particularly Jordan) have recently attracted more attention. Latin American voices are not often heard in the field of bioethics, and mostly in papers published in Spanish; and the theoretical analysis on Islam Bioethics in the context of the Malayan Archipelago can be seen as unique. As such, these “unheard voices” are particularly welcome to participate in the dialogue fostered by a cross-cultural perspective within the bioethics community.

The Arab and Islamic world is in cultural, political and ethical flux. Pressures of globalisation contend with ancient ideas and concepts that permeate cultural frameworks. Health professionals are among the many groups battling to accommodate the rapidly changing conditions. In many predominantly Muslim countries intense debates are underway among clinicians about the impact of the forces of change on their practices. To help understand these forces we conducted a study of the experiences of clinicians in the Hashemite Kingdom of Jordan, a Middle Eastern nation state where the overwhelming majority of the population is Muslim. The sample contained 508 doctors and doctors-in-training, of whom 63% were male and 80% were younger than 40 years of age. It included both a quantitative survey, covering a wide range of issues, and qualitative, free-text written responses. Our results demonstrated high levels of disquiet related to the overall organisation and administration of the health care system, the specific content of ethical decisionmaking, and the impact of changing social, cultural and religious factors. Concerns included overcrowding, widespread corruption and hierarchical, non- democratic, management practices, and tensions relating to traditional and modern approaches to ethics, especially in relation to consent, organ donation, confidentiality, privacy, abortion, and the role of women. The roles of religion and religious authorities, the relative importance of the family, and community and tribal obligations were also areas of contention. The study exposes profound divisions and widely differing perspectives among Jordanian doctors and an abiding sense of uncertainty and instability within the profession. Many doctors express ambivalence in relation to both modern trends and traditional precepts. Three main axes of ethical contention were demonstrated, relating to the tensions between: “conservative” and “pragmatic” styles of decision-making; “traditional” approaches and internationalised standards of ethics; and the role of Islam and pressures to disengage ethical decision- making from religious authority. We speculate that these issues and divisions, and the deep sense of disquiet revealed by our data reflect large-scale forces to which Jordanian society is exposed and to a substantial degree may provide a way to understand the ethical predicament of many other countries in the contemporary Arab world.

Objective: To present a narrative review of the history of bioethics in Latin America and of scientific output in this interdisciplinary field. Methods: This was a mixed-methods study. Results: A total of 1458 records were retrieved, of which 1167 met the inclusion criteria. According to the Web of Science classification, the predominant topics of study were medical ethics (n= 488), social sciences and medicine (n= 354), and environmental and public health topics (n= 279). Four themes of bioethics output in the Latin American literature have emerged: (a) issues involving the beginning and end of life, (b) ethics in human research, (c) patient–provider relationships, and (d) ethics training for health professionals. Conclusion: Although bioethics is a growing interdisciplinary field in Latin America, its academic impact is still very low, and programmes are highly concentrated in large urban centres in a few countries. Challenges includes the regional and international impact of local scientific output.

Maqasid al-Shariah based Islamic bioethics is an Islamic bioethics concept which uses the objectives of the Shariah (maqasid al-Shariah) as its approach in analysing and assessing bioethical issues. Analysis based on maqasid al-Shariah based Islamic bioethics will examine any bioethical issues from three main aspects namely intention, method, and output or final goal of the studied issues. Then, the evaluation will be analysed from human interest hierarchy, inclusivity, and degree of certainty. The Islamic bioethics concept is a manifestation of dynamic Islamic jurisprudence which can overcome new complex and complicated bioethical issues such as tri-parent baby technology issues. Therefore, this article will introduce and explain the concept of maqasid al-Shariah based Islamic bioethics and outline a general guidance of maqasid al-Shariah based Islamic bioethics to determine a maqṣad (objective) based on standards of human good or well-being (maslahah) and harm (mafsadah).

