Governing the Global Antimicrobial Commons: Introduction to Special Issue.

Antimicrobial resistance is one of the greatest public health crises of our time. The natural biological process that causes microbes to become resistant to antimicrobial drugs presents a complex social challenge requiring more effective and sustainable management of the global antimicrobial commons-the common pool of effective antimicrobials. This special issue of Health Care Analysis explores the potential of two legal approaches-one long-term and one short-term-for managing the antimicrobial commons. The first article explores the lessons for antimicrobial resistance that can be learned from recent climate change agreements, and the second article explores how existing international laws can be adapted to better support global action in the short-term.

Control and Ownership of Neuroprosthetic Speech.

Implantable brain-computer interfaces (BCIs) are being developed to restore speech capacity for those who are unable to speak. Patients with locked-in syndrome or amyotrophic lateral sclerosis could be able to use covert speech - vividly imagining saying something without actual vocalisation - to trigger neural controlled systems capable of synthesising speech. User control has been identified as particularly pressing for this type of BCI. The incorporation of machine learning and statistical language models into the decoding process introduces a contribution to (or 'shaping of') the output that is beyond the user's control. Whilst this type of 'shared control' of BCI action is not unique to speech BCIs, the automated shaping of what a user 'says' has a particularly acute ethical dimension, which may differ from parallel concerns surrounding automation in movement BCIs. This paper provides an analysis of the control afforded to the user of a speech BCI of the sort under development, as well as the relationships between accuracy, control, and the user's ownership of the speech produced. Through comparing speech BCIs with BCIs for movement, we argue that, whilst goal selection is the more significant locus of control for the user of a movement BCI, control over process will be more significant for the user of the speech BCI. The design of the speech BCI may therefore have to trade off some possible efficiency gains afforded by automation in order to preserve sufficient guidance control necessary for users to express themselves in ways they prefer. We consider the implications for the speech BCI user's responsibility for produced outputs and their ownership of token outputs. We argue that these are distinct assessments. Ownership of synthetic speech concerns whether the content of the output sufficiently represents the user, rather than their morally relevant, causal role in producing that output.

Evidence-Based Neuroethics, Deep Brain Stimulation and Personality - Deflating, but not Bursting, the Bubble.

Gilbert et al. have raised important questions about the empirical grounding of neuroethical analyses of the apparent phenomenon of Deep Brain Stimulation 'causing' personality changes. In this paper, we consider how to make neuroethical claims appropriately calibrated to existing evidence, and the role that philosophical neuroethics has to play in this enterprise of 'evidence-based neuroethics'. In the first half of the paper, we begin by highlighting the challenges we face in investigating changes to PIAAAS following DBS, explaining how different trial designs may be of different degrees of utility, depending on how changes to PIAAAS following DBS are manifested. In particular, we suggest that the trial designs Gilbert et al. call for may not be able to tell us whether or not DBS directly causes changes to personality. However, we suggest that this is not the most significant question about this phenomenon; the most significant question is whether these changes should matter morally, however they are caused. We go on to suggest that neuroethical analyses of novel neuro-interventions should be carried out in accordance with the levels of evidence hierarchy outlined by the Centre for Evidence-Based Medicine (CEBM), and explain different ways in which neuroethical analyses of changes to PIAAAS can be evidence-based on this framework. In the second half of the paper, we explain how philosophical neuroethics can play an important role in contributing to mechanism-based reasoning about potential effects on PIAAAS following DBS, a form of evidence that is also incorporated into the CEBM levels of evidence hierarchy.

An empirical bioethical examination of Norwegian and British doctors' views of responsibility and (de)prioritization in healthcare.

In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions regarding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare resources. A large proportion of doctors in both countries supported including responsibility for illness in prioritization decisions. This finding was more prominent in zero-sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsibility (through patient contracts), and low support for integrating responsibility into co-payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)-potentially because of the certainty of impact and direct link to ill health. In zero-sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced-and clear-policy. Such policy should account for the distinctions we draw between responsibility-sensitive and prognostic justifications for deprioritization.

