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Essay question

“Despite Lord Browne Wilkinson’s obiter comments in Bolitho , the Bolam test remains an insurmountable hurdle for claimants to succeed in clinical negligence actions”.

Discuss this statement with reference to case law.

Outline answer

The focus of this question is upon an evaluation of the standard of care expected in medical negligence cases. A critical evaluation of the Bolam test is required as well as a consideration of the actual or potential effect of Bolitho.

Remember that in cases of medical negligence all three components, namely a duty of care, breach of duty and causation, have to be proved by the claimant on the balance of probabilities. Establishing a duty of care in a doctor and patient relationship is not usually difficult and will exist in most situations. However, establishing breach of duty and causation can be more problematic.

With regard to breach of duty, the question that arises is whether or not the claimant received a standard of medical care that was acceptable in the circumstances. If the answer to this is yes, then the claimant will fail. If the answer is no, then the case continues to the next stage in respect of establishing causation.

The traditional test used to establish breach of duty is to measure the standard of care received against the Bolam standard. You might wish to recall McNair J’s comments in this case, encapsulated in the principle that a doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of professionals skilled in that particular art. This means that if a responsible body of professionals would support the defendant’s action then that standard (according to the Bolam test) is acceptable (even if there is a body of opinion that is to the contrary).

The Bolam test has come under considerable criticism in the academic literature on the basis that the standard is set by the medical profession, rather than by the court. The test has been perceived as being too high a burden for claimants, too deferential to doctors and lacking in external objectivity. Consider these criticisms and also consider how the Bolam test has been applied in practice, such as in the context of diagnosis (Maynard) and treatment (Whitehouse v. Jordan). While it may be considered acceptable in these circumstances where medical expert opinion is necessary, it is important to consider whether the same should apply to information disclosure in the context of consent. Although previously, in Sidaway, the Bolam test was held to apply, this doctor centred approach has now been replaced by a patient-focused matter in Montgomery.

In the case of Bolitho, the Bolam test was commented upon in the House of Lords. Remember, however, that the ratio of Bolitho concerned causation and not the standard of care. Lord Browne Wilkinson’s obiter comments qualified the Bolam standard by stating that the body of opinion relied upon should have a logical basis, which means it should be capable of withstanding logical analysis and external scrutiny. In other words, if there were two differing bodies of opinion regarding the standard of care, it is for the court to scrutinise these and accept the one that is more plausible. So whilst Bolitho may not have altered the substance of the Bolam test, it has applied a gloss to it. Consider also the cases of Reynolds and Marriott where the court took a more interventionist stance towards the application of the Bolam standard. You may wish to provide your own critical thoughts as to how you see the Bolam standard in the balance and whether Bolitho has modified the test sufficiently so that it is less difficult for claimants to overcome, and draw your conclusions on the basis of your discussions. Finally remember that causation must still be proved to succeed in medical negligence.

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Question: Critically analyse the legal issues surrounding pre-implantation genetic diagnosis (PGD) and IVF. Apply relevant principles of law to the medical facts and assess the ethical considerations surrounding the circumstances of so called ‘saviour siblings’ as well as IVF more generally. Mark 1st Class 79% - LLB Year 3 Undergraduate

Answer: IVF also known as ‘in vitro’ fertilisation is a form of conception governed by the 1990 act. This gives people access to facilities of Assisted Reproductive Technology (ART) to reproduce and the...

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Aug 21, 2020
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Medical Law and Ethics 7840 First-Class Essay (Written at Master's level and Awarded an 80)

Updated: Nov 3, 2020

Submitted by LLM (Hons) Graduate Megan Edwards.

This module is available for masters students as well as final year undergraduate LLB students.

"The judgment in Evans v Amicus Healthcare [2004] EWCA Civ 727 remains unsatisfactory and underscores"

Critically discuss the above statement by reference to relevant legal authority and secondary literature.

INTRODUCTION

In October 2001, Natallie Evans (Evans) was diagnosed with a pre-cancerous condition of her ovaries during a routine fertility treatment appointment and was informed that she would need a complete ovariectomy. After having tried and failed to get pregnant for over a year with her fiancé Howard Johnston (Johnston), she was offered one cycle of in vitro fertilisation (IVF) treatment in the same appointment. After asking whether it would be possible to freeze her eggs unfertilised she was advised that the clinic in question did not have the facilities to do so. Adding to this, she was assured by Johnston that there was no need to do so, as they could freeze embryos fertilised using his sperm since they were going to stay together. A few weeks later in November, 11 eggs were harvested from Evans and fertilised with sperm from Johnston, from which 6 embryos were created and put into storage. 2 weeks later Evans underwent the procedure for removal of her ovaries, and was told to wait at least two years before attempting an embryo transfer.

In the UK, The Human Fertilisation and Embryology Act 1990 (as amended by the Human Fertilisation and Embryology Act 2008) (hereafter referred to as HFEA 1990), regulates the storage and use of gametes and embryos in assisted reproductive technologies (ARTs). Schedule 3 HFEA controls the issue of consent with regards to this, and in coordination with the supplementary Code of Practice, provides that consent to storage and use must be ‘effective’. [1] Thus, where a party withdraws consent to the further storage of their gametes or embryos, treatment clinics must give effect to this by way of disposing of the embryos.

Following the subsequent breakdown of the relationship between Evans and Johnston, in July 2002 Johnston wrote to the clinic advising them of this and withdrawal of his consent for the continued storage of the embryos. Thus, his consent could no longer be considered effective and so Evans initiated proceedings in order to prevent disposal of the embryos.

This essay will consider the social, legal and cultural context in which Evans’ case, Evans v Amicus Healthcare Ltd [2] was decided and the implications of the judgment. First, the issues raised will be considered. The idea of consent with regards to the law and its relationship with gender will then be explored, before turning to analyse the idea that the judgment reached in Evans discriminates women based on sex, an argument unexplored in the case. [3] Finally, it will be concluded that not only does the judgment remain unsatisfactory, but that it also underscores the need for the regulatory framework governing ARTs to be revised and updated.

THE ISSUES WITH EVANS

Evans remains the cornerstone case concerning issues of ARTs where gamete progenitors are in dispute over the disposition of embryos. In Evans’ original submission to the High Court, she contended that Johnston should be prevented from varying or withdrawing his consent to the storage and use of the embryos and that failure to allow her to use the embryos in future was a violation of her human rights under Articles 2, 8, 12 and 14 of the European Convention of Human Rights (ECHR). Her case failed on all counts and she subsequently appealed. This essay will focus specifically on the arguments related to Articles 8 and 14 ECHR.

While the judge at first instance found that Evans’ Article 8 ECHR right to respect for her private life had indeed been engaged, he held that Johnston’s parallel right was of equal weight, in line with what the statutory scheme intended. The Court of Appeal (CA) agreed with this finding. This essay contends however that appropriate consideration was not given to the analysis of this right in accordance with Article 14 ECHR.

Article 14 provides that all rights set forth in the ECHR shall be secured without discrimination on a number of grounds, one of which is sex. It is unique in that it can only be asserted where another Convention right is engaged. Thus, in finding that Evans’ Art 8 rights were in fact breached, it follows that Art 14 is engaged. However, the discrimination argument was largely unexplored by the court since they held that the Art 8 breach was justified as necessary and proportionate and thus Johnston was ‘entitled to withdraw his consent with the effect that withdrawal was to prevent both the use and continued storage of the embryo fertilised by the sperm’. [4]

CONSENT: THE ‘BRIGHT-LINE’

The HFEA 1990 provides that ‘effective consent’ is consent which has not been withdrawn. [5]

Any consent given for the purpose of treatment under the Act must also be in writing and signed. [6] What’s more, paragraph 6(3) of Schedule 3 to the Act provides that any embryo created in vitro ‘must not be used for any purpose unless there is consent by each relevant person in relation to the embryo to the use for that purpose (…)’. Gamete providers therefore also have the right to withdraw or vary the terms of their consent at any time up until the embryo has been used in treatment services. [7] Thus, consent from both gamete providers is required up to the point of implantation and so the fact Johnston had withdrawn his consent to further storage and use of the embryos to treat Evans meant she inevitably would face an uphill battle in convincing the Human Fertilisation and Embryology Authority, and the courts, otherwise.

