Sexual Consent: The Criminal Law in Europe and Overseas

What role can the criminal law play in the battle against child sexual abuse? Should sexual relations of and with, persons under a certain age be criminalized regardless of the circumstances, even if they are consensual (“age of consent,” “minimum age”)? Where should such a minimum age-limit be fixed? Should there be a special, higher age-limit for particular conditions (e.g., “seduction,” “corruption”)? Should sexual contacts with minors within a relationship of authority be criminalized generally, or just if authority is abused? Should criminal proceedings be instituted ex officio or upon complaint only? Should authorities be provided with a power of discretion or should they be obliged to prosecute and sentence in each case? In answering these questions, it is highly beneficial to have a look across the borders to the solutions other countries have reached. This study presents an overview on the criminal law governing the sexual behavior of, and with, children and adolescents in all European jurisdictions and in selected jurisdictions outside of Europe. It shows which categories of offences exist and from which age onward young people can effectively consent to various kinds of sexual behavior and relations in the different countries. All states in Europe and all of the studied jurisdictions overseas have minimum age limits for sexual relations, and punish sexual relations with persons under a certain age. Nowhere is this age set lower than 12 years. In Europe, in one-half of the jurisdictions, consensual sexual relations with 14-year-old adolescents are legal; in three-quarters, with 15-year olds; in a majority, this is also the case when the older partner has started the relation (and also when the initiative contains an offer of remuneration). In nearly all jurisdictions, such relations are legal from age 16 onward. Most states apply a higher age limit for contacts in relationships of authority. If the authority is not misused, the age limit in most jurisdictions is set between 14 and 16; if it is misused, between 16 and 18. Most states make no difference between heterosexual and homosexual relations.     

Persons and Their Parts: New Reproductive Technologies and Risks of Commodification

This paper explores one aspect of the social implications of new reproductive technologies, namely, the impact such technologies have on our understandings of family structures and our expectations of children. In particular it considers whether the possibilities afforded by such technologies result in a more contractual and commodified understanding of children. To do this the paper outlines the possibilities afforded by NRTs and their commodificatory tendencies; second, it explores the commodification debate using the somewhat parallel example of commodification of organs; and third, in light of these debates the link between the commodification of body parts and persons is addressed. It will argue that there is a prime facie connection between body parts and persons and thus, although needing to be balanced with other ethically relevant factors, commodification remains an issue of ethical concern. Accordingly we should only be supporting potentially commodifying practices when there are ethically pressing reasons to do so (such as in organ transplantation). Moreover given this link between body part and persons we should attempt to lessen commodifying attitudes and thus should resist the increasing use of practices which regard children as having choose-able parts.

SUPPORT Tools for Evidence-informed Policymaking in health 18: Planning monitoring and evaluation of policies

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.The term monitoring is commonly used to describe the process of systematically collecting data to inform policymakers, managers and other stakeholders whether a new policy or programme is being implemented in accordance with their expectations. Indicators are used for monitoring purposes to judge, for example, if objectives are being achieved, or if allocated funds are being spent appropriately. Sometimes the term evaluation is used interchangeably with the term monitoring, but the former usually suggests a stronger focus on the achievement of results. When the term impact evaluation is used, this usually implies that there is a specific attempt to try to determine whether the observed changes in outcomes can be attributed to a particular policy or programme. In this article, we suggest four questions that can be used to guide the monitoring and evaluation of policy or programme options. These are: 1. Is monitoring necessary? 2. What should be measured? 3. Should an impact evaluation be conducted? 4. How should the impact evaluation be done?     

Could the ethics of institutionalized health care be anything but Kantian? Collecting building blocks for a unifying metaethics

Is a Health Care Ethics possible? Against sceptical and relativist doubts Kantian deontology may advance a challenging alternative affirming the possibility of such an ethics on the condition that deontology be adopted as a total programme or complete vision. Kantian deontology is enlisted to move us from an ethics of two-person informal care to one of institutions. It justifies this affirmative answer by occupying a commanding meta-ethical stand. Such a total programme comprises, on the one hand, a dual-aspect strategy incorporating the macro- (institutional) and micro- (person-to-person) levels while, on the other, it integrates consistently within moral epistemology a meta-ethics with lower-ground moral theories. The article describes the issues to be dealt with and the problems which have to be solved on the way to a unifying theory of that kind (Sections I-III) and indicates elements of Kantian moral philosophy which may serve as building blocks (Section IV). Among these are not only Kant’s ideas concerning the moral acting of persons and his ideas concerning civil society and state but also his ideas concerning morality, schematism and religion.     

