International treaties have mostly failed to produce their intended effects.

There are over 250,000 international treaties that aim to foster global cooperation. But are treaties actually helpful for addressing global challenges? This systematic field-wide evidence synthesis of 224 primary studies and meta-analysis of the higher-quality 82 studies finds treaties have mostly failed to produce their intended effects. The only exceptions are treaties governing international trade and finance, which consistently produced intended effects. We also found evidence that impactful treaties achieve their effects through socialization and normative processes rather than longer-term legal processes and that enforcement mechanisms are the only modifiable treaty design choice with the potential to improve the effectiveness of treaties governing environmental, human rights, humanitarian, maritime, and security policy domains. This evidence synthesis raises doubts about the value of international treaties that neither regulate trade or finance nor contain enforcement mechanisms.

Human Rights in Hospitals: an End to Routine Shackling.

Medical students (NSB, NM, JDW) spearheaded revision of the policy and clinical practice for shackling incarcerated patients at Boston Medical Center (BMC), the largest safety net hospital in New England. In American hospitals, routine shackling of incarcerated patients with metal restraints is widespread-except for perinatal patients-regardless of consciousness, mobility, illness severity, or age. The modified policy includes individualized assessments and allows incarcerated patients to be unshackled if they meet defined criteria. The students also formed the Stop Shackling Patients Coalition (SSP Coalition) of clinicians, public health practitioners, human rights advocates, and community members determined to humanize the inpatient treatment of incarcerated patients. Changes pioneered at BMC led the Mass General Brigham health system to follow suit. The Massachusetts Medical Society adopted a resolution authored by the SSP Coalition, which condemned universal shackling and advocated for use of the least restrictive alternative. This will be presented to the American Medical Association in June 2024. The Coalition led a similar effort to coauthor a policy statement on the issue, which was formally adopted by the American Public Health Association in November 2023. Most importantly, in an unprecedented human rights victory, a BMC patient who was incarcerated, sedated, and intubated was unshackled by correctional officers for the purpose of preserving human dignity.

Why identification matters: an explorative study on six cases of family reunification.

The escalating phenomenon of migration, accompanied by a disturbing surge in associated tragedies, has persistently violated internationally protected human rights. Absence of physical evidence, namely the presence of adequately identified corpses, may impede the full enjoyment of human rights and-in some cases-the course of justice as it obstructs the initiation of legal proceedings against individuals implicated in causing such catastrophes. It also presents administrative obstacles, as death certificates are indispensable in legitimizing statuses like orphanhood and widowhood. Family reunification, particularly for orphans, plays a significant role for those attempting to reconnect with their relatives all over the world. Likewise, for mothers, the acknowledgment of their marital status or widowhood can be a pathway to regain their marginalized right to social life. To elucidate this issue, we analyzed six representative cases from the tragic October 3, 2013, shipwreck near the Italian island of Lampedusa, where 366 individuals were retrieved dead from the sea. These cases underscore the practical challenges involved, highlighting the compelling need for continued efforts to ensure that this burdensome problem transcends from being a mere ethical, moral, and legal discourse. Although considerable progresses, these cases also reveal that substantial work still lies ahead. There is a pressing need for improved mechanisms to certify kinship ties, which are often the limiting factor in many reunifications, and can hinder the granting of custody to children. The severity and far-reaching implications of this problem necessitate thoughtful attention and action, especially considering the ongoing escalation in migration and related fatalities.

Mapping a research-advocacy-policy agenda on human rights and albinism: a mixed methods project.