Prospective Intention-Based Lifestyle Contracts: mHealth Technology and Responsibility in Healthcare.

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual's role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare.

Praiseworthiness and Motivational Enhancement: 'No Pain, No Praise'?

The view that exertion of effort determines praiseworthiness for an achievement is implicit in 'no pain, no praise'-style objections to biomedical enhancement. On such views, if enhancements were to reduce the need for effort, agents would be less praiseworthy. Motivational enhancement would appear to be the most problematic in this respect, given that increased motivation reduces the need for agents to rally themselves and to exert effort in activity. We use the prospect of motivational enhancement to re-examine the grounds of praiseworthiness for achievements. We consider the place of effort amongst the grounds for praise, whether effort exhausts these grounds, and how they can be better specified. We argue that praiseworthiness depends on (i) the voluntariness and strength of the agent's committed pursuit of a valuable end (E), (ii) the costliness of the committed pursuit of E, and (iii) the value of E. Effort is just one cost amongst many, and costs of activities can be traded-off. Motivational enhancement reduces the praise due to an agent only when it reduces the net cost to the agent (without strengthening the voluntary commitment). We emphasize the importance of a diachronic perspective on active agency for praiseworthiness, to include training, prior planning, and deliberate strategies to overcome weakness of will, even where this reduces the need for effort.

When Thinking is Doing: Responsibility for BCI-Mediated Action.

Technologies controlled directly by the brain are being developed, evolving based on insights gained from neuroscience, and rehabilitative medicine. Besides neuro-controlled prosthetics aimed at restoring function lost somehow, technologies controlled via brain-computer interfaces (BCIs) may also extend a user's horizon of action, freed from the need for bodily movement. Whilst BCI-mediated action ought to be, on the whole, treated as conventional action, law and policy ought to be amended to accommodate BCI action by broadening the definition of action as "willed bodily movement". Moreover, there are some dimensions of BCI mediated action that are significantly different to conventional cases. These relate to control. Specifically, to limits in both controllability of BCIs via neural states, and in foreseeability of outcomes from such actions. In some specific type of case, BCI-mediated action may be due to different ethical evaluation from conventional action.

Sugar, Taxes, & Choice.

Population obesity and associated morbidities pose significant public health and economic burdens in the United Kingdom, United States, and globally. As a response, public health initiatives often seek to change individuals' unhealthy behavior, with the dual aims of improving their health and conserving health care resources. One such initiative-taxes on sugar-sweetened beverages-has sparked considerable ethical debate. Prominent in the debate are arguments seeking to demonstrate the supposed impermissibility of SSB taxes and similar policies on the grounds that they interfere with individuals' freedom and autonomy. Commentators have often assumed that a policy intended to restrict or change private individuals' consumption behavior will necessarily curtail freedom and, as a corollary, will undermine individuals' autonomy with respect to their consumption choices. Yet this assumption involves a conceptual mistake. To address the misunderstanding, it's necessary to attend to the differences between negative liberty, freedom of options, and autonomy. Ultimately, concerns about negative liberty, freedom, and autonomy do not provide strong grounds for opposing SSB taxes.

Responsible Use of Machine Learning Classifiers in Clinical Practice.

Machine learning models are increasingly being used in clinical settings for diagnostic and treatment recommendations, across a variety of diseases and diagnostic methods. To conceptualise how physicians can use them responsibly, and what the standard of care should be, there needs to be discussion beyond model accuracy levels and the types of explanation provided by such classifiers. There needs to be consideration of how the explanations are provided and how historical accuracy rates can together constitute the overall epistemic status of the model, and how models with different epistemic statuses should subsequently be deferred to by medical practitioners. Answering this will require a multi-disciplinary consideration of the literature on automation bias in human factors and ergonomics to higher-order evidence in social epistemology. Adjudicating physician responsibility will also require assessing when a physician's ignorance of the appropriate ways to engage with such classifiers, as outlined above, will be culpable and when not.

