Artykuły w czasopismach na temat „Probate law and practice, pennsylvania”

The introduction of the notary public service in the Serbian legal system has introduced a number of novelties in matters concerning inheritance law. The most important of them is the possibility of entrusting the probate proceedings in inheritance cases to notaries public. In the Serbian legal system, probate proceedings dealing with inheritance matters have traditionally beed conducted competent courts. This long-standing tradition is difficult to break with. Thus, the Serbian legislator still envisages the jurisdiction of the court to discuss inheritance matters, but now there is a possibility of entrusting this procedure to a notary public, when it is deemed to be expedient. In this paper, the author examines the judicial practice and the public notaries practice in an attempt to determine the justification of entrusting some probate proceedings to notaries public. Concurrently, the author analyzes the possibility of transferring competences for conducting probate proceedings entirely to public notaries. In the author's opinion, it is a realistic possibility considering that the hetherto practice of public notaries in probate proceedings speaks in favour of this legal solution, particularly taking into account the reduced caseload and timeframe needed to complete these non-litigious probate proceedings.

Book of Civil Law (KUHPer), the concept of Grant is divided into two forms, yaito Grant and probate grant. The basic difference between the two is that the grant is made while the grantor is still alive, while the will grant is only carried out after the will grantor dies. The law regarding grants is regulated in Article 1666 of the Civil Code, while probate grants are regulated in Article 957 of the Civil Code. Related to the collection of duties on the acquisition of land and building rights, although the acquisition value of non-taxable taxable objects is regulated by local regulations under Article 46 paragraph 8,. in this study raised the issue of how the implementation of probate grants in the practice of law in Indonesia? And how the legal certainty of probate grants in terms of Law No. 1 year 2022 on the financial relationship between Central and local governments?by using the theory of Agreement and The Theory of legal certainty The method used in this study is normative legal research is legal research literature or secondary data with sources of primary, secondary and tertiary legal materials. The approach used legislation approach, case approach, conceptual approach and analytical approach. And legal material collection techniques are carried out by identifying and inventorying positive legal rules, book literature, journals and other legal material sources, for legal material analysis techniques (interpretation) grammatical interpretation, systematic interpretation and legal construction methods. That the court will certify the will if it meets the requirements of the law, checks for compliance with the provisions of applicable law, and ensures that there are no disputes that prevent the execution of the grant. The implementation of this will grant is a harmonization between the principles of treaty law and agrarian law. Although it is a form of agreement, the probate Grant is also subject to agrarian regulations governing land and property rights. Thus, the legal process in accordance with the applicable provisions is important to maintain the validity and continuity of the implementation of the probate Grant and protect the rights of the parties involved and that Law No. 1 of 2022 on financial relations between Central and local governments has an important impact on the legal certainty of the implementation of probate grants in Indonesia, especially in terms of the protection and management of donated property. Although it does not directly regulate probate grants, it does provide a broader legal context that can support clarity of procedure and protection of the rights of grantees

This paper1 addresses the practical aspects of mediation. Experienced mediators will know what mediations look like and feel like and need no reminding how effective mediation has become as a means of resolving disputes. My own practice as a mediator – which tends to focus on inheritance and probate disputes, where the emotional element is often highly toxic – has some parallels with the mediation of Church disputes where an understanding of and sensitivity to theology is crucial.

Abstract Medical evaluators must understand the context for the impairment assessments they perform. This article exemplifies issues that arise based on the role of impairment ratings and what edition of the AMA Guides to the Impairment of Permanent Impairment (AMA Guides) is used. This discussion also raises interesting legal questions related to retroactivity, applicability of prior precedent, and delegation. On June 20, 2017, the Supreme Court of Pennsylvania handed down its decision, Protz v. WCAB (Derry Area Sch. Dist.), which disallows use of the “most recent edition” of the AMA Guides when determining partial disability entitlement under the Pennsylvania Workers’ Compensation Act. An attempted solution was passed by the Pennsylvania General Assembly and was signed into law Act 111 on October 24, 2018. Although it affirms that the AMA Guides, Sixth Edition, must be used for impairment ratings, the law reduces the threshold for total disability benefits from 50% to 35% impairment. This legislative adjustment benefited injured workers but sparked additional litigation about whether, when, and how the adjustment should be applied (excerpts from the laws and decisions discussed by the authors are included at the end of the article). In using impairment as a threshold for permanent disability benefits, evaluators must distinguish between impairment and disability and determine an appropriate threshold; they also must be aware of the compensation and adjudication process and of the jurisdictions in which they practice.

This case illustrates the importance for school leaders and teachers to be knowledgeable about current legal precedent when creating district and school policies. We describe a legal battle that occurred in Lancaster, Pennsylvania, in which a school district instituted a policy affecting English learners that was in violation of two federal laws. Then, we analyze the case to explain the barriers school leaders encounter that prevent them from operationalizing federal laws and policies. We conclude by arguing the need for the legal literacy of school leaders to create district and school policies and train the teachers working under their direction.