BACKGROUND: Persons with albinism face challenges to their wellbeing, safety, and security, ranging from vision impairment and skin cancer to stigma and discrimination. In some regions, they also face human rights atrocities including mutilation and murder. Research on human rights and albinism is a relatively new field that has gained momentum since the United Nations appointment of an Independent Expert on the enjoyment of human rights by persons with albinism. In this paper, we present the results of a mixed methods study undertaken to identify priorities for research, advocacy, and policy on albinism and human rights. METHODS: The first component was a synthesis of peer-reviewed and grey literatures at the nexus of albinism, spiritual/cultural beliefs and practices, and human rights. We then conducted a priority-setting survey, informed by Delphi methods, on extant knowledge-practice gaps and research, advocacy, and policy priorities. Inclusion criteria included demonstrated expertise in the field (e.g., peer-reviewed publications, funded research), membership on national or international associations, or advocacy (civil society organizations) of more than 2 years in albinism and human rights. Thereafter, we gathered leading researchers, policy-makers, and civil society stakeholders for a Roundtable to gain consensus on these priorities. RESULTS: Access to skin and vision care, and education were not deemed high priority for research, likely because the evidence supporting the need for these is well established. However, they were priorities for advocacy and policy: what is needed is mobilization of this evidence through advocacy and implementation of such services (policy). Other social determinants of health (rurality, poverty, and gender equality) are present as subtext in the findings, more so than priorities for research, advocacy, or policy, despite their preponderance in the lives of persons with albinism. Research was prioritized on stigma and discrimination; advocacy; and witchcraft, but with some differentiation between Global North and Global South priorities. Priorities for research, advocacy, and policy vary in keeping with the explanatory frameworks at play, including how harmful practices and witchcraft are viewed. CONCLUSIONS: The lived experience of albinism is profoundly shaped by the social determinants of health (SDOH). Threats to the security and well-being of persons with albinism should be viewed through a human rights lens that encompasses the explanatory frameworks at play.

Discovering significant topics from legal decisions with selective inference.

We propose and evaluate an automated pipeline for discovering significant topics from legal decision texts by passing features synthesized with topic models through penalized regressions and post-selection significance tests. The method identifies case topics significantly correlated with outcomes, topic-word distributions which can be manually interpreted to gain insights about significant topics, and case-topic weights which can be used to identify representative cases for each topic. We demonstrate the method on a new dataset of domain name disputes and a canonical dataset of European Court of Human Rights violation cases. Topic models based on latent semantic analysis as well as language model embeddings are evaluated. We show that topics derived by the pipeline are consistent with legal doctrines in both areas and can be useful in other related legal analysis tasks. This article is part of the theme issue 'A complexity science approach to law and governance'.

Messages about climate, pollution and social justice harms of tobacco as motivators to quit: an untapped communication opportunity?

BACKGROUND: Campaigns highlighting the health harms of smoking have demonstrated success in motivating people who smoke to quit. Tobacco production and use also exert a toll on the environment, sustainable development and human rights. However, messages highlighting these harms of tobacco have been relatively unexplored as a cessation motivation strategy. In this study, we examined the extent to which a range of messages about climate, pollution and social justice harms of tobacco are perceived as motivating among people who smoke, overall and by sociodemographics. DATA AND METHODS: Australian adults who smoke (n=395) aged 18-59 years reported the 'extent to which each of the following motivated them to quit smoking' and were then presented with messages about climate (four items), pollution (three items) and social justice (three items) harms of tobacco, which they rated on a 5-point scale ranging from 1 'Not at all' to 5 'Very much so' in this online cross-sectional survey. Differences by age, education, gender, socioeconomic status (SES) and geographical region were examined using prevalence ratios from generalised linear models with log-link (Poisson regression). RESULTS: For each of the 10 messages, between one-half and two-thirds of the overall sample perceived them as motivating (49-65%), particularly messages highlighting harms to human or animal life and welfare (all ≥60%). Across all message themes, younger adults (18-35 years) and those who completed tertiary education were more likely to perceive some messages as motivating. Perceived motivation did not vary significantly by gender, SES or geographical region. CONCLUSION: Findings suggest that value-based messaging featuring the environmental and social justice footprint of tobacco is perceived as motivating for smoking cessation, especially among younger people and those with higher education who may be more engaged with these issues. Inclusion of such messages as part of a comprehensive antitobacco communication strategy may provide an untapped opportunity by potentially providing people who smoke with additional compelling reasons to quit.

Towards health with justice: making the tobacco industry accountable through administrative liability.