The field of Islamic bioethics is currently in development as thinkers delineate its normative content, ethical scope and research methods. Some scholars have offered Islamic bioethical frameworks based on the maqāṣid al-Sharīʿah, the higher objectives of Islamic law, to help advance the field. Accordingly, a recent JBI paper by Ibrahim and colleagues describes a method for using the maqāṣid al-Sharīʿah to provide moral end-goals and deliberative mechanisms for an Islamic bioethics. Herein I highlight critical conceptual and practical gaps in the model with the hopes of fostering greater discussion about how maqāṣid al-Sharīʿah frameworks may fit within Islamic bioethics deliberation.

Although “you are what you eat” is a well-worn cliché, personal identity does not figure prominently in many debates about the ethics of eating interventions. This paper contributes to a growing philosophical literature theorizing the connection between eating and identity and exploring its implications for eating interventions. I explore how “identity-policing,” a key mechanism for the social constitution and maintenance of identity, applies to eating and trace its ethical implications for eating interventions. I argue that identity policing can be harmful and that eating interventions can subject people to these harms by invoking identity policing qua intervention strategy or by encouraging people to eat in ways that subject them to policing from others. While these harms may be outweighed by the benefits of the intervention being promoted, they should nonetheless be acknowledged and accounted for. To aid in these evaluations, I consider factors that modulate the presence and severity of identity-policing and discuss strategies for developing less harmful eating interventions. I conclude by considering the relationship between identity-policing and identity loss caused by long-term diet change. This paper contributes to the centering of identity in food ethics and to a more comprehensive picture of identity’s ethical importance for eating interventions.

This paper discusses the findings of qualitative research that examined the accounts of five “mostly recovered” ex-patients who had experienced transition between two or more eating disorder diagnoses. This study found that, in the minds of participants, the different diagnostic labels were associated with various good or bad character traits. This contributed to the belief in a diagnostic hierarchy, whereby individuals diagnosed with anorexia nervosa were viewed as morally better than those diagnosed with bulimia nervosa or binge eating disorder. Consequently, diagnostic crossover from a “better” to a “worse” eating disorder was often experienced as shameful moral failing, and a new diagnosis impacted the individual’s sense of self-identity. These findings are of significance for both ethicists and clinicians; the paper concludes by outlining the relevance and possible clinical implications of shame in diagnostic crossover and suggesting avenues for future research.

Medicalization occurs when an aspect of embodied humanity is scrutinized by the medical industry, claimed as pathological, and subsumed under medical intervention. Numerous critiques of medicalization appear in academic literature, often put forth by bioethicists who use a variety of “lenses” to make their case. Feminist critiques of medicalization raise the concerns of the politically disenfranchised, thus seeking to protect women—particularly natal sex women—from medical exploitation. This article will focus on three feminist critiques of medicalization, which offer an alternative narrative of sickness and health. I will first briefly describe the philosophical origins of medicalization. Then, I will present three feminist critiques of medicalization. Liberal feminism, trans feminism, and crip feminism tend to regard Western medicine with a hermeneutics of suspicion and draw out potential harms of medicalization of reproductive sexuality, gender, and disability, respectively. While neither these branches of feminism—nor their critiques—are homogenous, they provide much-needed commentaries on phallocentric medicine. I will conclude the paper by arguing for the continual need for feminist critiques of medicalization, using uterus transplantation as a relevant case study.

Research shows that a high majority of parents receiving prenatal diagnosis of intellectual disability terminate pregnancy. They have reasons for rejecting a child with intellectual disabilities—these reasons are, most commonly, beliefs about quality of life for it or them. Without a negative evaluation of intellectual disability, their choice makes no sense. Disability-based abortion has been critiqued through virtue ethics for being inconsistent with admirable moral character. Parental selectivity conflicts with the virtue of acceptingness (the commitment to welcome whatever child comes naturally) and exhibits the vice of wilfulness (the project of picking and choosing what children one will take). In this paper I claim that, beyond failures of moral virtue, disability abortion often involves failures of epistemic virtue on the part of parents. I argue two things: parents believe something false, or at least contested, about life with intellectual disability—and they do so because they are not epistemically conscientious. I first explain why a central motivation for disability abortion—that it prevents harm to the child—is mistaken. I next give a brief account of intellectual virtue and culpable ignorance. I then indicate why many parents fail to be intellectually virtuous when choosing to terminate pregnancy. I focus on elimination of intellectual disability and have little to say about physical and sensory impairments.