When Should the Police Investigate Cases of Non-recent Child Sexual Abuse?

Non-recent child sexual abuse (CSA) and child sexual exploitation (CSE) have received recent attention. Victims often do not report their ordeal at the time the incident occurred, and it is increasingly common for agencies to refer concerns to the police years, or decades, after the event. The combination of the non-recent nature of the offence, the lack of engagement by the (potentially vulnerable) victim, and the huge resource burden of investigation make deciding whether to proceed with investigation complex and ethically challenging. Although there will always be a presumption in favor of investigation, for some cases the reasons against investigating will outweigh this presumption. We examine the considerations at stake in making a decision about whether to make contact with the victim and proceed with investigating a particular non-recent CSA case. Arguing for a "broad rights" approach, we identify considerations relating to (1) the victim, (2) criminal justice and crime prevention, (3) limited resources, and (4) legitimacy. We argue that, all other things being equal, non-recent and current investigations are equally worthy of investigation. We assess the implications of suspects being persons of public prominence. We outline a principled decision-making framework to aid investigators. The Oxford CSA Framework has the potential to reduce unnecessary demand on police resources.

Ethical Challenges of Risk, Informed Consent, and Posttrial Responsibilities in Human Research With Neural Devices: A Review.

Importance: Developing more and better diagnostic and therapeutic tools for central nervous system disorders is an ethical imperative. Human research with neural devices is important to this effort and a critical focus of the National Institutes of Health Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative. Despite regulations and standard practices for conducting ethical research, researchers and others seek more guidance on how to ethically conduct neural device studies. This article draws on, reviews, specifies, and interprets existing ethical frameworks, literature, and subject matter expertise to address 3 specific ethical challenges in neural devices research: analysis of risk, informed consent, and posttrial responsibilities to research participants. Observations: Research with humans proceeds after careful assessment of the risks and benefits. In assessing whether risks are justified by potential benefits in both invasive and noninvasive neural device research, the following categories of potential risks should be considered: those related to surgery, hardware, stimulation, research itself, privacy and security, and financial burdens. All 3 of the standard pillars of informed consent-disclosure, capacity, and voluntariness-raise challenges in neural device research. Among these challenges are the need to plan for appropriate disclosure of information about atypical and emerging risks of neural devices, a structured evaluation of capacity when that is in doubt, and preventing patients from feeling unduly pressured to participate. Researchers and funders should anticipate participants' posttrial needs linked to study participation and take reasonable steps to facilitate continued access to neural devices that benefit participants. Possible mechanisms for doing so are explored here. Depending on the study, researchers and funders may have further posttrial responsibilities. Conclusions and Relevance: This ethical analysis and points to consider may assist researchers, institutional review boards, funders, and others engaged in human neural device research.

Nudging Immunity: The Case for Vaccinating Children in School and Day Care by Default.

Many parents are hesitant about, or face motivational barriers to, vaccinating their children. In this paper, we propose a type of vaccination policy that could be implemented either in addition to coercive vaccination or as an alternative to it in order to increase paediatric vaccination uptake in a non-coercive way. We propose the use of vaccination nudges that exploit the very same decision biases that often undermine vaccination uptake. In particular, we propose a policy under which children would be vaccinated at school or day-care by default, without requiring parental authorization, but with parents retaining the right to opt their children out of vaccination. We show that such a policy is (1) likely to be effective, at least in cases in which non-vaccination is due to practical obstacles, rather than to strong beliefs about vaccines, (2) ethically acceptable and less controversial than some alternatives because it is not coercive and affects individual autonomy only in a morally unproblematic way, and (3) likely to receive support from the UK public, on the basis of original empirical research we have conducted on the lay public.