For many decades, the transnational tobacco industry has evaded the consequences of harming people and the planet. Despite selling a deadly product, it has continued to remain one of the most profitable industries in the world, now venturing into 'wellness and pharmaceutical' businesses as part of its diversification strategy. Meanwhile, efforts to make the tobacco industry pay through court systems have not progressed due to the inherent challenges within the judicial systems in most countries. This paper explores mechanisms for ensuring accountability through administrative liability, including the use of compensation mechanisms and adjudicatory bodies. Such mechanisms operationalise vital principles and practices derived from international law, such as the imposition of effective, proportionate, and dissuasive non-criminal sanctions, victims' right to compensation, and 'polluter pays' principles. Measures such as taxation, surcharges, penalties, financial guarantees or insurance, along with the establishment of adjudicatory bodies and trust funds, are discussed. In order to hold the tobacco industry to account for the wide range of harms caused by its products and its misconduct; policies on 'liability' must clearly articulate how the industry will compensate for past and future harms in a manner that deters it from causing further damage.

Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

INTRODUCTION: Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities. METHODS: A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected. RESULTS: Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback. DISCUSSION: These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour. CONCLUSION: The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.

Female genital mutilation/cutting among girls aged 0-14: evidence from the 2018 Mali Demographic and Health Survey data.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is considered a social norm in many African societies, with varying prevalence among countries. Mali is one of the eight countries with very high prevalence of FGM/C in Africa. This study assessed the individual and contextual factors associated with female FGM/C among girls aged 0-14 years in Mali. METHODS: We obtained data from the 2018 Mali Demographic and Health Survey. The prevalence of FGM/C in girls was presented using percentages while a multilevel binary logistic regression analysis was conducted to assess the predictors of FGM/C and the results were presented using adjusted odds ratios with associated 95% confidence intervals (CIs). RESULTS: The results indicate that more than half (72.7%, 95% CI = 70.4-74.8) of women in Mali with daughters had at least one daughter who has gone through circumcision. The likelihood of circumcision of girls increased with age, with women aged 45-49 having the highest odds compared to those aged 15-19 (aOR = 17.68, CI = 7.91-31.79). A higher likelihood of FGM/C in daughters was observed among women who never read newspaper/magazine (aOR = 2.22, 95% CI = 1.27-3.89), compared to those who read newspaper/magazine at least once a week. Compared to women who are not circumcised, those who had been circumcised were more likely to have their daughters circumcised (aOR = 53.98, 95% CI = 24.91-117.00). CONCLUSION: The study revealed the age of mothers, frequency of reading newspaper/magazine, and circumcision status of mothers, as factors associated with circumcision of girls aged 0-14 in Mali. It is, therefore, imperative for existing interventions and new ones to focus on these factors in order to reduce FGM/C in Mali. This will help Mali to contribute to the global efforts of eliminating all harmful practices, such as child, early and forced marriage and female genital mutilation by 2030.

A human right to pleasure? Sexuality, autonomy and egalitarian strategies.

A growing focus on pleasure in human rights discourse has been used to address patterns of sexual exclusion, often when addressing the problems of people with disabilities (PWD). As convincingly argued by Liberman, however, not all PWD suffer from sexual exclusion, and not all who suffer from sexual exclusion are PWD. Danaher and Liberman have thus argued in various ways for a broader range of measures, addressing sexual exclusion. This article builds on previous research and offers a conceptual framework for addressing sexual pleasure and exclusion in terms of human rights. It argues that human rights aim to safeguard autonomy, which is interpreted as multidimensional. It, thus, divides autonomy into the four dimensions of liberty (freedom from threat and coercion), opportunity (options to choose between), capacity (what an agent is capable of doing) and authenticity (the extent to which choices are genuine). Furthermore, it distinguishes between distinct egalitarian strategies, which offer different problems and possibilities, and may be combined. Thus, there is direct egalitarian distribution, indirect egalitarian distribution, baseline or threshold strategies and general promotion strategies. By way of conclusion, the importance of sexual authenticity as the ultimate aim of sexual rights is emphasised.

Courts, rights and the critically brain-injured patient.

The reality of current clinical practice in the UK is that where a patient's family refuses to agree to testing for brain stem death (BD), such cases will ultimately end up in court. This situation is true of both adults and children and reinforced by recent legal cases. While recourse to the courts might be regrettable in such tragic cases, if public trust in the medical diagnosis of BD is to be maintained all aspects of the process must be conducted in a way that is transparent and open to scrutiny. This is not an 'ineffective expenditure' of resources, but an essential element of a human rights-compliant legal system.

Consent to testing for brain death.

