• Ethics

Medical ethics is not known for being a fast-paced discipline; many of the principles we draw on are 2000 years old. And yet, during John McMillan’s 7 -year tenure as editor of the Journal of Medical Ethics (JME), the journal has changed a great deal and has in turn changed the discipline. The issues discussed and the ethical concepts in play have broadened while the purpose itself has been refined to publish excellent medical ethics articles that are both philosophically sound and of practical use to clinicians, patients and policy makers. Under his leadership, the journal remained committed to the idea that bioethics is not merely an academic exercise but a normative enterprise—concerned, at its core, with how we ought to respond to the ethical challenges that arise in medicine, science and public life.

John’s vision of good bioethics is rooted in a belief that philosophical clarity and real-world relevance should not be seen as competing aims but as mutually reinforcing. As he argued in a 2018 editorial, good medical ethics is defined not just by its analytic sharpness or theoretical sophistication but by how well it is framed, how transparent it is about its normative commitments and how seriously it takes engagement with diverse perspectives.1 For John, good medical ethics needs to be open to input from law, social science and clinical experience but without losing sight of the responsibility to make reasoned ethical judgments. Good medical ethics needs to take a normative stand.

In this spirit, John has encouraged work that grapples with moral complexity without retreating into abstraction and that draws on a wide range of disciplinary tools while maintaining a clear normative focus. He has also been attentive to how bioethical arguments are presented—not only in terms of structure and clarity but also in terms of tone, audience and accessibility. During his editorship, the JME remained a place where rigorous philosophical argument could coexist with work that was more policy-oriented or empirically informed, so long as it contributed meaningfully to ethical debate. Moreover, under John’s leadership, the journal did not shy away from controversy but instead provided space for careful, reasoned debate, even (and perhaps especially) when the stakes were high and consensus far from settled. That is never an easy position for an editor to occupy, but John has been led by his principles and been a reliable bulwark for the rest of the team.

One of the most widely discussed papers published during John McMillan’s time as editor-in-chief was by Bardosh and colleagues,2 which critically examined the ethics of COVID-19 vaccine mandates for college students, arguing, in particular, that for young adult males, the balance of benefits and risks might not clearly favour mandatory vaccination. The article, which drew a significant response across academic, media and public forums, went on to achieve the highest Altmetric score in the Journal of Medical Ethics’ history. While many readers disagreed with the authors’ conclusions—including some on scientific or ethical grounds3—the piece exemplified something essential about the role of journals like JME in a functioning democratic society: namely, that robust public health policy depends on open engagement with dissenting voices, especially when they are argued seriously in good faith. The paper by Bardosh et al has been cited more than 60 times since its 2024 publication, contributing to wide-ranging critical discussions of the science and ethics of vaccine mandates. These are now more important than ever, as the global health community begins to undertake a more ‘retrospective’ analysis of the handling and mishandling of science and policy during the height of the pandemic.

Another notable paper that attracted both controversy and productive scholarly attention was by Anna Smajdor and Joona Räsänen, provocatively titled “Is pregnancy a disease?”.4 The authors did not argue, as some critics hastily assumed, that pregnancy ought to be treated as a disease in a straightforward clinical sense. Rather, they explored whether, under standard definitions used in medicine and philosophy of health, pregnancy might meet the relevant criteria for disease status—and what ethical implications might follow from that classification. The title alone triggered strong reactions on social media, with many superficial responses suggesting that academia had lost the plot—that such questions were absurd or offensive. But as the more thoughtful engagement within and beyond the pages of the JME revealed, even arguments that challenge our most basic presumptions can play a constructive role in bioethics. By asking uncomfortable questions—especially when done with care and philosophical precision—such work can force us to clarify the grounds for our commitments, uncover hidden tensions, and, in so doing, open up new lines of inquiry. This was a recurring theme during John McMillan’s editorship: a willingness to publish work that provokes, not for its own sake, but in the service of deeper ethical reflection.