Neuroprosthetic Speech: The Ethical Significance of Accuracy, Control and Pragmatics.

Neuroprosthetic speech devices are an emerging technology that can offer the possibility of communication to those who are unable to speak. Patients with 'locked in syndrome,' aphasia, or other such pathologies can use covert speech-vividly imagining saying something without actual vocalization-to trigger neural controlled systems capable of synthesizing the speech they would have spoken, but for their impairment.We provide an analysis of the mechanisms and outputs involved in speech mediated by neuroprosthetic devices. This analysis provides a framework for accounting for the ethical significance of accuracy, control, and pragmatic dimensions of prosthesis-mediated speech. We first examine what it means for the output of the device to be accurate, drawing a distinction between technical accuracy on the one hand and semantic accuracy on the other. These are conceptual notions of accuracy.Both technical and semantic accuracy of the device will be necessary (but not yet sufficient) for the user to have sufficient control over the device. Sufficient control is an ethical consideration: we place high value on being able to express ourselves when we want and how we want. Sufficient control of a neural speech prosthesis requires that a speaker can reliably use their speech apparatus as they want to, and can expect their speech to authentically represent them. We draw a distinction between two relevant features which bear on the question of whether the user has sufficient control: voluntariness of the speech and the authenticity of the speech. These can come apart: the user might involuntarily produce an authentic output (perhaps revealing private thoughts) or might voluntarily produce an inauthentic output (e.g., when the output is not semantically accurate). Finally, we consider the role of the interlocutor in interpreting the content and purpose of the communication.These three ethical dimensions raise philosophical questions about the nature of speech, the level of control required for communicative accuracy, and the nature of 'accuracy' with respect to both natural and prosthesis-mediated speech.

Against Moral Responsibilisation of Health: Prudential Responsibility and Health Promotion.

In this article, we outline a novel approach to understanding the role of responsibility in health promotion. Efforts to tackle chronic disease have led to an emphasis on personal responsibility and the identification of ways in which people can 'take responsibility' for their health by avoiding risk factors such as smoking and over-eating. We argue that the extent to which agents can be considered responsible for their health-related behaviour is limited, and as such, state health promotion which assumes certain forms of moral responsibility should (in general) be avoided. This indicates that some approaches to health promotion ought not to be employed. We suggest, however, that another form of responsibility might be more appropriately identified. This is based on the claim that agents (in general) have prudential reasons to maintain their health, in order to pursue those things which make their lives go well-i.e. that maintenance of a certain level of health is (all-things-considered) rational for many agents, given their pleasures and plans. On this basis, we propose that agents have a self-regarding prudential responsibility to maintain their health. We outline the implications of a prudential responsibility approach to health promotion.

The Human Brain Project: Responsible Brain Research for the Benefit of Society.

Recognizing that its research may raise various ethical, social, and philosophical issues, the HBP has made the identification, examination, and management of those issues a top priority. The Ethics and Society subproject is part of the core research project.

"A Steadying Hand": Ascribing Speech Acts to Users of Predictive Speech Assistive Technologies.

Neuroprosthetic speech technologies are in development for patients suffering profound paralysis, such as can result from amyotrophic lateral sclerosis. These patients would be unable to speak without intervention, but with neurotechnology can be offered the chance to communicate. The nature of the technology introduces a neuroprosthesis that mediates neural activity to generate synthesised speech. How word prediction coheres with speaker intentions requires scrutiny. Some future forms of prostheses, using statistical language models to predict word patterns, could be thought of as participating with communicative intent - not merely channelling it. Concepts relating to vicarious liability, may serve to clarify these issues. This column shows how technology might interact with speaker intent in cases of delegated action, and how it should be seen as participating in the implementation of user "instructions".

Influenza Vaccination Strategies Should Target Children.