Canada has recently published a new Clinical Practice Guideline on the diagnosis and management of brain death. It states that consent is not necessary to carry out the interventions required to make the diagnosis. A supporting article not only sets out the arguments for this but also contends that 'UK laws similarly carve out an exception, excusing clinicians from a prima facie duty to get consent'. This is supplemented by the claim that recent court decisions in the UK similarly confirm that consent is not required, referencing two judgements in Battersbee We disagree with the authors' interpretation of the law on consent in the UK and argue that there is nothing in Battersbee to support the conclusion that consent to testing is not necessary. Where there is a disagreement about testing for brain death in the UK, court authorisation is required.

Human equality and the impermissibility of abortion: a response to Bozzo.

I have recently offered a defence of human equality, and consequently an argument against abortion. This has been objected to by Bozzo, on the grounds that my account of human equality is unclear and could be grounded in utilitarian or Kantian ethics, that my account struggles to ground the permissibility of therapeutic abortions, and that my proposed foundation for human equality itself is parasitic on a scalar property which generates the same difficulties I am attempting to solve. I provide an account of human equality which cannot easily be grounded in utilitarianism or Kantianism, offer a variety of defences of therapeutic abortion consistent with treating the mother and child equally, and show that even if the value of humanness is ultimately grounded in a scalar quality, my argument succeeds.

Total lockdown and fairness towards the sufferer: an egalitarian response to Savulescu and Cameron.

Savulescu and Cameron supported selectively locking down the elderly during the COVID-19 pandemic on two grounds: first, that preserving total lockdown would entail levelling down and, second, that levelling down is wrong. Their first assumption has been thoroughly addressed, but more can be said about their wider antiegalitarian point that levelling down is simply wrong. Egalitarians are not defenceless against the levelling-down objection. Even though some consider it the most serious challenge to supporters of equality, egalitarianism possesses sound reasons to assert, not only that something valuable is preserved when we level down, but also that preserving it may be, in certain circumstances, preferable to pursuing other fundamental moral goals. Although troublesome from a well-being maximising standpoint, levelling down ensures that healthcare policy reflects a commitment with the idea that people are equal in moral worth. That commitment is important enough to trump certain improvements in individual well-being. In the case of pandemic lockdowns, not all the interests protected by free movement are as fundamental as to pursue them at the cost of equality. Savulescu and Cameron's framework is so reliant on the view that levelling down is wrong that it fails to account for the valuable loss that having the elderly suffer alone represents.

Response: arguments to abolish the legal age limits of access to information about the gamete donor by donor offspring.

The Journal of Medical Ethics previously published on the debate in the UK and the Netherlands concerning the legal age limits imposed on donor-conceived people for access to information about the identity of gamete and embryo donors. In that publication, three arguments were foregrounded against lowering these age limits as a general rule for all donor-conceived people. In this contribution, we engage with these arguments and argue why we think they are insufficient to maintain the age limits. In contrast, we argue for a more suited, contextual and relational ethical framework based on care ethics, which emphasises relational autonomy and its dynamic, contextual development. This framework, we argue, provides a comprehensive approach for the analysis we made of the question of age limits and was applied in research performed in the Netherlands, commissioned by the Dutch Minister of Health. The framework enabled us to weigh the multidisciplinary-legal, psychological, phenomenological and ethical-findings of our research.

Abortion and the basis of equality: a reply to Miller.

Miller has recently argued that the standard liberal and moderate positions on abortion are incapable of grounding the claim that 'all non-disabled adult humans are equal'. The reason, he claims, is such accounts base the intrinsic moral worth of a human being on some property (or set of properties) which comes in degrees. In contrast, he argues that moral equality must reside in some binary property, such as the property of being human. In this paper, I offer three criticisms of Miller's position.

OPCAT: How an international treaty regarding torture is relevant to the Australian mental health system.

The United Nations Subcommittee on the Prevention of Torture visits signatory nations to the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). Its role is to monitor and support signatory nations in implementing and complying with the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). In October 2022, the United Nations Subcommittee on the Prevention of Torture visited Australia but was barred from visiting mental health wards in Queensland and all detention facilities in New South Wales leading to the termination of its visit. This breach of Australia's obligations under the OPCAT presents a significant setback for the rights of people with mental illness and other involuntarily detained populations. This piece sets out to demonstrate the relevance of OPCAT to the mental health system in Australia. Individuals who are detained for compulsory treatment in locked facilities such as acute psychiatric inpatient wards and forensic mental health facilities are deprived of their liberty, often out of public view. Thus, it highlights the ethical and professional obligations of all mental health professionals, especially psychiatrists, to safeguard the human rights of individuals being detained in mental health facilities as enshrined in Australia's international legal obligations under the OPCAT. Adhering to these obligations diminishes the risk of future human rights violations of people with mental illness.