It remains unclear how pervasive police-community corrections partnerships are, and to what extent they are integrated into routine practice, as well as whether or not police chiefs and chief probation or parole officers within the same jurisdictions perceive them to be effective. The current study enhances our understanding of such partnerships between police and probation or parole. Data were collected through a statewide survey of a random sample of municipal police chiefs and county chief probation or parole officers in Pennsylvania. The primary research questions focus on identifying the following: (a) empirically derived and meaningful patterns of police-community corrections partnerships, (b) a comparison of police chief and chief probation or parole officer perceptions of benefits and problems regarding their partnerships, and (c) the predictors of these perceptions. Results reveal that such partnerships are prevalent, but they are predominantly informal, with formalization largely contingent on the progressiveness of the police chief (i.e., newer police chiefs were more likely to engage in formalized partnerships). Further, the crime prevention and recidivism reduction potential of these partnerships remain unclear from the perspectives of both law enforcement and community supervision leaders. In general, Pennsylvania police chiefs are less favorable to the partnerships than are the chiefs of probation or parole offices, and certain partnership types relate to the negative perceptions of some agency leaders. The implications of the findings reported here for policies, training, and future research are discussed.

Environmental constitutionalism is a relatively recent phenomenon at the confluence of constitutional law, international law, human rights, and environmental law. It embodies the recognition that the environment is a proper subject for protection in constitutional texts and for vindication by constitutional courts worldwide. This chapter posits ten “good practices” – those attributes that make effective outcomes more likely, but not assured – in environmental constitutionalism for advancing positive environmental outcomes considering energy, and governance and sustainability. Good practices in environmental constitutionalism can serve as a useful construct for considering the relationship between sustainability, energy and governance. Accordingly, Section A examines the ten practices that are consequential for effectuating environmental constitutionalism and positive environmental outcomes. Section B then explains how the Robinson Township decision out of the Commonwealth of Pennsylvania in the United States provides a recent example just how good practices can have a positive impact on environmental outcomes in practice.

In Barbara Ferman’s collection, The Fight for America’s Schools, grassroots resistance to neoliberal education reform holds the spotlight. Her geographic lens is the Pennsylvania/New Jersey region. In this article, the geographic focus shifts to Memphis, Tennessee, and Washington, D.C. Experiences in these two cities show how the neoliberal agenda is protected in the face of disappointing results. The Memphis case centers on a state takeover driven by a market ideology. Its experience underscores that reducing local representation to an inconsequential advisory role also diminishes what education policy leaders believe they need to consider. D.C. offers a more complex narrative, one haunted by the corrupted metrics of Campbell’s Law. In both cities, the neoliberal toolbox proved unable to deliver in practice what the drawing board had promised.

In American criminal law, the practice of taking premeditation as the classification standard of murder degree originates from the legislative reform of Pennsylvania in 1794, which divides premeditated intentional murder as the first-degree murder and the rest intentional killing as the second-degree murder. As only the first-degree murder can be sentenced to death, this reform succeeded to limit the number of capital punishments. However, there are also some problems in taking premeditation as the murder grading’s standard. Firstly, the definition of premeditation is vague, causing difficulties in judicial application. Secondly, premeditation cannot accurately reflect the actor’s culpability every time. If premeditation is the only factor in convicting and sentencing punishment, the result may be unfair. Therefore, some states in the United States abandoned the murder grading system based on premeditation, and instead applied the new paradigm of the Model Penal Code, which stipulated that only first-degree murder with aggravating circumstances can be sentenced to death. Although premeditation is regarded as the sentencing circumstance of intentional homicide in judicial interpretation, it is still vague in practice. The theoretical discussion and practical reform of premeditation in American murder law have certain reference significance for the conviction and sentencing of subjective factors of intentional homicide in China.

Whereas research has shown improvements in decision-making shortly after the introduction of risk/need assessment (RNA) tools, studies of routine practice nonetheless show shortcomings in RNA utilization. The current study uses an experimental survey-based vignette method to assess juvenile probation officer decision-making several years into a sustained evidence-based effort to implement an RNA in Pennsylvania. Consistent with the risk-need-responsivity (RNR) model, results show officer decisions correspond with clients’ risk and need. Moreover, adherence to the RNR model was found for clients across risk levels and offense categories. However, officers often relied on services for low-risk clients, and made decisions about interventions based on offense characteristics. Results suggest a discretionary form of decision-making, taking cues from within and beyond the RNR model, including from punitive and traditional welfare-oriented approaches. Findings highlight the challenges of producing RNR-consistent decision-making, even when using a sustained scientific RNA implementation strategy.