The role of attorneys on Hospital Ethics Committees: potential influence on committee decisionmaking

Conclusion The most important issue remains: Whether attorneys should serve on HECs? Will they tend to inhibit the development of other discussions, ethical discussions, regarding the issues brought before the HEC? D. Niemira (17, p. 982) suggests that what a hospital needs is not necessarily an attorney to help in their ethical deliberations, but an ethicist. This suggestion should receive further analysis. What types of ethical deliberations to which attorneys have not been exposed in their legal training are important given the broader attorney-role (beyond giving legal opinion) in HEC discussions?The pro-active attorney faces many challenges, both in the current setting (as cases are brought to the HEC) and as future questions are raised (due to innovations in medical technology). These questions remain unclarified by the courts. The nature of the attorney's role is ever challenging; he or she remains in a key position that is currently needed (regarding the uncharted areas of HEC decisionmaking) and important for the future (as new cases emerge and require extensive deliberations).     

Influenza vaccination in Dutch nursing homes: Is tacit consent morally justified?

Objectives: Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study’s objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified. Design: A survey among nursing home physicians. Setting &; Participants: We sent a questionnaire to all (356) nursing homes in the Netherlands, to be completed by one of the physicians. Results: We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03). Conclusions: In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures.     

SUPPORT Tools for evidence-informed health Policymaking (STP) 14: Organising and using policy dialogues to support evidence-informed policymaking

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.Policy dialogues allow research evidence to be considered together with the views, experiences and tacit knowledge of those who will be involved in, or affected by, future decisions about a high-priority issue. Increasing interest in the use of policy dialogues has been fuelled by a number of factors: 1. The recognition of the need for locally contextualised 'decision support' for policymakers and other stakeholders 2. The recognition that research evidence is only one input into the decision-making processes of policymakers and other stakeholders 3. The recognition that many stakeholders can add significant value to these processes, and 4. The recognition that many stakeholders can take action to address high-priority issues, and not just policymakers. In this article, we suggest questions to guide those organising and using policy dialogues to support evidence-informed policymaking. These are: 1. Does the dialogue address a high-priority issue? 2. Does the dialogue provide opportunities to discuss the problem, options to address the problem, and key implementation considerations? 3. Is the dialogue informed by a pre-circulated policy brief and by a discussion about the full range of factors that can influence the policymaking process? 4. Does the dialogue ensure fair representation among those who will be involved in, or affected by, future decisions related to the issue? 5. Does the dialogue engage a facilitator, follow a rule about not attributing comments to individuals, and not aim for consensus? 6. Are outputs produced and follow-up activities undertaken to support action?     

Informed consent: ideal or reality?

Is it ever possible to give informed consent to treatment or research? Are the standards of consent set by ethicists and lawyers too high for ordinary people to reach? Should these standards be abandoned or modified? These questions are discussed in this paper mainly in relation to the extensive literature on consent in medicine, with examples about consent to children's treatment and research which raise extra dilemmas. Paradoxical meanings are considered: consent as an informed correct choice or a courageous best guess, and autonomy as isolated, uncompromised freedom or reasonably uncoerced self-realisation. Beyond being informed, consent involves evaluating, making and signifying a decision. It is better understood as a process than an event, in which reasoned understandings can be complemented by emotional insights. Ethical and legal standards of voluntary consent, although partly an unrealistic ideal, provide important guidelines for people who request and give consent to research.     

Deferred consent for inclusion of patients unable to give their consent in studies in the field of emergency medicine

Respect for individual autonomy, expressed in the concept of informed consent, is a basic principle in research with humans. Many patients in intensive care are unable to give consent because of mental incapacity, and this can be further complicated in emergency research, in which the treatment or experiment needs to be initiated without delay. In those situations consent can be deferred. Randomization is done without prior consent, followed by patients' or relatives' consent at a later stage. Butwhat should one do with the data if the patient dies at an early stage after randomization before consent could be obtained? Should the data be used or not? Should the relatives be asked for consent for using the data? The Dutch Central Committee on Research involving Human Subjects (CCMO) states that asking for consent after the patient has died makes no sense, because with the death of the patient the research has ended. Relatives do not have the authority to give consent for the use of medical data after the patient has died. Data can be used anonymously in the final analysis of the trial. We propose a flowchart for this procedure.     

‘Sorry,it's my first time!' Will patients consent to medical students learning procedures?