Preimplantation genetic diagnosis (PGD) allows the detection of genetic abnormalities in embryos produced through in vitro fertilization (IVF). Current funding models in Australia provide governmental subsidies for couples undergoing IVF, but do not extend to PGD. There are strong reasons for publicly funding PGD that follow from the moral principles of autonomy, beneficence and justice for both parents and children. We examine the objections to our proposal, specifically concerns regarding designer babies and the harm of disabled individuals, and show why these are substantially outweighed by arguments for subsidizing PGD. We argue that an acceptance of PGD is aligned with present attitudes towards procreative decision making and IVF use, and that it should therefore receive government funding.

People with dementia have commonly been excluded from research. The adverse impacts of this exclusion are now being recognized and research literature, position statements, and ethics guidelines increasingly call for inclusion of people with dementia in research. However, few published studies investigate the views of potential participants on taking part in research should they experience dementia-related cognitive impairment. This cross-sectional survey examined the views of people aged sixty and older (n=174) attending hospital outpatient clinics about clinical research participation if they had dementia and impaired decision-making ability. Over 90 percent of respondents were agreeable to participating in a wide range of research activities, such as cognitive testing, physical measurements, imaging procedures, and blood draws. For drug studies, however, agreement dropped to 60 percent. Altruism was a strong motivator for research participation. In regard to who should be involved in decisions about their participation in research during periods of incapacity, respondents mostly preferred the person they appoint as their substitute decision-maker for healthcare matters (88%) or a doctor or health professional on the research team (78%). Over three-quarters (79%) expressed interest in making an advance research directive. The study findings are discussed in relation to law reforms in Australia that aim to strengthen respect and inclusion for people with impaired decision-making capacity, especially by providing frameworks for advance planning for research participation.

Decision-making capacity in children and adolescents in healthcare requires thorough assessment: the minor’s maturity, understanding of the decision, risk of the situation and contextual factors needs to be explored. The intention was to design and validate a test—the Maturtest—to assess the maturity of minors in decision-making processes in healthcare. A reasoning test on moral conflicts for adolescents was designed to infer the degree of maturity of minors applied to decision-making regarding their own health. The test was completed by a sample of 441 adolescents aged from twelve to sixteen, with a corresponding analysis of their psychometric skills to measure feasibility, viability, reliability, validity, and sensitivity to change. Psychometric test results showed viability, reliability, validity, and sensitivity to change. High correlation (correlation index = 0.74) between the test score and the reference method were notable. A high stability was obtained with an intraclass correlation coefficient (r = 0.77). The average response time of the test was twenty-three minutes. This test measures the moral maturity of adolescents. It is presented as an objective, useful, valid, reliable tool, easy to fill out, edit and apply in a healthcare context. It helps to assess the maturity of minors faced with a decision.

The World Anti-Doping Agency (WADA) sets out a detailed description of what its own conception of the “spirit of sport” as employed in the World Anti-Doping Code (WADC) entails. However, controversies as to the significance and meaning to be ascribed to the term abound in the literature. In order to unravel the core of the debates and to move discussions forward, the authors aimed at reviewing understandings of the spirit of sport in the conceptual literature. The main databases were searched using relevant keywords. After the inclusion and exclusion criteria were applied, eighteen publications were included in the review. The most striking result to emerge from the data is the multivalence of the concept of spirit of sport. Our thematic analysis generated the contestability of the spirit of sport as the predominant theme in the conceptual literature. There is a need for empirical research to generate data about perspectives on the spirit of sport from other stakeholders especially those of the athletes themselves.