Strategies to increase influenza vaccination rates have typically targeted healthcare professionals (HCPs) and individuals in various high-risk groups such as the elderly. We argue that they should (instead or as well) focus on increasing vaccination rates in children. Because children suffer higher influenza incidence rates than any other demographic group, and are major drivers of seasonal influenza epidemics, we argue that influenza vaccination strategies that serve to increase uptake rates in children are likely to be more effective in reducing influenza-related morbidity and mortality than those targeting HCPs or the elderly. This is true even though influenza-related morbidity and mortality amongst children are low, except in the very young. Further, we argue that there are no decisive reasons to suppose that children-focused strategies are less ethically acceptable than elderly or HCP-focused strategies.

Rationing elective surgery for smokers and obese patients: responsibility or prognosis?

BACKGROUND: In the United Kingdom (UK), a number of National Health Service (NHS) Clinical Commissioning Groups (CCG) have proposed controversial measures to restrict elective surgery for patients who either smoke or are obese. Whilst the nature of these measures varies between NHS authorities, typically, patients above a certain Body Mass Index (BMI) and smokers are required to lose weight and quit smoking prior to being considered eligible for elective surgery. Patients will be supported and monitored throughout this mandatory period to ensure their clinical needs are appropriately met. Controversy regarding such measures has primarily centred on the perceived unfairness of targeting certain health states and lifestyle choices to save public money. Concerns have also been raised in response to rhetoric from certain NHS authorities, which may be taken to imply that such measures punitively hold people responsible for behaviours affecting their health states, or simply for being in a particular health state. MAIN BODY: In this paper, we examine the various elective surgery rationing measures presented by NHS authorities. We argue that, where obesity and smoking have significant implications for elective surgical outcomes, bearing on effectiveness, the rationing of this surgery can be justified on prognostic grounds. It is permissible to aim to maximise the benefit provided by limited resources, especially for interventions that are not urgently required. However, we identify gaps in the empirical evidence needed to conclusively demonstrate these prognostic grounds, particularly for obese patients. Furthermore, we argue that appeals to personal responsibility, both in the prospective and retrospective sense, are insufficient in justifying this particular policy. CONCLUSION: Given the strength of an alternative justification grounded in clinical effectiveness, rhetoric from NHS authorities should avoid explicit statements, which suggest that personal responsibility is the key justificatory basis of proposed rationing measures.

Would you be willing to zap your child's brain? Public perspectives on parental responsibilities and the ethics of enhancing children with transcranial direct current stimulation.

BACKGROUND: Transcranial direct current stimulation (tDCS) is an experimental brain stimulation technology that may one day be used to enhance the cognitive capacities of children. Discussion about the ethical issues that this would raise has rarely moved beyond expert circles. However, the opinions of the wider public can lead to more democratic policy decisions and broaden academic discussion of this issue. METHODS: We performed a quantitative survey of members of the U.S. public. A between-subjects design was employed, where conditions varied based on the trait respondents considered for enhancement. RESULTS: There were 227 responses included for analysis. Our key finding was that the majority were unwilling to enhance their child with tDCS. Respondents were most reluctant to enhance traits considered fundamental to the self (such as motivation and empathy). However, many respondents may give in to implicit coercion to enhance their child in spite of an initial reluctance. A ban on tDCS was not supported if it were to be used safely for the enhancement of mood or mathematical ability. Opposition to such a ban may be related to the belief that tDCS use would not represent cheating or violate authenticity (as it relates to achievements rather than identity). CONCLUSIONS: The wider public appears to think that crossing the line from treatment to enhancement with tDCS would not be in a child's best interests. However, an important alternative interpretation of our results is that lay people may be willing to use enhancers that matched their preference for "natural" enhancers. A ban on the safe use of tDCS for enhancing nonfundamental traits would be unlikely to garner public support. Nonetheless, it could become important to regulate tDCS in order to prevent misuse on children, because individuals reluctant to enhance may be likely to give in to implicit coercion to enhance their child.