The law here can be denoted as a ‘bright-line’ rule in the sense that it is clearly defined and objective in its scope. The ‘bright-line’ rule however, and the accompanying bright-line approach taken by the courts in their interpretation of the Act, is arguably a problematic one and ‘needs to be considered with caution’. [8] It leaves little room for interpretation and thus should only be employed in cases in which there are no issues of uncertainty. In the context of Evans, this was undoubtedly not the case, particularly considering the circumstances in which initial consent was given.

Is ‘effective consent’ effective?

Beauchamp and Childress maintain that ethical conduct is underpinned by four basic principles; autonomy, beneficence, non-maleficence and justice. [9] They argue that, at a minimum, autonomy ‘encompasses self-rule that is free from both controlling interference by others and limitations that prevent meaningful choice’. [10] Autonomy therefore ‘obligates professionals in healthcare … to disclose information, to probe for and ensure understanding and voluntariness, and to foster adequate decision making’ while also requiring that freely made decisions are not restricted by others. [11]

Harris-Short contends that consent should be considered an expression of autonomous will. [12] Paragraph 3 to Schedule 3 HFEA 1990 gives effect to this somewhat in that it stipulates a person must be given the opportunity ‘to receive proper counselling about the implications of taking the proposed steps’ concerning fertility treatment before they can give consent. Neither Evans nor Johnston however were given such counselling. Instead, when Evans enquired about the option of egg freezing she was told the clinic did not provide such services. Moreover, in his evidence Johnston also made the point that neither of them were given the opportunity to discuss their options privately with clinic staff. [13] Thus, can it be said that the choices made by both parties were free from constraint and limitations? Both parties were not given ample opportunity to be fully informed and thus their ability to make a fully autonomous decision was incapacitated. Consequently, ‘the robustness of the consent obtained from each party is surely open to question.’ [14]

In order to determine whether consent can be deemed ‘effective’ or not, especially in the context of assisted reproduction cases in which one party has simultaneously more to lose or gain than the other, a holistic approach should be employed by the courts. This would involve analysing the situation in which consent was given as a whole, rather than merely considering whether consent has been withdrawn or not. In the present case, all the decisions made and forms signed were done so in the same appointment in which Evans had been delivered the news about the pre-cancerous condition of her ovaries and the fact they would need to be removed. Bearing in mind the fact this all occurred within the span of 90 minutes, it perhaps fair to say that life-changing decisions were made in an overwhelming environment.

An interesting point to note here is the language used to refer to the relationship between Evans and Johnston both in the judgment and literature written about it. Johnston is consistently referred to as Evans’ ‘partner’, but they were in fact engaged to be married. While it is understood the term ‘fiancé’ is perhaps not considered a legal one, the word partner can equally refer to a boyfriend. However, being engaged to be married arguably indicates a greater level of commitment than that found between boyfriend and girlfriend. Of course, this is not always the case but it is somewhat fair to say in our society an engaged couple are considered to be more serious than those who are not and that where someone has proposed then it is likely they foresee a future with the other person. What’s more, a lot of the time that life or future, especially in heterosexual relationships, includes children.

Thus, the fact the judgment repeatedly uses the term ‘partner’ glosses over the fact they were engaged, perhaps to downplay the significance of their relationship, as well as the weight of the assurances Johnston made during the consultation in which initial consent was given. This arguably only works in Johnston’s favour, since it minimises his role in the situation. The court therefore in its judgment created a classic narrative of a woman who wants too much, even if unintentionally. The message that women want to have it all to the detriment of men is one that is ‘far removed’ from reality, since women are in fact penalised for wanting pregnancy and motherhood, as is evident from this case. [15] The argument could therefore be made that the Evans judgment is in fact complicit in compounding the suffering of and discrimination against women.

Moreover, framing Evans’ decision as being a matter of choice in the context of her making a choice to have a child and his choice not to, misses the point that her choices were already restricted. Freedom of choice is autonomy enhancing only if a person has a range of valuable options to choose from. Evans had been trying to get pregnant for 7 years to no avail, and thus the fact no egg-freezing facilitates were available meant her only option to preserve her chance of having a genetically related child was to fertilise her eggs using Johnston’s sperm to create embryos she could later use.

It is important to note here that the option of using donor sperm was in fact not one available to her, since the point was made that had she expressed a desire to do so, the clinic would have ‘been bound to enquire into why’. [16] Thus, either Johnston’s sperm was used, or Evans would invite unwanted and arguably unnecessary scrutiny into her relationship and private life. Such a request to use donor sperm would only compound what was an already emotional and burdensome situation. Consequently, whereas Johnston had multiple options in that he could consent to use of his sperm to create embryos, and could later withdraw or vary the terms of his consent, Evans was arguably presented with only one viable option to preserve her chance of genetic motherhood; use of his sperm. The circumstances were such that the sole decision-maker in whether Evans would ever have the chance to have a genetically related child was in fact Johnston.

Withdrawal of consent as veto of initial mutual consent

When the case came before the courts it attracted much media scrutiny and public sympathy.

The woman behind the original legislative framework, Mary Warnock, even went as far to state that law in the area was in fact ‘ambiguous’ and that a situation such as that of the Evans case had not been envisaged. [17] The CA held that the ‘clear policy of the Act is to ensure continuing consent from the commencement of treatment to the point of implant’ and that, taking into account the fact consent can be varied or withdrawn, ‘the court should be extremely show to recognise or create a principle of waiver that would conflict with the Parliamentary scheme’. [18] The point could be made here however that permitting the withdrawal of consent up to the point of implantation effectively gives one party a veto in the life of the other where consent was initially mutual. Since both Evans and Johnston were initially united in the pursuit of fertility treatment, his subsequent withdrawal meant that she now had to face the reality she would never be able to have a genetically-related child of her own and that the embryos would be destroyed. Her consent effectively no longer mattered without his.

In the aftermath of the case’s progression through the courts the British Medical Association in their submission to the Parliamentary Select Committee on Science and Technology advised that it was time for the 1990 Act to be reviewed and updated. [19] Considering the issues presented by the consent provisions of the Act as highlighted by the Evans case, they recommended that before embryos can be destroyed, consent should be given by both gamete providers. [20] Where no agreement can be reached, the embryos should then be kept in storage until the end of a statutory period recommended to be five years, after which they would be disposed of. [21]

The Human Fertilisation and Embryology Act 2008 thus updated and amended numerous provisions of the 1990 Act, one of which was to introduce a ‘cooling-off’ period in line with the above advice whereby storage of embryos remains lawful after one gamete provider withdraws consent. [22] It was hoped that the amendments introduced in 2008 would give provide for more clarity and thus, should a similar situation arise again, it could be resolved in an equitable way. However, this has not been the case and this essay maintains that the updates to the HFEA 1990 did not go far enough. Rather than the 5 year ‘cooling-off’ period as advised by the BMA, the new provision allows for only 12 months. [23] Moreover, the rest of the consent provisions were hardly amended at all. Thus, while it could be argued a year-long cooling period might allow for some disputes to be resolved privately between gamete providers, it will not help where those disputes evolve into something that cannot be merely negotiated or mediated between two parties. Such a provision would not have been of any help to Evans, nor is it likely that should the same dilemma presented in Evans come before the courts again the result would be any different. It remains the case that one parties consent or withdrawal of such can veto the effective consent of the other party.