Context The clinical teaching of medical students is essential to medicine; however, medical students often may not inform patients of their inexperience. Hence patients do not have the opportunity to consent specifically to the procedures being performed by medical students. Objectives The purpose of this study was to determine whether patients, when informed of the inexperience of a medical student, would still consent to the procedure. Methods Adult emergency department patients (114) were enrolled if they required one of the following procedures: sutures, intravenous (i.v.) access or splinting. Patients were first surveyed about his or her perceptions of medical student performing procedures. The first-year medical student then informed the patient of their inexperience (the number of procedures they had performed successfully). Finally, the patient was asked to consent to the student performing the procedure (i.e. ‘this is my first/third time suturing, may I suture you?’) The main outcome measure was patient consent to the student performing the procedure. Results Only 48% of participants knew they could be the first patient on whom a medical student might perform a procedure. A total of 66% thought they should be told if a student was performing his or her first procedure on them. The majority of patients (90%) consented (69/80 i.v., 20/20 splints, 13/14 sutures). For 7 of the 12 refusals, it was the student's first time performing the procedure. Conclusion Most patients will allow medical students to perform minor procedures, even when informed of the student's inexperience.     

Rights and respect. Legal and ethical issues challenge today's mental healthcare professionals

The special circumstances of patients in mental health facilities often make questions concerning patient autonomy, freedom of choice, and consent to treatment even more complex than they are in other contexts. Individual facilities need to identify the ethical issues they are likely to encounter and create policies that address them effectively. The advent of managed care has created unprecedented access problems for mental healthcare providers. In many cases patients must be proven dangerous to themselves or others before they can be admitted for emergency care; because it is difficult to prove this, many persons go without needed treatment. The high costs of care and prejudices against persons with mental illness also create ethical problems. The necessity of performing clinical evaluations raises important ethical issues as well. Care givers evaluating someone at the request of a school, employer, or court should be sensitive to the possible consequences of their evaluation. They should also restrict their diagnoses to their area of competency and inform clients of the purpose of the evaluation, its possible consequences, and the limits of its confidentiality. Mental health professionals must also respect patients' rights to informed consent and understand the issues of voluntary or involuntary admissions. In addition, care givers should be aware of the various issues created by the need to occasionally control patients' behavior. Finally, for mental healthcare facilities, it is essential to establish an ethics committee to address these issues.     

What should we want to know about our future? A Kantian view on predictive genetic testing

Recent advances in genomic research have led to the development of new diagnostic tools, including tests which make it possible to predict the future occurrence of monogenetic diseases (e.g. Chorea Huntington) or to determine increased susceptibilities to the future development of more complex diseases (e.g. breast cancer). The use of such tests raises a number of ethical, legal and social issues which are usually discussed in terms of rights. However, in the context of predictive genetic tests a key question arises which lies beyond the concept of rights, namely, What should we want to know about our future? In the following I shall discuss this question against the background of Kant’s Doctrine of Virtue. It will be demonstrated that the system of duties of virtue that Kant elaborates in the second part of his Metaphysics of Morals offers a theoretical framework for addressing the question of a proper scope of future knowledge as provided by genetic tests. This approach can serve as a source of moral guidance complementary to a justice perspective. It does, however, not rest on the – rather problematic – claim to be able to define what the “good life” is.     

Children,Longitudinal Studies,and Informed Consent

This paper deals with ethical issues of particular relevance to longitudinal research involving children. First some general problems concerning information and lack of understanding are discussed. Thereafter focus is shifted to issues concerning information and consent procedures in studies that include young children growing up to become autonomous persons while the project still runs. Some of the questions raised are: When is it right to include children in longitudinal studies? Is an approval from the child needed? How should information to children be handled? A general point stressed is that autonomy considerations underline the importance of adjusting the information given to meet demands. A “presumption of competence” may be needed in research involving children, in order to pay their views sufficient attention.     

Lead and Arsenic Accumulation and Its Effects on Plasma Cortisol Levels in <Emphasis Type="Italic">Oreochromis</Emphasis> sp.

The accumulation, elimination and effect of heavy metals on plasma cortisol levels in Oreochromis sp. were studied in the exposure and recovery phases. In the exposure phase, the mean rate of accumulation in the tissues was in the order gill?>?liver?>?muscle for Pb exposure and muscle?>?liver?>?gill for As exposure. In the recovery phase, the order of elimination in the tissues was gill?>?liver?>?muscle for Pb and liver?>?gill?>?muscle for As. The amount of cortisol secreted by the Oreochromis sp. after Pb or As treatment was lower compared to Oreochromis sp. in the control group during the exposure phase. In the recovery phase, plasma cortisol levels in Oreochromis sp. increased in all Pb treatment groups while it continuously decreased in all As treatment groups. A fish affected by As has obvious difficulty recovering from the stress response. It was concluded that exposure to the tested concentrations of Pb and As over 20 days could be a potent endocrine disruptor, which may lead to adverse impacts on the health of the Oreochromis sp.     