<p>Merced a los inventarios de bienes de la ciudad de Burgos a lo largo del Setecientos, se accede a las disponibilidades de dinero en efectivo y a los tipos de monedas que los hogares atesoraban en el interior de sus viviendas. No en todos ellos hallamos liquidez monetaria. A la postre, la tipología del numerario diferenciaba, de manera notoria, a quienes, ya fuera al hilo de su óbito o en sus existencias cotidianas, eran poseedores de “buena” moneda –en plata y en oro– de aquellos que únicamente disponían de vellón, la “mala” moneda. Empero, los hogares acaparaban los metales “nobles” no sólo a través del numerario sino también en las cuberterías, en los relojes, en las alhajas y adornos personales, en algunos pertrechos religiosos, etcétera. La ley de Gresham, “La moneda buena expulsa a la mala”, se traducía en la práctica no sólo en la circulación habitual de la moneda de peor calidad cuanto en que los hogares menos afortunados disponían, cuando les era posible, de la moneda más modesta. La buena moneda era propiedad de los aristócratas y los privilegiados.</p><p>With probate inventories in the city of Burgos during the eighteenth century, we gain access to the available cash and the types of coins hoarded in households. Not in all of them we find liquidity. Ultimately, type of cash made a noticeable difference between those who, close to their deaths or in their daily lives, had “good money –silver or gold– and those who only possessed fleece –the bad money. However, households hoarded “noble” metals not only through cash but also in cutlery, clocks, jewellery and personal ornaments, some religious supplies, and so on. Gresham’s law, “The good money drives out the bad”, was put into practice not only in the normal movement of poorer quality coin as but also in the fact that the less fortunate households when they could, possessed more modest currency. The coin was owned by aristocrats and privileged ones.</p>

Most U.S. farms today specialize in either crop or livestock production, failing to harness the potential economic and environmental benefits of integrated crop–livestock systems (ICLS). This specialization is particularly contradictory for organic operations, which aim to promote biodiversity and reduce reliance on outside sources of feed and fertility. This study investigated the challenges and opportunities experienced by farmers interested in integrating crops and livestock on organically managed farms in Iowa, Pennsylvania, and Minnesota. Qualitative methods, including focus groups and interviews, generated four categories of challenges: farming norms, complexity of management, biophysical conditions, and financial costs, and four categories of opportunities: increasing support for ICLS, financial and labor advantages, biophysical improvements, and animal welfare. Discussion of the data analysis demonstrates how most of the challenges of ICLS are mitigated by opportunities. For instance, increasing support for ICLS means there are growing communities of practice in which farmer-to-farmer knowledge exchange and peer support overcome obstacles to success in these systems. Unmitigated challenges that are beyond the control of farmers include regional infrastructure, financing and insurance, and long time horizon for returns. These three unmitigated challenges may require interventions such as policy support, economic incentives and social infrastructure to enable successful farm transitions to ICLS in this region.

The Consumer Protection Act 68 of 2008 came into effect on 1 April 2011. The purpose of this Act is, among other things, to promote fairness, openness and respectable business practice between the suppliers of goods or services and the consumers of such good and services. In consumer protection legislation fairness is usually approached from two directions, namely substantive and procedural fairness. Measures aimed at procedural fairness address conduct during the bargaining process and generally aim at ensuring transparency. Transparency in relation to the terms of a contract relates to whether the terms of the contract terms accessible, in clear language, well-structured, and cross-referenced, with prominence being given to terms that are detrimental to the consumer or because they grant important rights. One measure in the Act aimed at addressing procedural fairness is the right to plain and understandable language. The consumer’s right to being given information in plain and understandable language, as it is expressed in section 22, is embedded under the umbrella right of information and disclosure in the Act. Section 22 requires that notices, documents or visual representations that are required in terms of the Act or other law are to be provided in plain and understandable language as well as in the prescribed form, where such a prescription exists. In the analysis of the concept “plain and understandable language” the following aspects are considered in this article: the development of plain language measures in Australia and the United Kingdom; the structure and purpose of section 22; the documents that must be in plain language; the definition of plain language; the use of official languages in consumer contracts; and plain language guidelines (based on the law of the states of Pennsylvania and Connecticut in the United States of America).