In Evans, the court exhibited a blatant disregard of Evan’s decision-making capacity and turned a blind eye to the role played by gender and medical paternalism in determining whether the breach of Evans’ Article 8 ECHR right was justified. Such a dismissal only serves to exacerbate the oppression of women. The ‘consenting procedures in this case were such as potentially to leave Ms Evans and Mr Johnston in a position of considerable uncertainty about the implications of their treatment’, [24] and it is argued that the same ambiguity remains regardless of the amendments made in 2008. The fact that no criticism of the clinic was made as a result of adopting of the bright-line approach is also questionable.

It is therefore argued that despite updates, the law governing the use of ARTs is still both morally and ethically problematic since one gamete provider can just cancel out the consent of another by withdrawing their consent. The fact judges are constrained by this ‘bright-line’ rule resulted in the unsatisfactory judgment of Evans, which therefore underscores the need for further reform. While it may be said that balancing both parties’ interests with regards to consent and their respective rights is treating them equally, this is only formal. Thus, without consideration of the wider context in which decisions were made it cannot be said that the law allows for substantive equality, which amounts to true equity, fairness and justice.

SEX DISCRIMINATION

Women’s Human Rights and Justice

Cherry contends that throughout history women have not had control ‘over their physical selves’ and that this still rings true today. [25] As a result, the idea of ‘choice’ concerning what women do with their bodies has become a focal point of reproductive justice and feminism. She goes on however to maintain that reliance on ideals of choice have created problems in which ‘substantive outcomes are subordinated to process neutrality … even though we know that formal equality has often allowed deep substantive oppression and subordination to continue’. [26] The case of Evans is an example of such subordination of a substantive outcome to formal equality. To this end, Lind agrees in stating that the modus operandi of the HFEA 1990 is one of formal equality and thus the CA failed to give the equality argument a fair chance by perpetuating cultural stereotypes and gender roles in an attempt to ‘straight-jacket women into a claim that requires male equivalence when there is no such equivalence’. [27]

Evans alleged that as an infertile woman she was being treated differently from fertile women under the HFEA 1990, which was discriminatory and thus in contravention of her Article 14 ECHR right in conjunction with Article 8. In considering this argument, the CA judges adopted 2 approaches; one which was held by the majority judges and reasoned that the difference was in fact between those women seeking fertility treatment whose partners had withdrawn consent [28] , and the other noted by Arden LJ which agreed with Evans’ submission in holding that the difference was between those women who could conceive naturally and those who could not. [29] In both situations the court held that the HFEA 1990 was in fact discriminatory but again it was justified for the same reasons the breach of Evans’ Article 8 rights were justified. [30]

While it is agreed that such differences are discriminatory, it is argued that the courts did not pay appropriate attention to the argument of discrimination. Rather than focusing on the differences between women, they should have looked at the broader spectrum of both sex and gender and the discriminatory elements which of such which are clearly present in the case. As outlined above, there were clear differences in the options presented to Evans and Johnston. It was suggested in the High Court (HC) judgment, that a situation in which a man had testicular cancer and presented himself for fertility treatment was analogous to that of Evans [31] , and such suggestion was not challenged by the CA. However, this is a pure false equivalency. Had the situations been reversed, Johnston would have had the option to freeze his unfertilised sperm and thus would undoubtedly never have had to face the same challenges as Evans. Forcing a woman to carry a pregnancy for 9 months is not the same as using a man’s sperm to create an embryo which is then implanted in a willing woman’s uterus who will carry a pregnancy to term herself for said man.

Colker maintains that ‘reproductive differences between women and men should be relevant to the disposition of disputes’. [32] Yet, it is precisely these reproductive biological differences which are both unaccounted for and overlooked by the HFEA 1990 and the courts. In their analysis of Evans, the judges were very specific in their examination of discrimination and in doing so seemed to disregard the blatant sex discrimination evident on the face of the facts as outlined above between Evans and Johnston’s situations. Thus, it is the opinion of this essay that it is apparent a discrimination claim with regards to the operation of the HFEA 1990 can be grounded in the argument of discrimination based on the difference in sex and gender between men and women. Dismissal of such an argument is led to the unsatisfactory judgment delivered in Evans, and consequently underscores the need to revise the HFEA 1990 in order to ensure substantive equality between men and women.

Biological and Reproductive Realities

In Evans, it was rationalised that deciding in favour of Johnston did not mean that Evans could never be pregnant; she still could carry a pregnancy but would just require donor eggs to do so. [33] However, this is a fallacy and ignores reproductive capabilities and reality. The chances of getting pregnant and then carrying a pregnancy to term diminish as a woman gets older. In a study carried out in Canada, it was reported that where a woman has been infertile for 3 years or more, each year in age reduced the probability of getting pregnant by 9%. [34] Moreover, a study on IVF patients conducted by Schröder in Germany found that the expected cumulative pregnancy rate for those women over 35 years and older was 44.8% after 4 cycles of IVF treatment. [35] A similar study in the Netherlands reported that the probability of a pregnancy leading to a healthy baby starts to fall in 31 years, and after 12 cycles of IVF treatment the probability of a women becoming pregnant this age or older was 0.54. [36]

Bearing in mind that Evans was 29 when she initially started treatment and notwithstanding the fact she eventually appealed to the European Court of Human Rights which delivered its final judgment in 2007, by the time the judgment was delivered by the CA she would have been around 32. Factoring in her infertility which would mean any chances of her getting pregnant would have to be aided through use of ARTs which are not only very expensive but time consuming, the chances of her being able to get pregnant at all without making use of her embryos as emphasised as a possibility for her by the court, would have been very slim in actuality.

Alghrani contends that the argument that women should have the decisive say in gamete disputes such as the situation in Evans because they ‘have given more to the IVF process’ is unconvincing since differences between men and women stem from biology and thus men should not be ‘penalised because it is easier for them to provide gametes than for women’. [37]

This essay however disagrees and maintains that it is discounting this simple fact that results in the law producing inequities and unsatisfactory judgments as in Evans. Women have consistently been marginalised, excluded and subordinated in all facets of society on the basis of their gender. The law is no exception here either, with MacKinnon noting that harms and violation of women tend not only to be ‘legally and socially rationalised, officially winked at, or in some instances formally condoned’ but in general ‘overlooked’. [38] Thus, the fact that it is indeed easier for a man to produce gametes should not be overlooked, as it was in Evans. Rather the consideration of such a fact should be central to the decision-making process.

The reality is that everyday life is gendered and thus the influence of gender and overarching patriarchal norms in healthcare as well as judicial decision-making cannot be underestimated. Equality goes beyond treating people the same, this is merely formal. True, substantive equality involves recognising and taking account of difference. In Evans , differences were largely ignored in balancing the respective reproductive rights of both parties as being equal. However, Johnston has limitless opportunities to have biological children despite the judgment, whereas Evans now has none.

The CA, constrained by the bright-line approach enshrined in the HFEA 1990, was not able to analyse the case in a manner which gave proper consideration to the context in which decisions were made as well as being attentive to gender, reproductive and biological realities. The case therefore highlights the problems that exist in the legislative framework governing the use of ARTs with respect to these issues. Despite amendments to the law in 2008, holes still exist which would allow for the same thing to happen again. It is therefore argued that the CA’s analysis of the Evans case was for the most part unsatisfactory and the law needs to be revised to ensure substantive equality.