The Neglect of Racism as an Ethical Issue in Health Care

Race and racism has been increasingly implicated in known disparities in the health and health care of racial, ethnic and cultural minorities groups. Despite the obvious ethical implications of this observation, racism as an ethical issue per se has been relatively neglected in health care ethics discourse. In this paper consideration is given to addressing the following questions: What is it about racism and racial disparities in health and health care that these command our special moral scrutiny? Why has racism per se tended to be poorly addressed as an ethical issue in health care ethics discourse? And why, if at all, must racism be addressed as an ethical issue in addition to its positioning as a social, political, cultural and legal issue? It is suggested that unless racism is reframed and redressed as a pre-eminent ethical issue by health service providers, its otherwise preventable harmful consequences will remain difficult to identify, anticipate, prevent, manage, and remedy.     

Choosing an evaluation strategy.

Most people making their first attempt at program evaluation will ask the same general kinds of questions at the outset of their endeavor: Why evaluate? How much will it cost? Can I do it myself, or will consultants be required? How scientifically rigorous must it be? Should I have a control group? How big should the sample be? etc. All of these questions can be answered, but only after a set of important assumptions about the program being evaluated has been carefully specified. In most cases, all of these questions can be answered quite adequately by the person(s) asking them. Very little technical expertise is required. In this article we present an approach to the formulation of a general evaluation strategy, including a method for answering some of the questions that need to be answered first.     

“Broad” consent,exceptions to consent and the question of using biological samples for research purposes different from the initial collection purpose

An important ethical issue regarding biological samples stored in biobanks is unforeseen future sample use, when no or limited subject consent is obtained. Biobanks of biological samples have significant future research potential, but may cause conflicts of interest regarding the consent obtained. Indeed, ethics, deontology, and jurisprudence generally advise that consent must be specific and circumstantiated. However, it is not possible to foresee all of the future circumstances in which the samples might be useful, nor is it possible to re-contact all subjects in order to gain consent for a new use. The main arguments for the use of “broad” consent are presented with a brief discussion of the conditions where it may be legitimate not to obtain consent. Particular attention is given to the expressed positions of national and international bioethics bodies.     

The gene-editing of super-ego

New emerging biotechnologies, such as gene editing, vastly extend our ability to alter the human being. This comes together with strong aspirations to improve humans not only physically, but also mentally, morally, and socially. These conjoined ambitions aggregate to what can be labelled “the gene editing of super-ego.” This article investigates a general way used to argue for new biotechnologies, such as gene-editing: if it is safe and efficacious to implement technology X for the purpose of a common good Y, why should we not do so? This is a rhetorical question with a conditional, and may be dismissed as such. Moreover, investigating the question transformed into a formal argument reveals that the argument does not hold either. Nonetheless, the compelling force of the question calls for closer scrutiny, revealing that this way of arguing for biotechnology is based on five assumptions. Analysis of these assumptions shows their significant axiological, empirical, and philosophical challenges. This makes it reasonable to claim that these kinds of question based promotions of specific biotechnologies fail. Hence, the aspirations to make a super-man with a super-ego appear fundamentally flawed. As these types of moral bioenhancement arguments become more prevalent, a revealing hype test is suggested: What is special with this technology (e.g., gene editing), compared to existing methods, that makes it successful in improving human social characteristics in order to make the world a better place for all? Valid answers to this question will provide good reasons to pursue such technologies. Hence, the aim is not to bar the development of modern biotechnology, but rather to ensure good developments and applications of highly potent technologies. So far, we still have a long way to go to make persons with goodness gene(s).     

Protective Effects of Calcium on Cadmium Accumulation in Co-Cultured Silver Carp (<Emphasis Type="Italic">Hypophthalmichthys molitrix</Emphasis>) and Triangle Sail Mussel (<Emphasis Type="Italic">Hyriopsis cumingii</Emphasis>)

Discovering cost effective strategies to reduce cadmium (Cd) uptake is of great concern for consumer food safety in the aquaculture industry. This study investigated the protective effects of calcium (Ca) on Cd uptake in co-cultured silver carp (Hypophthalmichthys molitrix) and triangle sail mussel (Hyriopsis cumingii). The results show that Ca—depending on its applied concentration—caused a significant decrease in the Cd uptake into muscle (by 48?%–72?%), gills (by 51?%–57?%), liver (by 52?%–81?%) and kidney (by 54?%–81?%) of silver carp (p?<?0.001), as well as foot (by 8?%–32?%) and visceral mass (by 40?%–47?%) of triangle sail mussels (p?<?0.05). The results indicate that Ca treatment is an effective means of reducing Cd accumulation in aquaculture. Since Ca is often used to increase the quality of pearls produced by triangle sail mussel, the quality of co-cultured edible fish might improve as a consequence of the potentially reduced Cd uptake.