Purpose The legal system’s use of risk assessment has grown exponentially over the past several decades. Empirically validated risk measures are commonly implemented in parole, bail, civil commitment, and presentence proceedings. Despite their growing popularity, both policy-makers and legal scholars question their moral and legal acceptability, particularly in presentence proceedings. The purpose of this paper is to assess the current role of risk assessment in sentencing through an examination of the instrument currently under construction in the state of Pennsylvania. Design/methodology/approach Drawing on the current state of the literature, this paper evaluates the current use of risk assessment in criminal sentencing and discusses its consequences, both positive and negative. Findings Four areas for improvement in the use of risk assessment in sentencing were identified. Recommendations for change are proposed. Practical implications While the use of risk assessment within the legal system has significantly increased over the past several decades, the incorporation of risk assessment in presentence proceedings is a relatively new practice. This paper provides readers with insight on the appropriateness of using risk assessment in this context and provides suggestions for reducing ethical concerns. Recommendations for increasing the validity and clinical utility of these instruments are also discussed. Originality/value Although the literature on the use of risk assessment in legal proceedings is dense, relatively little is written about their use in criminal sentencing. This paper introduces readers to this concept by examining a risk measure proposed for use in the state of Pennsylvania’s presentence proceedings. The authors discuss concerns and propose recommendations for the future use of risk assessment in this setting.

IntroductionThis paper discusses the application of the synthetic control method to injury-related interventions using aggregate data from public information systems. The method selects and determines the optimal control unit in the data by minimising the difference between the pre-intervention outcomes in one treated unit (eg, a state) and a weighted combination of potential control units.MethodI demonstrate the synthetic control method by an application to Florida’s post-2010 policy and law enforcement initiatives aimed at bringing down opioid overdose deaths. Using opioid-related mortality data for a panel of 46 states observed from 1999 to 2015, the analysis suggests that a weighted combination of Maine (46.1%), Pennsylvania (34.4%), Nevada (5.4%), Washington (5.3%), West Virginia (4.3%) and Oklahoma (3.4%) best predicts the preintervention trajectory of opioid-related deaths in Florida between 1999 and 2009. Model specification and placebo tests, as well as an iterative leave-k-out sensitivity analysis are used as falsification tests.ResultsThe results indicate that the policies have decreased the incidence of opioid-related deaths in Florida by roughly 40% (or −6.19 deaths per 100.000 person-years) by 2015 compared with the evolution projected by the synthetic control unit. Sensitivity analyses yield an average estimate of −4.55 deaths per 100.000 person-years (2.5th percentile: −1.24, 97.5th percentile: −7.92). The estimated cumulative effect in terms of deaths prevented in the postperiod is 3705 (2.5th percentile: 1302, 97.5th percentile: 6412).DiscussionRecommendations for practice, future research and potential pitfalls, especially concerning low-count data, are discussed. Replication codes for Stata are provided.

Resumen: El presente artículo se encuentra dividido en cinco apartados que permiten que su lectura y comprensión sea mucho más amigable. Es interesante y entender que el tema del terrorismo es un tema de naturaleza dinámica y cambiante, en el artículo se estudiara los diferentes tipos de terrorismo que existe y el impacto que ha tenido en el establecimiento de los estados de seguridad pública, así como la afectación a los derechos humanos de las personas y los regímenes jurídicos en los cuales se tipifica esta figura. Abstract: This article is divides into five sections that allow its reading and understanding to be much more user-friendly. It is interesting to understand that the issue of terrorism is a dynamic and changing issue, the article will study the different types of terrorism that exist and the impact it has had on the establishment of states of publica security as well as the impact to the human rights of persons and the legal regimes in which this figure is typified. 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Judge Joy Flowers Conti has served as a district judge for the United States District Court for the Western District of Pennsylvania since 2002, when she was nominated by President George W. Bush. Prior to her service as a district judge, Judge Conti served as a law clerk to a Pennsylvania Supreme Court Justice, was a partner in private practice at Kirkpatrick & Lockhart, LLP, and a shareholder at Buchanan Ingersoll. She also served as a member of the faculty at Duquesne University School of Law. Judge Conti is a member of the Allegheny County Bar Association, the Pennsylvania Bar Association, the American Bar Association, the Women’s Bar Association of Western Pennsylvania, the Federal Bar Association and the American Inns of Court. She received a Bachelor of Arts Degree from Duquesne University in 1970, and a JD degree summa cum laude from Duquesne University School of Law in 1973.

Judge Nora Barry Fischer has served as a district judge for the United States District Court for the Western District of Pennsylvania since 2007, when she was appointed by President George W. Bush. Prior to her service as a district judge, Judge Fischer worked as a legal editor at Callaghan & Company, was a partner in private practice at Meyer Darragh Buckler Bebenek & Eck, and was an equity partner at Pietragallo Bosick & Gordon. Additionally, Judge Fischer worked as a trained mediator and arbitrator in Pennsylvania and West Virginia. Judge Fischer is a Fellow of the American College of Trial Lawyers, an active member of the Executive Women’s Council of Pittsburgh, a past President of the Academy of Trial Lawyers of Allegheny County, and a member of the Pennsylvania Bar Association Commission on Women in the Profession, where she serves on the Mentoring Subcommittee. She received a Bachelor of Arts Degree magna cum laude from Saint Mary’s College, and a JD degree from Notre Dame Law School in 1976.