Bibliography

Table of Legislation (UK)

The Human Fertilisation and Embryology Act 2008

The Human Fertilisation and Embryology Act 1990

Table of Cases (UK)

Evans v Amicus Healthcare Ltd [2004] EWCA Civ 727, [2004] 3 WLR 681

Evans v Amicus Healthcare Ltd and others [2003] EWHC 2161 (Fam), [2004] 2 WLR 713

Table of Cases (EU)

Evans v United Kingdom (2008) 46 EHRR 34

European Statutory Instruments

Convention for the Protection of Human Rights and Fundamental Freedoms as amended by Protocols Nos. 1 and 14 (adopted 4 November 1950, entered into force 3 September 1953) ETS 5

Alghrani A, Regulating Assisted Reproductive Technologies: New Horizons (Cambridge University Press 2008)

Beauchamp T and Childress J, Principles of Biomedical Ethics (OUP 2012)

MacKinnon C, Are Women Human? And Other International Dialogues (Harvard University Press 2007)

McColgan A, Women Under the Law: The False Promise of Human Rights (Longman 1999)

Book Chapters

Harris-Short S, ‘Evans v Amicus Healthcare Ltd and others (Secretary of State for Health and another intervening’ in Rosemary Hunter, Clare McGlynn and Ericka Rackley (eds) Feminist Judgments: From Theory to Practice (OUP 2010)

Journal Articles

Cherry A, ‘Choosing Substantive Justice: A Disucssion of ‘Choice’, ‘Rights’ and the New Reproductive Technologies’ (1997) 11 New Reproductive Technologies 431

Colker R, ‘Pregnant Men Revisited Or Sperm is Cheap, Eggs are Not’ (1996) 47 Hastings Law Journal 1063

Schröder A, ‘Cumulative Pregnancy Rates and Drop-Out Rates in a German IVF Programme: 4102 cycles in 2130 patients’ (2004) 8(5) Reproductive BioMedicine Journal 600

Sheldon S, ‘ Evans v Amicus Healthcare: Revealing Cracks in The Twin Pillars?’ (2004) 16(4) Child and Family Law Quarterly 437

Van Nord-Zaadstra B et al, ‘Delaying childbearing: effect of age on fecundity and outcome of pregnancy’ (1991) 302 British Medical Journal 1361

Consultation Reports and Guidance

House of Commons Science and Technology Committee, Human Reproductive Technologies and the Law: Fifth Report of Session 2004-05 Volume II Oral and Written Evidence (2005, HC 7-II)

Human Fertilisation and Embryology Authority, Code of Practice (8th edn, 2009)

Royal Commission on New Reproductive Technologies, Proceed With Care: Final Report of the Royal Commission on New Reproductive Technologies (Canada 1993)

Online News Reports

BBC News, ‘Fertility laws branded “ambiguous”’ ( BBC News England, 24 August 2002) < http://news.bbc.co.uk/1/hi/england/2213640.stm > accessed 14 May 2020

[1] Human Fertilisation and Embryology Authority, Code of Practice (8th edn, 2009). [2] [2004] EWCA Civ 727, [2004] 3 WLR 681. [3] The term ‘sex’ is used to refer to biological differences, whereas ‘gender’ is based on the construct of gender-roles in society. [4] Evans (CA) (n 2) [41]. [5] The Human Fertilisation and Embryology Act 1990, sch 3 para 1(3) (HFEA 1990). [6] Ibid, sch 3 para 1(1). [7] HFEA 1990 (n 5), sch 3 para 4. [8] Sonia Harris-Short, ‘Evans v Amicus Healthcare Ltd and others (Secretary of State for Health and another intervening’ in Rosemary Hunter, Clare McGlynn and Ericka Rackley (eds) Feminist Judgments: From Theory to Practice (OUP 2010) 72. [9] Tom Beauchamp and James Childress, Principles of Biomedical Ethics (OUP 2012). [10] Ibid 101. [11] Beauchamp and Childress (n 9) 107. [12] Harris-Short (n 8). [13] Evans v Amicus Healthcare Ltd and others [2003] EWHC 2161 (Fam), [2004] 2 WLR 713 [49]. [14] Sally Sheldon, ‘ Evans v Amicus Healthcare: Revealing Cracks in The Twin Pillars?’ (2004) 16(4) Child and Family Law Quarterly 437, 447. [15] Aileen McColgan, Women Under the Law: The False Promise of Human Rights (Longman 1999) 7. [16] Evans (HC) (n 13) [308]. [17] BBC News, ‘Fertility laws branded “ambiguous”’ ( BBC News England, 24 August 2002) < http://news.bbc.co.uk/1/hi/england/2213640.stm > accessed 14 May 2020. [18] Evans (CA) (n 2) [37]. [19] House of Commons Science and Technology Committee, Human Reproductive Technologies and the Law: Fifth Report of Session 2004-05 Volume II Oral and Written Evidence (2005, HC 7-II). [20] Ibid. [21] HOC Committee (n 19). [22] The Human Fertilisation and Embryology Act 2008, sch 3 para 7. [23] Ibid. [24] Sheldon (n 14) 447. [25] April Cherry, ‘Choosing Substantive Justice: A Discussion of ‘Choice’, ‘Rights’ and the New Reproductive Technologies’ (1997) 11 New Reproductive Technologies 431, 433. [26] Ibid 435. [27] Craig Lind, ‘Evans v United Kingdom” Judgements of Solomon: Power, Gender and Procreation’ (2006) 18(4) Child and Family Law Quarterly 576, 587. [28] Evans (CA) (n 2) [73]. [29] Ibid [117]. [30] Evans (CA) (n 2) [74]. [31] Evans (HC) (n 13) [320]. [32] Ruth Colker, ‘Pregnant Men Revisited Or Sperm is Cheap, Eggs are Not’ (1996) 47 Hastings Law Journal 1063. [33] Evans (CA) (n 2) [75]. [34] Royal Commission on New Reproductive Technologies, Proceed With Care: Final Report of the Royal Commission on New Reproductive Technologies (Canada 1993). [35] Annika Kristen Schröder, ‘Cumulative Pregnancy Rates and Drop-Out Rates in a German IVF Programme: 4102 cycles in 2130 patients’ (2004) 8(5) Reproductive BioMedicine Journal 600. [36] Boukje van Nord-Zaadstra et al, ‘Delaying childbearing: effect of age on fecundity and outcome of pregnancy’ (1991) 302 British Medical Journal 1361. [37] Amel Alghrani, Regulating Assisted Reproductive Technologies: New Horizons (Cambridge University Press 2008) 92. [38] Catherine MacKinnon, Are Women Human? And Other International Dialogues (Harvard University Press 2007) 36.

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The Unlikely Women Fighting for Abortion Rights

The end of Roe has turned women who terminated pregnancies for medical reasons into a political force.

Riata Little Walker, right, with her husband, Ian Walker, and their family in Casper, Wyo. Credit... Jimena Peck for The New York Times

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By Kate Zernike

Kate Zernike covers abortion for The Times.

May 27, 2024

For a long time, many women who had abortions because of catastrophic fetal diagnoses told their stories only privately. Grieving pregnancies they dearly wanted and fearing the stigma of abortion, they sought the closely guarded comfort of online communities identified by the way many doctors had described the procedure — TFMR, or “termination for medical reasons.”

In the two years since the Supreme Court overturned Roe v. Wade, their pain has been compounded into anger by new abortion bans across the country. While these women account for a fraction of abortions in the United States, they have emerged as the most powerful voices in the nation’s post-Roe debate, speaking out against bans with their stories of being forced across state lines and left to feel like criminals in seeking care.

Many of these women started out opposing abortion, but as they have changed their minds, they have changed the way Americans speak about it. Shifting from private anguish to public outrage, they have also helped shift public opinion toward more support for abortion.

“After going through all this I wondered, why are we not the poster child for abortion rights?” said Riata Little Walker, who traveled from her home in Casper, Wyo., for an abortion in Colorado at 22 weeks, after doctors diagnosed Down syndrome and a heart defect in her fetus, which they said would require surgery and later a transplant if it survived until delivery.