While always remaining deeply engaged with the normative details of bioethical enquiry, John has posed important questions about the ethics of editing. In 2024, he brought the editorial team together to think through the ethics of collecting data on ‘race’ in academic publishing. The resulting editorial5 further reflects John’s commitment to tackling ethically complex and politically sensitive issues with nuance and intellectual rigour. It addresses the growing practice among academic publishers of collecting data on race and ethnicity as part of efforts to promote equity, diversity and inclusion. While affirming the importance of such goals, the editorial argues that collecting racialised identity data is far from ethically neutral. It carries risks—including privacy concerns, cultural misinterpretation and the potential reinforcement of harmful stereotypes—that must be carefully weighed against its potential benefits. The editorial critiques the use of standardised racial categories, particularly in global publishing initiatives, as potentially inappropriate (or even harmful) in culturally diverse contexts. It calls for more thoughtful, context-sensitive approaches to data collection, grounded in ethical reflection and empirical evidence. In publishing this piece, the JME once again demonstrated its willingness to lead the field in asking difficult questions about justice, identity and institutional responsibility. That leadership is emblematic of John’s tenure—one defined by intellectual bravery, moral seriousness and an unwavering belief that medical ethics must hold itself to the same standards it demands of others.

Another notable feature of John’s tenure was his concerted effort to engage with Chinese scholars and foster dialogue about medical ethics beyond the predominantly Anglo-European contours of the bioethics literature. This included publishing an editorial offering concrete guidance for how Chinese academics might successfully publish in JME,6 as well as undertaking trips to China and participating in international bioethics conferences to help build lasting professional relationships.

During John’s time as editor-in-chief, he made several innovative improvements to sustain the JME’s reputation as a leading and dynamic journal in the field that both new and senior scholars seek to publish their best work in. John and his editorial team initiated an ‘Open Peer Commentary’ process for each month’s feature article (FA). Authors are able to submit short abstract proposals for a commentary, and the editorial team selects around five proposals to develop their ideas into commentaries on the FA. This initiative has increased engagement with some of the key issues being considered by the bioethics community, the JME articles themselves, and opened up the number of voices and perspectives on pressing bioethical issues. And while we share John’s scepticism about the value of a journal’s ‘impact factor’ in capturing its intellectual contribution, it is notable that for the last 7 years the JME has had greater impact than at any other point in its history. That has never been John’s motivation, but it is the effect of making astute and imaginative editorial decisions that have ensured the relevance, utility and quality of the journal’s outputs.

A key challenge for the new editors will be preserving editorial independence when addressing controversial topics in an increasingly polarised and cautious publishing environment, thereby upholding the courageous and principled standards set by John over the past 7 years and ensuring the field progresses unencumbered by broader political pressures.

This month’s edition of the JME is a good example of the breadth and depth of scholarship that is now standard in the journal. Three studies (one examining the views of practitioners on bias and responsibility in AI,7 one interrogating the views of early-adopting physician providers on Medical Assistance in Dying8 and an ethnographic study considering how tensions between patient-centred and risk-centred medicine are managed when screening patients9) combine qualitative research with ethical analysis, helping to challenge the status quo and direct future research and policy. A conceptual and practically relevant paper considers the impacts of calling infertility a disease, rather than seeing it as a missing capability;10 an in-depth analysis of pronatalism assesses the ethical and medical consequences of a political policy,11 generating reasoned and substantial commentary.12–15 And finally, the ethical issues associated with stem cell embryo models16 and the role of professional regulators in ensuring doctors practice sustainable healthcare are addressed in current controversies.17

As his editorial team, we are very grateful for the support and teaching he has given us and for his exacting standards of academic rigour and calibration and maintaining consistency in how we approach articles and authors. There has been almost no turnover within the editorial team during his tenure, which is a testament to his self-professed ‘team builder and team member’ identity. The JME is much stronger for his direction: philosophically grounded and practically relevant, it stands ready to continue to provoke thought, debate and new policies for the future.