Gender affirmation and mental health in prison: A critical review of current corrections policy for trans people in Australia and New Zealand.

BACKGROUND: Trans people in prison experience disproportionate rates of harm, including negative mental health outcomes, and thus require special protections. Instead, corrections policies have historically further marginalised them. This critical policy review aimed to compare corrections policies for trans people in Australia and New Zealand with human rights standards and consider their mental health impact. METHODS: Online searches were conducted on corrections websites for each state/territory in Australia and New Zealand. Drawing on the Nelson Mandela Rules and Yogyakarta Principles, 19 corrections policies relevant to placement, naming, appearance and gender-affirming healthcare for trans people were reviewed. The potential mental health impact of these policies on incarcerated trans people was discussed using the Gender Minority Stress and Resilience framework. RESULTS: Australian and New Zealand corrections policies have become more concordant with human rights standards in the past 5 years. However, gender-related discrimination and human rights violations were present in corrections policies of all jurisdictions. New South Wales and Victorian policies had the highest concordance with human rights standards, while Queensland and South Australian policies had the lowest. CONCLUSION: Policies that contribute to discrimination and minority stress may increase risk of mental health problems and suicide for incarcerated trans people. Mental health professionals working in prisons need to be aware of these risks to provide safe and accessible mental healthcare for trans people. Collaborative policy development with trans people is essential to protect the safety and rights of incarcerated trans people and consider models beyond the gender binary on which correctional systems have been founded.

The ambiguities of social inclusion in mental health: learning from lived experience of serious mental illness in Ghana and the occupied Palestinian territory.

PURPOSE: Social inclusion of people living with serious mental illness is widely promoted. However, only limited consideration has been given to the meanings of social inclusion within different settings and the ways in which it is envisioned, negotiated, and practised. In this paper, we explore meanings and practises of social inclusion from the perspectives of people living with serious mental illness and their families in Ghana and Palestine and how this is shaped by differing political and socio-cultural contexts. METHODS: This paper draws on comparative ethnographic research including participant observation and interviews with people living with mental illness and family members in Ghana and the occupied Palestinian territory. Data were triangulated and analysed using thematic analysis. RESULTS: Participants described experiences of social inclusion and participation within communities, home and family life, friendships and social life, and work and livelihoods. This revealed how such experiences were variously shaped by differing political contexts and socio-cultural norms and expectations within the two settings. These in turn intersected with aspects such as gender roles, age, and socio-economic status. Aspirations for inclusion included greater awareness and understanding within society, accompanied by opportunities and support for meaningful inclusion at the political as well as community level. CONCLUSION: Findings point to the value of a contextual understanding of social inclusion, taking account of the impact of the wider socio-cultural, political, and economic environment. They also point to the need for an intersectoral approach, beyond communities and mental health services, to provide meaningful opportunities and support for social inclusion.

Proposed Principles for International Bioethics Conferencing: Anti-Discriminatory, Global, and Inclusive.

This paper opens a critical conversation about the ethics of international bioethics conferencing and proposes principles that commit to being anti-discriminatory, global, and inclusive. We launch this conversation in the Section, Case Study, with a case example involving the International Association of Bioethics' (IAB's) selection of Qatar to host the 2024 World Congress of Bioethics. IAB's choice of Qatar sparked controversy. We believe it also may reveal deeper issues of Islamophobia in bioethics. The Section, Principles for International Bioethics Conferencing, sets forth and defends proposed principles for international bioethics conferencing. The Section, Applying Principles to Site Selection applies the proposed principles to the case example. The Section, Applying Principles Beyond Site Selection addresses other applications of the proposed principles. The Section, Objections responds to objections. We close (in the Section, Conclusion) by calling for a wider discussion of our proposed principles. One-Sentence Capsule Summary: How should bioethicists navigate the ethics of global bioethics conferencing?