“Yes, your body, your choice, but that’s not the story that pulls people in,” she said. “We have to bring our stories to the front because otherwise it’s so easy for those over here to do, ‘But they’re killing babies.’”

Ms. Walker is Catholic and had worked for Wyoming Republicans, including Senator John Barrasso. She opposed abortion, and did not realize she was having one because doctors called it “termination.” In the months that followed, she came to support abortion whatever the reason, and after Roe was overturned in June 2022, she testified against the ban on abortion passed by the Wyoming Legislature.

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Replacing the Major Questions Doctrine with Originalist Statutory Interpretation

San Diego Legal Studies Paper No. 24-016

Harvard Journal of Law & Public Policy Per Curiam, Forthcoming

15 Pages Posted: 13 Jun 2024

Michael B. Rappaport

University of San Diego School of Law

Date Written: June 12, 2024

This short essay, written for a symposium, argues against the major questions doctrine from the perspective of statutory originalism. The essay contends that the doctrine in its leading form – which is understood as a substantive canon of interpretation – is inconsistent with statutory originalism. The doctrine cannot at present be justified as protecting the Constitution’s prohibition on delegation. The essay also argues that the arguments in favor of substantive canons, made by then Professor Amy Coney Barrett, are much weaker than normally thought, as the history does not indicate that federal courts believed they had the power to establish new substantive canons. The essay then argues that substantive canon version of the major questions doctrine is not necessary to protect against unduly expansive agency interpretations of their statutory authority. A variety of originalist interpretive methods, such as the mouseholes canon, the elimination of Chevron deference, contemporaneous exposition, and the mischief rule would operate to restrain such interpretations while also being consistent with originalism. The essay concludes by acknowledging that the linguistic version of the major questions doctrine is far superior to the substantive version but argues that it is best to dispense with even the linguistic version. It is better to focus directly on discovering the original meaning rather than to do so indirectly by attempting to define the acceptable limits of the linguistic version of the doctrine.

Keywords: Major Questions Doctrine, Originalism, Supreme Court Chevron, Administrative Law, MQD, Statutory Originalism,Textualism,Congress Amy Coney Barrett, Neil Gorsuch, Justices Constitution Public Policy, Regulation, Delegation, Canons of Statutory Interpretation

Suggested Citation: Suggested Citation

Michael B. Rappaport (Contact Author)

University of san diego school of law ( email ).

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Certificate of need laws con rural patients out of health care

By Sofia Hamilton and Thomas Kimbrell June 14, 2024

A rural farmland scene consists of trees with autumn leaves, grassy areas with cows, dry lands, and a few barns — first opinion coverage from STAT

N ews watchers around the U.S. have likely seen the warnings: without certificate of need (CON) laws, hospitals will be forced to close their doors when for-profit organizations open and cherry pick commercially insured patients, leaving those in rural areas without care. The reality is that even with certificate of need laws in place, rural patients are already without care . States with these laws have 30% fewer rural hospitals and 13% fewer rural ambulatory surgical centers.

CON laws require a state government to approve the establishment or expansion of health care facilities, services, or equipment. These certificates are essentially a government-mandated permission slip that individual health care providers, physician groups, hospitals, and health systems must obtain before they are allowed to care for patients. Essentially, CON laws empower bureaucrats to decide what health care services are offered, instead of that decision being driven by patients’ needs.

Facilities and services regulated under CON laws vary from state to state , but there is significant overlap. In many states, health care professionals or systems that want to open a nursing home , psychiatric or substance abuse treatment facility, birthing center , or ambulatory surgical center must first obtain a certificate of need. The same goes for those seeking to offer MRI , ultrasound, or other diagnostic services . Hospital systems that want to develop or expand neonatal intensive care units or burn units to provide necessary, lifesaving care must first navigate the lengthy CON process before being allowed to legally treat these vulnerable patients.

Certificate of need laws restrict access to health care services by artificially limiting the establishment and expansion of health care facilities. In some cases, CON schemes prevent providers from offering low-cost alternatives to hospital care. For example, CON laws barred an ophthalmologist from performing eye surgeries at his facility in North Carolina, and blocked an aspiring entrepreneur from opening a birthing center in Georgia. In other cases, CON programs stopped construction of hospitals in counties without one. In South Carolina, legal wrangling over certificate of need delayed the opening of a hospital for nearly two decades after the state identified the need for one in York County.

Related: Rural hospitals are closing labor and delivery services. Babies’ lives are in jeopardy

By 1972, more than half of U.S. states had enacted certificate of need laws. In 1974, the federal government coerced the remaining states to implement their own CON laws by threatening to withhold federal funding for health care facilities. But the federal government made a course correction in 1986 and repealed that law after CON laws failed to reduce health care costs. Since then, every presidential administration has implored state governments to repeal their certificate of need laws.

Like many bad policies, certificate of need laws were established with good intentions. Policymakers believed that certificates of need would control health care costs for patients by reducing waste and duplicity.

In practice, however, the aptly named CON laws artificially limit the health care market and drive up costs, effectively conning patients out of access to affordable care. Basic economics says that supply controls do not decrease prices — they actually do the opposite. CON laws negatively affect individuals in cities, suburbs, and beyond by increasing wait times, limiting choices , and inflating costs . In rural communities where the supply of health care is already limited, these controls can lead to life-threatening problems .

Unsurprisingly, the loudest defenders of certificate of need requirements are incumbent providers who benefit greatly from this monopolistic system that crowds out competition.

So far, 12 states have followed the federal government’s guidance to repeal their certificate of need laws. The current legislative session has seen some minor successes. Georgia passed a bill exempting psychiatric and substance abuse inpatient programs, basic prenatal services, birthing centers, and general acute hospitals from the state’s CON process. Likewise, Tennessee passed a bill removing CON requirements for several services as well as medical facilities in counties without an acute care hospital. Both bills follow last year’s massive success in South Carolina which passed a full repeal of certificates of need for virtually all services.

Related: Medicare offers financial perks for rural hospitals that convert to its new provider type. Will they bite?

These reforms follow a national trend of states reducing the regulatory burdens of their certificate of need laws: Montana reformed its CON law to cover only long-term care facilities in 2021; Florida eliminated CON requirements for numerous services in 2019; and West Virginia removed CON requirements for birthing centers and all hospital services in 2023 after exempting telehealth, remedial care, imaging services, and ambulatory health facilities in 2017.

Some states, however, continue to drag their heels. In 2023, the Kentucky General Assembly formed a legislative task force to study reforming its certificate of need program. After six months, the task force issued a disappointing one-sentence recommendation for “further study.” Earlier this year, the Mississippi House and Senate passed differing versions of a limited reform bill that would have exempted from its CON law chemical dependency and psychiatric services and birthing centers, but the bill died last month after the two chambers could not agree on the details, leaving in place unnecessary barriers between health care providers and some of Mississippi’s most vulnerable people.

Health care systems in states that have repealed their CON requirements have not fallen apart, as hospital associations had predicted. In actuality, states that have repealed their programs have seen increases in health care investment . Research also shows that safety-net hospitals in states without CON laws had considerably higher margins than safety-net hospitals in states with these laws.

The successes of these reforms have prompted some CON defenders to begin making concessions to their long-standing opposition to repealing these laws. In 2023, for example, the Kentucky Hospital Association proposed CON “modernization” reforms that would “provide flexibility for existing Kentucky hospitals to improve patient service” by allowing existing hospitals to receive expedited CON reviews for several types of services and facilities. These same conveniences, however, would not be extended to other providers that apply for certificates of need. The Georgia Hospital Association recommended similar reforms to allow existing hospitals to add, expand, or relocate services without a certificate of need but leave CON requirements in place for new providers.