In 2016, 4,642 Pennsylvanians died from a drug overdose and 85% of these deaths were due to an opioid overdose (U.S. Drug Enforcement Administration and University of Pittsburgh School of Pharmacy 2017). With a 37% increase in deaths from 2015, the Commonwealth’s response to this epidemic has come from several fronts. One valuable resource has been the modernization and implementation of Pennsylvania’s Prescription Drug Monitoring Program (PDMP). PDMPs are state-­run programs that record dispensing of most controlled substances and provide this data to physicians and pharmacists (among others) to inform their practice about possible opioid use disorder by a given patient. This article discusses the role of Pennsylvania’s PDMP in patient care and law enforcement to reduce opioid overdoses in the Commonwealth. Recent evidence is discussed that demonstrates the effectiveness of state-­run PDMPs and their impact on opioid misuse and prescribing patterns. It is important to note that additional research into the effectiveness of PDMPs in preventing opioid-­related morbidity and mortality is needed.

This mixed-method study examined changes implemented in Pennsylvania community corrections agencies during the early phases of the COVID-19 pandemic. We surveyed ( N = 54; 83% response rate) and interviewed ( N = 10) county Chiefs of probation and parole regarding changes to agency policies, processes of this change, and expected sustainability. Findings revealed meaningful changes to community corrections policy initiated by the pandemic through new modes of supervision contact —such as “ curbside probation”— and new policies regarding violations of supervision that align with evidence-based principles. The moment’s urgency provided a rare but effective impetus for reform, but perceptions of sustainability varied across Chiefs’ role orientations. Our findings demonstrate how this moment expanded the footprint of evidence-based practice through local criminal justice reform and reveal new insights into capacities for and processes of change.

Context: State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination. Objective: To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality. Design: Qualitative document analysis. Setting: High school athletics. Participants: In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018–2019 academic year. Main Outcome Measures: Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test. Results: There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5–22.5] versus 6 [3–10.5] median components; U = 377.5, p &lt; .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

