Sociocultural learning theories play an important part in medical education. When Etienne Wenger-Trayner described 'communities of practice' oriented around three common features (mutual engagement, joint enterprise, shared repertoire), his approach was enthusiastically embraced across a range of fields, including those of

In this paper we consider the impact that the COVID-19 pandemic is having on access to abortion care in Great Britain (England, Wales, and Scotland) and the United States. The pandemic has exacerbated problems in access to abortion services because social distancing or lockdown measures, increasing caring responsibilities, and the need to self-isolate are making clinics much more difficult to access; and this is when clinics are able to stay open which many are not. In response we argue there is a need to facilitate telemedical early medical abortion in order to ensure access to essential healthcare for people in need of terminations. There are substantial legal barriers to the establishment of telemedical abortion services in parts of Great Britain and parts of the United States. We argue that during a pandemic any restriction on telemedicine for basic healthcare is an unjustifiable human rights violation and, in the United States, is unconstitutional.

Discharging a homeless patient from hospital raises ethical issues which are compounded when the patient is from outside the United Kingdom. This article begins with an extended case study of a 30-year-old homeless man from Lithuania describing his complex medical and social needs. It is best practice for all homeless patients to have their housing needs planned for prior to discharge, but this is made more difficult by the United Kingdom’s ‘hostile environment’ policy which creates a subclass of homeless people who are not eligible for support. This means healthcare professionals discharge patients back to homelessness, even when this is likely to adversely affect their health and dignity both directly and indirectly through impairing access to care for chronic conditions. Policies in health and social care which compel professionals to treat some patients with second-class care undermine the ethics of healthcare professions.

Focusing on the UK as a case study, this article argues that having the choice to enter into an international commercial surrogacy arrangement can be harmful, but that neither legalisation nor punitive restriction offers an adequate way to reduce this risk. Whether or not having certain options can harm individuals is central to current debates about the sale of organs. We assess and apply the arguments from that debate to international commercial surrogacy, showing that simply having the option to enter into a commercial surrogacy arrangement can harm potential vendors individually and collectively, particularly given its sexed dimension. We reject the argument that legalizing commercial surrogacy in the UK could reduce international exploitation. We also find that a punitive approach towards intended parents utilizing commercial rather than altruistic services is inappropriate. Drawing on challenges in the regulation of forced marriage and female genital cutting, we propose that international collaboration towards control of commercial surrogacy is a better strategy for preserving the delicate balancing of surrogate mothers’ protection and children’s welfare in UK law.

1 In this respect sex is sometimes contrasted with gender, an equally if not more contentious concept, commonly taken to refer to psychosocial scripts, expectations, meanings, or relational experiences associated with, but nevertheless distinct from, sex or sex-based categorizations. For reasons of space we will not be able to explore the concept of gender in this editorial, but will instead focus solely on sex and sexuality. 2

Commitment devices (CDs) can help people overcome self-control problems to act on their plans and preferences. In these arrangements, people willingly make one of their options worse in order to change their own future behaviour, often by setting aside a sum of money that they will forfeit it if they fail to complete the planned action. Such applications of behavioural science have been used to help people stick to healthier lifestyle choices, overcome addictions and adhere to medication; they are acceptable to many patients and even relatively small sums can be effective. Some authors have objected to the use of nudges in healthcare. Engelen has listed nine potential objections to nudges in relation to means (why nudge rather than persuade?), ends (what action is being promoted?) and agents (who is nudging whom?). These objections are shown to lack force in the context of CDs. Instead, an analysis specific to the ethical issues in CDs is employed. CDs exclude certain groups including so-called ‘naifs’ and risk increasing health inequality. CDs may promote the wrong behaviour and people might legitimately change their minds. Intermediaries might encounter perverse incentives. Approaches to overcoming these problems are described and eight key ethical considerations for those considering implementing CDs in the future are described. Altogether this paper illustrates the advantages of appraising the ethics of behavioural science in medicine on a case-by-case basis.

ObjectivesIncentives have been effectively used in several healthcare contexts. This systematic review aimed to ascertain whether incentives can improve antipsychotic adherence, what ethical and practical issues arise and whether existing evidence resolves these issues.DesignSystematic review of MEDLINE, EMBASE and PsycINFO. Searches on 13 January 2021 (no start date) found papers on incentives for antipsychotics. Randomised controlled trials (RCTs), cohort studies, qualitative research and ethical analyses were included. Papers measuring impact on adherence were synthesised, then a typology of ethical and policy issues was compiled, finally the empirical literature was compared with this typology to describe current evidence and identify remaining research questions.Results26 papers were included. 2 RCTs used contingent financial incentives for long-acting injectable antipsychotic preparations. Over 12 months, there were significantly larger increases in adherence among the intervention groups versus control groups in both RCTs. There were no consistently positive secondary outcomes. 39 ethical and practical issues were identified. 12 of these are amenable to empirical study but have not been researched and for 7 the current evidence is mixed.ConclusionsIn keeping with other areas of healthcare, antipsychotic adherence can be increased with financial incentives. Payments of 2.5 times minimum wage changed behaviour. The typology of issues reported in this systematic review provides a template for future policy and ethical analysis. The persistence of the effect and the impact of incentives on intrinsic motivation require further research.PROSPERO registration numberCRD42020222702.

BackgroundThe most common obstacle to registration with a GP practice in the UK is difficulty presenting proof of address. NHS guidelines stipulate that inability to provide ID or proof of address is not reasonable grounds to refuse registration. Practices may ask patients to present ID/proof of address, but need a policy in case patients cannot.AimTo find out how many London GP practice websites ask for documentation without a policy for where this cannot be provided and compare how GP practice websites describe the registration process in patient-facing material.Design and settingCross-sectional study of practices from 10 London boroughs (n = 100).MethodA proforma was piloted and then implemented, recording whether practices ‘demanded’, ‘requested’, or ‘mentioned’ photo ID or proof of address and whether there was a plan for patients without documentation. Text relating to documentation from all 100 practices for registration was subjected to thematic analysis.ResultsOut of 100 practices 75% asked for documentation. The majority of these were ‘demanded’. A plan was included for people without documentation in 12% of practice websites. Five themes emerged from analysis of website content: reassuring people without documentation; diverse requirements between practices; conflating administration and treatment; withholding treatment; and immigration and ethnicity.ConclusionMany practice websites breached NHS Standard Operating Principles and possibly the Equalities Act 2010. All practices should create a clear policy for patients who do not have photo ID/proof of address (for example, including a named receptionist), and update their websites accordingly.