Decades after their implementation, the touted benefits of certificate of need laws have not been realized. Instead, the regulations have unnecessarily limited the supply of, and access to, quality health care options for all Americans. The rollback and repeal of CON laws will allow patients and providers to access each other without the unnecessary intrusion of the government.

Maintaining CON regimes at the behest of incumbent providers will only enrich their bottom lines at the expense of the health and safety of rural communities.

Sofia Hamilton is a policy analyst at Americans for Prosperity. Thomas Kimbrell is an investigative analyst at Americans for Prosperity Foundation.

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What You Need to Know About Marijuana Rescheduling

by Victoria Litman, M.Div., J.D., LL.M.

On May 21, 2024, the Drug Enforcement Administration (DEA) published a Notice of Proposed Rulemaking (NPRM) signed by Attorney General Merrick Garland in the Federal Register. This publication kicks off a 62-day comment period on a rule that would move marijuana to Schedule 3 of the Controlled Substances Act (CSA), classifying it as a substance with “a moderate to low potential for physical and psychological dependence.” The process of rescheduling may be long and is unlikely to create a pathway to federal compliance for state-legal marijuana businesses without further federal legislation. Ultimately, Congress likely will need to clarify the division of federal and state regulatory powers over cannabis.

The CSA is a federal law that classifies substances into schedules based on their potential for medical use and risk of abuse. The cannabis plant has been in the most restrictive category, Schedule 1, since the CSA was enacted in 1970. In the 2018 Farm Bill , cannabis plants with less than .3% concentration of the major psychoactive component of marijuana, delta-9-tetrahydrocannabinol (THC), were removed from the CSA and legally defined as hemp. All other cannabis remains Schedule 1 , defined as a substance with no currently accepted medical use (CAMU), lack of safety for use under medical supervision, and a high potential for abuse.

Despite ongoing cannabis restrictions on the federal level, since 1996 many states have enacted legislation regulating and taxing medical and recreational marijuana and creating dispensaries for patients and consumers to access it. For several decades, these state-regulated businesses have existed under the shadow of federal illegality. Marijuana’s Schedule 1 status has impacted the economic feasibility of these businesses due to punitive federal taxes , significant burdens on banks willing to work with cannabis businesses, and no legal interstate commerce.

Since 2014, Congress has passed spending amendments that limit the use of federal funds for enforcement against state-compliant medical marijuana programs. From 2009-2018, several U.S. Attorneys General issued memos directing federal prosecutors to limit enforcement against all state-compliant marijuana businesses, medical and recreational. In 2018 Attorney General Jeff Sessions technically rescinded prior memos and encouraged prosecution of federally illegal marijuana activity; however, in practice there has been limited federal enforcement.

In the fall of 2022, President Biden issued a statement on marijuana reform, announcing federal pardons for some federal crimes involving marijuana and urging state governors to pardon state-level cannabis possession charges. Biden also asked the Secretary of the U.S. Department of Health and Human Services (HHS) and the Attorney General to initiate the administrative process to review the scheduling of cannabis under the CSA.

In August 2023, HHS sent an official recommendation to the DEA that it categorize marijuana under the less restrictive Schedule 3 category. The recommendation became public in early 2024 as a result of a lawsuit . Notably, the recommendation was the first statement from a federal government agency that marijuana has a currently accepted medical use and a low potential for abuse. An April 11, 2024 opinion from the Office of Legal Counsel (OLC) asserted that DEA must “accord significant deference” to HHS’ recommendation until the beginning of formal rulemaking. However, the NPRM notes that DEA has not decided how marijuana should be scheduled.

Now that the NPRM has been published, individuals and businesses may submit comments on the proposal until July 22nd. Interested persons (defined in regulations ) may request an administrative law hearing before June 20th in accordance with the requirements of the Administrative Procedure Act.

Once comments are received and after any hearing, the DEA will review all evidence and generally respond to comments when publishing the final rule. There is no set statutory time for this process but in other situations, for example telemedicine , it has taken over a year.

Once published, the DEA’s final rule will not go into effect for 30 days, during which time aggrieved parties who submitted comments and can demonstrate they have standing can challenge the final rule in court. At least one major opposition group is already fundraising for the legal effort.

The two main issues likely to be challenged are the impact of rescheduling on adherence to United Nations treaty obligations and the way HHS determined that marijuana has a CAMU. For the first time, HHS considered the existing widespread use of medical marijuana under the supervision of health care practitioners within state medical marijuana programs. The OLC’s opinion addresses these issues directly.

A letter from Democratic senators opposing rescheduling and supporting removal of marijuana from the CSA entirely explains that although rescheduling likely provides tax relief, it does not impact criminal justice and immigration issues related to cannabis criminalization. Rescheduling would not be a panacea for the challenges faced by state legal marijuana businesses and would not necessarily make marijuana easier to research .

Schedule 3 drugs must be approved by the Food and Drug Administration (FDA,) prescribed by a doctor, and distributed by a pharmacy. Thus, none of the existing state-regulated marijuana dispensaries would be able to comply without extreme cost or further regulation or legislation. Another Attorney General’s memo is expected to clarify enforcement priorities against marijuana-related businesses that are legal in the state, but federally non-compliant.

I have previously written that no matter what happens with rescheduling, Congress will need to clarify the division of federal and state regulatory powers over cannabis. Congress must specify that FDA’s jurisdiction over cannabis should be no more than that over alcohol and designate cannabis in food as “generally recognized as safe.” These, and other FDA-related fixes, already drafted as part of proposed legislation, the States Reform Act , would create legal pathways for existing state-licensed marijuana operators to be in compliance with the Federal Food, Drug, and Cosmetic Act . By doing so, Congress could reduce unnecessary spending on unfeasible federal enforcement and preserve limited federal resources to evaluate clinical research on cannabis-derived drugs . Thus, even if marijuana is moved to Schedule 3, federal legislation is necessary. The only question is how long it will take Congress to act.

Victoria Litman M.Div, J.D., LL.M. is a nonprofit tax lawyer focused on the emerging cannabis and psychedelic tax exempt sectors and an adjunct law professor. She is also an Affiliated Researcher of the Project on Psychedelics Law and Regulation (POPLAR) at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.

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100 great medical ethics topics for a research project.

One of the most important aspects of writing a great assignment in medicine is coming up with a great topic. There are endless issues and debates that are worth discussing, but we know that students do not always have the time to find medical ethics topics that meet their requirements. This list of medical ethics topics that was put together by our academic experts can be modified to fit numerous situations.

Medical Ethics Essay Topics for College Students

The following medical ethics paper topics are suited for students that have mastered the skill of researching and writing. They are designed for college students that have the time and dedication to put in the work craft a great assignment:

Doctor withholding information from families for extended periods.
Testing fetuses for birth defects to determine abortion cases.
The obligation to treat prisoners serving life-term sentences.
The federal mandate to treat prisoners with degenerative diseases.
Donating organs to relatives in lower need versus non-relatives with greater need.
Privacy rights for minors getting abortions without parental consent.
Patients’ rights to refuse treatment in any state.
The right to refuse an organ donation without a medical reason.
The point in which an unborn baby is considered alive.
Importance of physical health in medical professionals to provide treatment.

Medical Ethics Topics for Essay in Graduate School

The following topics in medical ethics are catered to students at the graduate level. They will require a lot of research and may take several weeks to complete:

Access to birth control for minors without parental consent.
Terminating a pregnancy because of a birth defect.
The ethics in allowing medical students to be more proactive.
End-of-life care patients and access to nutrition.
Advance directives and non-resuscitation orders.
The negative impact a physician’s stress level can have on patients.
The ethical way of using social media in medicine.
How social media has enabled individuals to seek medical care.
The impact online communication has on patient-physician relationships.
Patient favor or gift exchange for special treatment.