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Photo by Anna Hecker on Unsplash ABSTRACT All people deserve the legal ability to outline their care decisions in advance and expect their decisions to govern during a pregnancy. However, until advance directives govern without pregnancy exceptions, people will not uniformly retain the ability to formulate autonomous decisions about their health care planning. INTRODUCTION In the last few years, states have passed increasingly restrictive laws regarding abortion and reproductive health care. Recent legislation in Alabama effectively banned the procedure altogether, while more than a dozen states have passed or are currently in the process of enacting so-called “fetal heartbeat laws,” which ban abortion at roughly six weeks post-conception after the detection of electrical activity in what could develop into fetal cardiac tissue.[1] While courts rarely uphold outright bans and broad sweeping legislation, they garner significant media and public attention.[2] In practice, however, often smaller legislative changes that garner the least attention have the most significant impact by steadily chipping away at healthcare rights. Few people realize the ethical impact of the poorly understood legal means by which a pregnant woman has already lost her right to make autonomous healthcare decisions over her body using an advance directive in nearly every state. BACKGROUND Advance directives are one of modern medicine’s most powerful yet underused tools. Most clinicians and patients think of advance directives as being only for the elderly or terminally ill. This association stems from the 1991 Congressional Patient Self-Determination Act that requires hospitals, nursing homes, and hospice agencies receiving federal funding to inform patients of their legal right to prepare an advance directive. The 2015 announcement by the Center for Medicare and Medicaid Services (CMS) to reimburse for advance directives without requiring a diagnosis code recognizes that all adult patients can benefit from advance directives regardless of illness or life expectancy.[3] Providers should be aware of a small but significant exemption found in most state advance directive laws. This exemption, commonly known as the pregnancy clause, invalidates the advance directive of a pregnant woman, negating autonomy. The pregnancy clause can lead to treatment against medical standards of care and places private interests over public health. Advance directive statutes are frequently amended, but currently, only eight states allow patients to write their pregnancy-related wishes into their advance directive and guarantee that their instructions will be followed. Eleven states automatically invalidate advance directives during pregnancy, while 18 states permit physicians to disregard a pregnant woman’s (or her proxy’s) wishes based on the likelihood of viability, pain, and suffering, or conscientious objector clauses. Thirteen states remain silent on whether an advance directive is binding during pregnancy or have contradictory statutes.[4] Viability has no standard definition for the purposes of the clauses and viability-based pregnancy clauses can lead to the same loss of rights as pregnancy clauses that invalidate advance directives due to pregnancy without any exceptions. Many may wonder about the clinical relevance of pregnancy clauses. The likelihood that a woman will need to effectuate an advance care directive while pregnant is higher than many people would realize. This situation is most commonly assumed to occur in instances of a brain-dead pregnant woman, of which there are a few cases reported each year. But brain death and persistent vegetative states are just two reasons to look to an advance directive. Advance directives more commonly apply to patients with dementia, strong religious objections to medical care, or during cancer treatments, surgery, or acute injury with temporary loss of capacity. In surgery or acute lapses of capacity, a proxy may be asked to make decisions if complications arise. The number of women potentially affected by pregnancy clauses is significant. Each year, 75,000 pregnant women will undergo non-obstetrical surgery;[5] one in 1,500 pregnant women will be diagnosed with cancer;[6] and an estimated 250,000 Americans will exhibit early-onset Alzheimer’s symptoms between the ages of 30 and 50.[7] ANALYSIS Though pregnancy clauses are a seemingly narrow focus, they can nullify an entire advance directive and restrict care not related to the fetus. By negating entire advance directives, the clauses negate proxy appointments, allowing decision-makers other than the intended proxy. Providers and proxies are left with little guidance over who can make decisions on behalf of the patient. Many states will appoint a biological family member as the surrogate decision maker if there is no designated proxy or the directive is invalid. The outdated language and assumptions about nuclear families found in these structures could significantly impact unmarried couples, same-sex partnerships, and relationships that do not meet state-defined partnership standards where the courts may appoint someone other than the woman’s significant other even when she designated them as a proxy.[8] Members of religious groups whose doctrines prohibit certain medical therapies must be informed that if they become pregnant, their autonomous ability to decide about medical care through an advance directive and their right to freely practice religion can be voided entirely. In addition to infringing on patient autonomy, pregnancy clauses also restrict how clinicians might practice medicine by mandating medically inappropriate treatments against the provider’s recommendations. For example, Illinois’s pregnancy clause stipulates that “if you are pregnant and your health care professional thinks you could have a live birth, your living will cannot go into effect.”[9] This clause places providers in a difficult position of sacrificing their therapeutic obligation to their patients. It may require them to use futile therapy against the patient’s best interest and without regard for prolonged pain and suffering. Pregnancy clauses are void of any consideration of the best clinical interest of the patient or the fetus and instead promote conservative rhetoric that all potential fetal life is paramount. Numerous medical and chromosomal conditions are incompatible with life or present significant potential disabilities that may be accompanied by pain and suffering. The same conditions also pose risks to the mother, including death. Accordingly, the medical profession recognizes that there are instances in which it may not be in the best medical interest of the mother or the fetus to continue the pregnancy. Yet providers are seemingly required by pregnancy clauses to violate codes of conduct and subject pregnant patients and their nonviable fetuses to treatments to which other patients would not be subjected. Without evidence of a patient’s clear and convincing intentions, states have an interest in protecting life, preventing suicide, and maintaining the ethical integrity of the medical profession that could interfere with the person’s ability to refuse care.[10] The legal defense of pregnancy clauses is that the state’s interest in fetal life is sufficiently important to override the mother. As established in Planned Parenthood v. Casey (1992), however, the state’s interest only exists for fetal life post-viability.[11] Therefore, to allow the state interest to override the person’s advance directive when the fetus is not yet viable violates Casey. Individuals have a legal and ethical interest in maintaining bodily privacy, integrity, and freedom from unwanted touching. They have the right to appoint a proxy or use a directive to govern care in the case of incapacity. Even when contemplating brain death, organ donation, and whether to be cremated or buried, there is an expectation that personal wishes will govern. Honoring an advance directive allows providers to uphold the integrity of the medical profession by respecting the principles of autonomy and beneficence. Pregnancy clauses are inherently unethical as their creation was not to further the integrity of the medical or legal profession, nor protect a state’s interest in the patient’s life. In 2016, the American College of Obstetricians and Gynecologists issued a committee opinion that pregnancy is not an ethical exemption to the right of capable patients to refuse treatment.