Balfe argues against enhanced interrogation. He particularly focuses on the involvement of U.S. healthcare professionals in enhanced interrogation. He identifies several empirical and normative factors and argues that they are not good reasons to morally justify enhanced interrogation. I argue that his argument can be improved by making two points. First, Balfe considers the reasoning of those healthcare professionals as utilitarian. However, careful consideration of their ideas reveals that their reasoning is consequential rather than utilitarian evaluation. Second, torture is a serious human rights abuse. When healthcare professionals become involved in enhanced interrogation, they violate not only human rights against torture but also human rights to health. Considering the consequential reasoning against human rights abuses, healthcare professionals’ involvement in enhanced interrogation is not morally justified. Supplementing Balfe’s position with these two points makes his argument more complete and convincing, and hence it can contribute to the way which shows that enhanced interrogation is not justified by consequential evaluation.

This comment responds to a defence of the right to try, a law adopted by the United States and many state governments that seeks to expand access to experimental drugs. In defending the right to try, Meyerson argues that it is part of a broader rights-based approach for patient access to innovation. But a drug that is still part of the experimental process may not be an innovation—indeed, it may be a failure and even harmful or dangerous. Further, this approach does not weigh other rights that may be at stake such as the property rights of the drug maker or the rights of future patients seeking access to cures. Lastly, research has found that many patients often fail to receive recommended treatments and preventive care from their providers, let alone experimental or innovative therapies. These policy problems suggest that there is a need for patients to have a greater involvement and role in their care and in how research funding is made, but the right to try fails to address these problems.

Oliver Kim’s (2019) criticisms of my article are a mixture of inaccuracies, non sequiturs, and terminological points.

1. (i)He states that I defend the Right to Try laws.
2. (ii)He states that I believe that patients have a right to access innovations “without interference by government agencies or institutional decision-makers.”
3. (iii)He objects that my approach “does not weigh” the other rights at stake.
4. (iv)He says that I have confused innovation with experimentation.
5. (v)He complains that patients often fail to receive recommended treatments, let alone experimental or innovative therapies, and that Right to Try fails to address this problem.

None of these claims survives scrutiny. I will address them in turn.

“Jane” is a mother of two, who was referred for psychotherapy. However, Jane had misgivings about engaging in the offered psychotherapy because of threats made by her domestically violent partner. The therapy sessions are audio recorded for the purpose of professional supervision and clinician reflective practices. Jane’s partner had threatened to subpoena the therapy recordings to legally separate Jane from her children. This article focuses on how three different parts of Jane’s multidisciplinary care (i.e. clinicians, policy professionals and medico-legal professionals) exhibit different competing ethical priorities. Psychotherapeutic clinicians private use of audio recordings of the therapy enhances patient care and their own professional development but with the risk of concealing possible unethical behaviour by either party. Medico-legal access to the therapy recordings preserves potentially relevant evidence in the pursuit of justice but risks the interpretation of the psychotherapeutic information outside of the therapeutic context. Policies advocating the inclusion of the therapy recordings in the medical record improves clinician (and health service) accountability but risks harming the vulnerable patient due to threats to patient-therapist confidentiality.

Carina Fourie and Annette Rid’s edited volume What Is Enough? Sufficiency, Justice, and Health comprises fifteen original contributions which explore the possibility of a sufficientarian approach to healthcare priority setting and resource allocation. Sufficientarianism is a well-established theory of distributive justice, which tells us that justice requires that each person has “enough,” and assigns particular importance to a threshold level of goods under which no person must fall. Sufficiency is under-explored as a distributive principle in the healthcare context, and this book makes a strong case for its inclusion among more familiar principles of justice such as utility, priority to the worst off, and equality.