Medical Ethics Research Paper Topics for Ph.D. Students

When you work on a Ph.D. you will likely be conduct research on what will become the foundation of your professional expertise. Consider these topics for a Ph.D. capstone project in your area of interest:

The ethics of treating patients without insurance.
The best way to address disparities in health care.
Approaches to dealing with patients that do not want treatment.
Methods for working with surrogate decision-makers.
Required use of masks during pandemics.
The Covid-19 vaccine and its implied risks.
Malpractice cases and the right for doctors to return to work.
The use of animals to test potentially harmful medications.
Using technology to conduct open-heart surgery.
Artificial intelligence to minimize human risk.

Current Medical Ethics Topics for 2023

These medical ethics topics for research papers are what are being discussed in the community today. From medical malpractice to Covid-19, you will find the latest issues here:

Overtime payments and fees for doctors.
Assisted suicide and affordable health.
The risks of selective reproduction.
Allowing technologies to monitor a patient’s health.
Saving the life of a pregnant woman while putting an unborn child at risk.
Human donor lists and the priority assigned to recipients.
HIV/AIDS testing and counseling for teenagers.
Challenges posed in family planning decisions.
The quality of care for low-income families.
Organ donation and ethnic preference.

Controversial Medical Ethics Topics in the News

Here are some medical debate topics ethics that are controversial and should generate a lot of interest from the reading community. Just be sure you conduct ample research to guarantee you are finding and using the latest information:

The vaccine against Covid-19 should be mandatory.
Criminal charges for accidental treatment deaths.
The impact stem cell research has on curing diseases.
The increase of biohackers around the world.
The risk of having genetic and medical data stolen.
Physician liability and legal responsibilities.
Patient information and privacy laws.
Patients’ rights to refuse types of treatment.
Organ and tissue transplant oversight laws.
The impact that bioterrorism has on people.

Medical Ethics Topics for Debate or Presentation

These medical ethics debate topics explore some more serious issues requiring students to think outside-of-the-box and to challenge themselves by developing logical and interesting presentations:

Acquiring patient’s private data for predictive analysis.
How to protect patient data through de-anonymization.
Current regulations provide adequate privacy protection.
Big data risks of exposing patient private information.
Limitations of patient information gathered through databases.
How to protect patients from inherent bias used in public health analysis.
Concerns with forced immunization around the world.
The effectiveness of the response to global pandemics.
The differences in medical ethics around the world.
International ethics in the global community.

Medical Law and Ethics Topics for 2023

Topics in medical law change drastically from year to year. We have gathered the current hot topics related to this field and trust that you will find something you like:

Laws that protect the well-being of patients.
Medical negligence in cases of death.
The rights of patients undergoing surgery.
Preliminary agreements before invasive surgery.
Ethical dilemmas that arise when acknowledging patients’ requests.
Ethical standards across the United States.
The importance of medical ethics in today’s world.
The best way to monitor ethics in the medical field.
The challenges of practicing medicine internationally.
Cultural differences in medical decisions and law.

Medical Ethics Topics for Discussion or Presentation

This medical ethics topics list is perfect for any student that has to participate in a round-table discussion or conduct a presentation on the impact that medical ethics has on society:

The ethical question regarding preventative medicine.
End-of-care decisions regarding patient comfort and care.
Religious beliefs contradict medical decisions and put patients at risk.
Medical ethics versus cultural bias across the United States.
Ethical questions when treating the mentally disabled.
How to deal with medical ethics in third-world countries.
The moral and ethical questions of treating patients without healthcare.
The connection between poor health and financial status.
The cost of healthcare in developed countries versus undeveloped countries.
The major factors that drive the costs of healthcare in the U.S.

Medical Ethics Issues Topics for a Quick Project

There are plenty of reasons why students would need to find a topic they can research and write about in a short amount of time. Consider these ideas for a quick turnaround:

The right to attain complete medical information despite age.
The obligation to report instances of alleged organ trafficking.
The right for patients to have access to all medical records after the age of 15.
Child vaccination is a mandatory requirement of all legal residents.
The ethics behind using surrogate pregnancies on-demand versus health reasons.
Giving the homeless population free healthcare across the United States.
A patient’s right to refuse treatment for religious purposes.
How to improve the selection process in which donor recipients are selected.
Encouraging patients to use homeopathy remedies before medicine.
Accepting eastern medical practices to help patient rehabilitation.

Medical Ethics Research Topics for a Dissertation

Dissertations are long projects that can take several months to several years to complete. Be sure to consider a topic that you know you can handle and one that will make working with your advisor a positive experience:

Allowing patients to opt-in or opt-out of the donor system in specific circumstances.
The legalization of doctor-assisted suicide is a federal right in the United States.
The advancements in technology improve the accuracy of treatments.
Patient confidentiality and treatment during the Covid-19 global pandemic.
Genetic testing, precision medicine, patient privacy, and confidentially challenges.
The extent to which people without healthcare should be provided services.
The international medical community during times of war.
Different examples of cultural humility and volunteerism around the world.
Moral and ethical obligations physicians have to society regardless of country.
The effect of data breaches on the doctor and patient relationship.

For more good medical ethics research topics, contact our support staff who can connect you with a qualified academic professional in this field. He or she can find topics for medical ethics paper to fit any situation and academic level. We are available to help 24/7 and can be reached conveniently by chat, email, and telephone.

The Buzz on Florida Politics

Florida ban on medical treatments for trans kids struck down by judge

Romy Ellenbogen Times staff

TALLAHASSEE — Florida’s restrictions on medical care for transgender children are unconstitutional, a federal judge ruled Tuesday as he struck down a signature priority of Gov. Ron DeSantis.

U.S. District Judge Robert Hinkle’s decision invalidates much of a 2023 law and rules approved by state boards prohibiting children from accessing medical treatments for gender dysphoria, such as puberty blockers and hormones.

“Florida has adopted a statute and rules that ban gender-affirming care for minors even when medically appropriate,” Hinkle wrote in his 105-page order. “The ban is unconstitutional.”

Attorneys that represented the transgender plaintiffs argued that the law signed by DeSantis was an act of discrimination and “animus” against transgender people. The state said it was targeting the treatments, not transgender people themselves.

In his ruling, Hinkle, who was appointed to the bench by former President Bill Clinton, said that it was “clear that anti-transgender animus” motivated bill sponsors and some legislators who approved the law.

“Transgender opponents are of course free to hold their beliefs,” Hinkle wrote. “But they are not free to discriminate against transgender individuals just for being transgender. In time, discrimination against transgender individuals will diminish, just as racism and misogyny have diminished. To paraphrase a civil-rights advocate from an earlier time, the arc of the moral universe is long, but it bends toward justice.”

Hinkle pointed to comments from DeSantis and House representatives about young children being castrated or sterilized because of medical treatments for gender dysphoria. Hinkle said that the state admitted during the trial that there was no factual basis for those remarks, and that the record showed no evidence any Florida child had been “castrated or mutilated.”

“Perhaps all this talk about castration and mutilation is just political hyperbole,” Hinkle wrote. “But it casts at least some doubt on the assertion that these decisionmakers’ motivation was sound regulation of medical care in the best interest of transgender patients rather than outright disapproval of transgender identity.”

Along with striking down the rules banning kids with gender dysphoria from accessing medical treatment, Hinkle also struck down rules that required transgender adults to only get medical treatment from physicians, instead of from other kinds of health providers.

Hinkle last year also struck down Florida’s ban on Medicaid covering treatments for gender dysphoria . The state is appealing that ruling, and opponents have argued that the state has been defying Hinkle’s order and still denying Medicaid coverage.