[12] The right to direct treatment while pregnant is consistent with modern medical practice, while the legislative promotion of a singular abstract interest in potential fetal life to the exclusion of all other medical and ethical considerations is not in line with the profession’s values.[13] Many pregnancy clauses are politically motivated, reflecting anti-abortion legality lobbying efforts and attempts to win over conservative voters. When Alaskan Attorney General Harold M. Brown argued the state’s pregnancy clause was unconstitutional, Governor Bill Sheffield – a Democrat in a historically red state – enacted the bill anyway. Georgia’s Governor Bill Kemp narrowly won his election, with some crediting his aggressive messaging against immigration and abortion.[14] With either advance directives, proxies, or even friends and relatives who know what the person (if not incapacitated) would have wanted, courts and legislatures should not have leeway to force care that a person, if conscious, would have refused.[15] The ability to harness advance directive law to force invasive and unwanted treatment upon a pregnant patient’s body continues to occur out of the fear of legal uncertainty. The lack of uniformity between states in their pregnancy clauses further adds to the confusion. Many advance directive statutes create a conditional proposition: if a provider acts in accordance with the carefully drawn circumstances of an advance directive, the provider is granted protective immunity from accusations of malpractice or wrongful death for that conduct. It is neither illegal nor unethical to remove a ventilator, for example, from a patient who has directed such a course of action in an advance directive. A pregnancy clause may remove that immunity making the unethical act of ignoring the directive legal, but the ethical act of following it (removing a ventilator, for example) could subject the practitioner to liability.[16] Without a pregnancy clause, providers retain the ability to both follow an advance directive and to act in the best medical interest of their patient. Pregnancy clauses create confusion over the permissibility of medical acts in an attempt to coerce providers into making decisions that violate the rights of their patients and their own ethical codes of conduct. Pregnancy clauses are a fallacy of consequentialist ethics in which the morality of the outcome justifies actions. Under consequentialist reasoning, any violation to the woman is justified if the fetus develops and results in a live birth. This reasoning is further faulty as it incorrectly assumes that mechanically ventilating an unconscious, sick, dying, or dead body will result in a live birth. Consequentialist theories should be limited to situations with predictable ends. Ethical medical providers refute consequentialism in certain contexts because it treats patients as a means to an end to produce benefit for others. In pregnancy, ignoring advance directives to achieve the chance that a fetus might survive is not justified by consequentialism. Pregnancy clauses also fail through the lens of deontological ethics in which an action must be ethical in and of itself and not based on outcomes. The choice to respect autonomy through an advance directive should be followed uniformly absent special circumstances. Proponents of pregnancy clauses may argue that pregnancy is an appropriate exception because a woman “has chosen to lend her body to bring [a] child into the world.”[17] Minnesota and Oklahoma echo this belief in their statutes, which contain an unjustified rebuttable presumption that all female patients would want life-sustaining treatment if they are pregnant.[18] Pregnancy should not abrogate the rights of a person to assign a proxy for access to an abortion or to control her medical treatment. Pregnancy exclusions are not grounded in the ethical “best interest” standards for the mother or the fetus. Instead, they are rooted in outdated expectations of female gender roles, which reaffirm a legislative assumption that a pregnancy is more morally valuable than a woman’s autonomy. CONCLUSION All people deserve the legal ability to outline their care decisions in advance and expect their decisions to govern during a pregnancy. Providers and the government do not have to approve of a person’s care decisions or values, but medical practitioners must respect a person’s right to dictate their own health narratives. With the push for more patients to execute advance directives, providers and patients must be aware that their advance directives may succumb to the authority of pregnancy clauses. Until advance directives govern without pregnancy exceptions, people will not uniformly retain the ability to formulate autonomous decisions about their health care planning. Advance directive law will continue to be hijacked by politically motivated legislators. When seeking to address inequities in healthcare laws and access, it is essential to take a closer look at not only the headline cases but also the clauses and exemptions to laws seemingly designed to benefit patients. [1] For proposed and current abortion legislation and maps, see https://www.guttmacher.org/state-policy# and Anne Godlasky, Nicquel Terry Ellis, and Jim Sergent, “Where is Abortion Legal? Everywhere, but…” USA Today, May 15, 2019, updated April 23, 2020 https://www.usatoday.com/in-depth/news/nation/2019/05/15/abortion-law-map-interactive-roe-v-wade-heartbeat-bills-pro-life-pro-choice-alabama-ohio-georgia/3678225002/ [2] https://www.guttmacher.org/state-policy# (Many bills fail in legislatures and are not enacted.) [3] Department of Health and Human Services Centers for Medicare & Medicaid Services; 42 CFR Part 405, 410, 411, 414, 425, and 495; “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Final Rule.” [4] DeMartino, E. S., Sperry, B. P., Doyle, C. K., Chor, J., Kramer, D. B., Dudzinski, D. M., & Mueller, P. S. (2019). US State Regulation of Decisions for Pregnant Women Without Decisional Capacity. JAMA, 321(16), 1629–1631. https://doi.org/10.1001/jama.2019.2587; Villarreal, Elizabeth. “Pregnancy and Living Wills: A Behavioral Economic Analysis.” The Yale Law Journal Forum. Vol. 128 (2019); 1052-1076. [5] “Surgery During Pregnancy.” Intermountain Healthcare: Fact Sheet for Patients and Families, (2018). https://intermountainhealthcare.org/ext/Dcmnt?ncid=520782026 [6] Basta, P. Bak, A. Roszkowski, K. “Cancer Treatment in Pregnant Women”. Contemporary Oncology, 19, no. 5 (2015): 354–360 [7] “31-Year-Old Woman Fights Alzheimer's While Pregnant.” San Francisco Globe. 9 July 2015, sfglobe.com/2015/02/19/31-year-old-woman-fights-alzheimers-while-pregnant. [8] “Health Care Proxies.” Human Rights Campaign, https://www.hrc.org/resources/health-care-proxy. [9] Illinois Department of Public Health website, Statement of Illinois Law on Advance Directives and DNR Orders, http://www.idph.state.il.us/public/books/advdir4.htm. [10] In the Matter of Karen Quinlan, 355 A.2d 647 (1976); Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990); and In re Conroy 486 A.2d 1209 (1985). [11] Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992). [12] The American College of Obstetricians & Gynecologists Committee on Ethics, Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy, (2016). [13] Lederman, Anne D. “A Womb of My Own: A Moral Evaluation of Ohio’s Treatment of Pregnant Patient’s with Living Wills”. Case W. Res. L. Rev. Vol. 45:351 (1995); 351-377. [14] Tavernise, Sabrina. “The Time Is Now: States Are Rushing to Restrict Abortion, or to Protect It.” The New York Times, 15 May 2019. [15] Cruzan. [16] Mayo, T.M. “Brain-Dead and Pregnant in Texas.” The American Journal of Bioethics, Vol. 14, no. 8 (Nov. 2014); 15-18. [17] In re A.C., 573 A. 2nd 1244 (1990). [18] Johnson, Kristeena L. “Forcing Life on the Dead: Why the Pregnancy Exemption Clause of the Kentucky Living Will Directive Act is Unconstitutional.” Kentucky Law Journal. Vol. 100 (2011-12); 209-233.