DeSantis’ press secretary, Jeremy Redfern, said that the state would appeal Hinkle’s new ruling, as well.

“Through their elected representatives, the people of Florida acted to protect children in this state, and the Court was wrong to override their wishes,” Redfern said in an emailed statement. “We disagree with the Court’s erroneous rulings on the law, on the facts, and on the science. As we’ve seen here in Florida, the United Kingdom, and across Europe, there is no quality evidence to support the chemical and physical mutilation of children. These procedures do permanent, life-altering damage to children, and history will look back on this fad in horror.”

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Major medical organizations like the American Academy of Pediatrics support children using treatments like puberty blockers for gender dysphoria. Hinkle said in his ruling that “not a single reputable medical association” has flatly opposed using puberty blockers and hormone therapy in appropriate circumstances.

If the state truly believed that gender dysphoria was being improperly treated in Florida, “despite the absence of complaints and despite the state’s inability, even now, to find a single adversely affected Florida patient,” they could have restricted or regulated care without banning it, Hinkle wrote in his order.

Simone Chriss, an attorney on the case and the director of the transgender rights initiative at the Southern Legal Counsel, said that Hinkle’s ruling “restores some balance in terms of, like, respect and dignity and decency in a state that has never been more in need of those things than right now.”

Chriss said that the ruling returns Florida to where it was just a few years ago, where decisions about transgender medical care are in the hands of patients, their families and their doctors.

The U.S. 11th Circuit Court of Appeals allowed a similar Alabama ban on medical treatment for transgender kids to take effect. But Chriss said the Florida case is different because the case out of Alabama didn’t argue that the laws were based on anti-transgender bias.

Jane Doe, one of the anonymous plaintiffs representing her transgender daughter, Susan Doe, said in a statement that the ruling means she won’t need to watch her daughter needlessly suffer.

“Seeing Susan’s fear about this ban has been one of the hardest experiences we’ve endured as parents,” Doe said in a statement. “All we’ve wanted is to take that fear away and help her continue to be the happy, confident child she is now.”

Romy Ellenbogen is a Tallahassee correspondent, covering state government with a focus on criminal justice and health. Reach her at [email protected].

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Information on the people and the population of Elektrostal.

Elektrostal Population	157,409 inhabitants
Elektrostal Population Density	3,179.3 /km² (8,234.4 /sq mi)

Elektrostal Geography

Geographic Information regarding City of Elektrostal .

Elektrostal Geographical coordinates	Latitude: , Longitude: 55° 48′ 0″ North, 38° 27′ 0″ East
Elektrostal Area	4,951 hectares 49.51 km² (19.12 sq mi)
Elektrostal Altitude	164 m (538 ft)
Elektrostal Climate	Humid continental climate (Köppen climate classification: Dfb)

Elektrostal Distance

Distance (in kilometers) between Elektrostal and the biggest cities of Russia.

Elektrostal Map

Locate simply the city of Elektrostal through the card, map and satellite image of the city.

Elektrostal Nearby cities and villages

Elektrostal Weather

Weather forecast for the next coming days and current time of Elektrostal.

Elektrostal Sunrise and sunset

Find below the times of sunrise and sunset calculated 7 days to Elektrostal.

Day	Sunrise and sunset	Twilight	Nautical twilight	Astronomical twilight
8 June	02:43 - 11:25 - 20:07	01:43 - 21:07	01:00 - 01:00	01:00 - 01:00
9 June	02:42 - 11:25 - 20:08	01:42 - 21:08	01:00 - 01:00	01:00 - 01:00
10 June	02:42 - 11:25 - 20:09	01:41 - 21:09	01:00 - 01:00	01:00 - 01:00
11 June	02:41 - 11:25 - 20:10	01:41 - 21:10	01:00 - 01:00	01:00 - 01:00
12 June	02:41 - 11:26 - 20:11	01:40 - 21:11	01:00 - 01:00	01:00 - 01:00
13 June	02:40 - 11:26 - 20:11	01:40 - 21:12	01:00 - 01:00	01:00 - 01:00
14 June	02:40 - 11:26 - 20:12	01:39 - 21:13	01:00 - 01:00	01:00 - 01:00

Elektrostal Hotel

Our team has selected for you a list of hotel in Elektrostal classified by value for money. Book your hotel room at the best price.

	Located next to Noginskoye Highway in Electrostal, Apelsin Hotel offers comfortable rooms with free Wi-Fi. Free parking is available. The elegant rooms are air conditioned and feature a flat-screen satellite TV and fridge...	from
	Located in the green area Yamskiye Woods, 5 km from Elektrostal city centre, this hotel features a sauna and a restaurant. It offers rooms with a kitchen...	from
	Ekotel Bogorodsk Hotel is located in a picturesque park near Chernogolovsky Pond. It features an indoor swimming pool and a wellness centre. Free Wi-Fi and private parking are provided...	from
	Surrounded by 420,000 m² of parkland and overlooking Kovershi Lake, this hotel outside Moscow offers spa and fitness facilities, and a private beach area with volleyball court and loungers...	from
	Surrounded by green parklands, this hotel in the Moscow region features 2 restaurants, a bowling alley with bar, and several spa and fitness facilities. Moscow Ring Road is 17 km away...	from

Elektrostal Nearby

Below is a list of activities and point of interest in Elektrostal and its surroundings.

Elektrostal Page

Direct link
DB-City.com	Elektrostal /5 (2021-10-07 13:22:50)

Information /Russian-Federation--Moscow-Oblast--Elektrostal#info
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Distance /Russian-Federation--Moscow-Oblast--Elektrostal#dist1
Map /Russian-Federation--Moscow-Oblast--Elektrostal#map
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Home — Essay Samples — Business — Conflict — Creon’s Laws in Antigone

Creon's Laws in Antigone

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Published: Jun 13, 2024

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Geographic coordinates of Elektrostal, Moscow Oblast, Russia

City coordinates

Coordinates of Elektrostal in decimal degrees

Coordinates of elektrostal in degrees and decimal minutes, utm coordinates of elektrostal, geographic coordinate systems.

WGS 84 coordinate reference system is the latest revision of the World Geodetic System, which is used in mapping and navigation, including GPS satellite navigation system (the Global Positioning System).

Geographic coordinates (latitude and longitude) define a position on the Earth’s surface. Coordinates are angular units. The canonical form of latitude and longitude representation uses degrees (°), minutes (′), and seconds (″). GPS systems widely use coordinates in degrees and decimal minutes, or in decimal degrees.

Latitude varies from −90° to 90°. The latitude of the Equator is 0°; the latitude of the South Pole is −90°; the latitude of the North Pole is 90°. Positive latitude values correspond to the geographic locations north of the Equator (abbrev. N). Negative latitude values correspond to the geographic locations south of the Equator (abbrev. S).

Longitude is counted from the prime meridian ( IERS Reference Meridian for WGS 84) and varies from −180° to 180°. Positive longitude values correspond to the geographic locations east of the prime meridian (abbrev. E). Negative longitude values correspond to the geographic locations west of the prime meridian (abbrev. W).

UTM or Universal Transverse Mercator coordinate system divides the Earth’s surface into 60 longitudinal zones. The coordinates of a location within each zone are defined as a planar coordinate pair related to the intersection of the equator and the zone’s central meridian, and measured in meters.

Elevation above sea level is a measure of a geographic location’s height. We are using the global digital elevation model GTOPO30 .

Elektrostal , Moscow Oblast, Russia

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Geographic coordinates of Elektrostal, Moscow Oblast, Russia in WGS 84 coordinate system which is a standard in cartography, geodesy, and navigation, including Global Positioning System (GPS). Latitude of Elektrostal, longitude of Elektrostal, elevation above sea level of Elektrostal.
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