A slash manip is a photo remix that montages visual signs from popular media with those from gay pornography, creating a new cultural artefact. Slash (see Russ) is a fannish practice that homoeroticises the bonds between male media characters and personalities—female pairings are categorised separately as ‘femslash’. Slash has been defined almost exclusively as a female practice. While fandom is indeed “women-centred” (Bury 2), such definitions have a tendency to exclude male contributions. Remix has been well acknowledged in discussions on slash, most notably video remix in relation to slash vids (Kreisinger). Non-written slash forms such as slash vids (see Russo) and slash fanart (see Dennis) have received increased attention in recent years. This article continues the tradition of moving beyond fiction by considering the non-written form of slash manips, yet to receive sustained scholarly attention. Speaking as a practitioner—my slash manips can be found here—I perform textual analysis from an aca–fan (academic and fan) position of two Merlin slash manips by male Tumblr artist wandsinhand. My textual analysis is influenced by Barthes’s use of image semiotics, which he applies to the advertising image. Barthes notes that “all images are polysemous”, that underlying their signifiers they imply “a ‘floating chain’ of signifieds, the reader able to choose some and ignore others” (274). That said, the advertising image, he argues, constructs an “undoubtedly intentional […] signification”, making it ideally suited for analysis (270). By supplementing my analysis with excerpts from two interviews I conducted with wandsinhand in February and April 2013 (quoted here with permission), I support my readings with respect to the artist’s stated ‘intentional reading’. I then contextualise these readings with respect to canon (Merlin) representations and gay pornography—via the chosen sexual acts/positions, bukkake and doggystyle, of the pornographic base models, as selected by the artist. This approach allows me to examine the photo remix qualities of slash manips with respect to the artist’s intentions as well as how artistic choices of inclusion function to anchor meaning in the works. I describe these choices as the ‘semiotic significance of selection’. Together the readings and interviews in this article help illustrate the value of this form and the new avenues it opens for slash scholars, such as consideration of photo remix and male production, and the importance of gay pornography to slash. My interviews also reveal, via the artist’s own assessment of the ‘value’ of his practice, a tendency to devalue or overlook the significance of this particular slash form, affirming a real need for further critical engagement with this under-examined practice. Slash Photo Remix: Famous Faces, Porny Bodies Lessig defines remix culture as based on an activity of “rip, mix and burn” (12–5); while Navas describes it as a “practice of cut/copy and paste” (159)—the latter being more applicable to photo remix. Whereas Lessig is concerned primarily with issues of copyright, Navas is interested in remix’s role in aesthetics and the political economy. Within fan studies, slash vids—a form of video remix—has been a topic of considerable academic interest in recent years. Slash manips—a form of photo or image remix—however, has not attracted the same degree of interest. Stasi’s description of slash as “a non-hierarchical, rich layering of genres” points to the usefulness of slash manips as an embodiment of the process of slash; whereby artists combine, blend and mutate graphic layers from popular media with those from gay pornography. Aesthetics and the slash manip process are central concerns of this article’s consideration of slash photo remix. Slash manips, or slash photo montage, use image manipulation software (Adobe Photoshop being the community standard, see wandsinhand’s tutorial) to layer the heads of male fictional characters from stills or promotional images with scenes—static or moving—from gay pornography. Once an artist has selected pornographic ‘base models’ anatomically suited to canon characters, these models are often then repositioned into the canon universe, which in the case of Merlin means a medieval setting. (Works not repositioned and without added details from canon are generally categorised as ‘male celebrity fakes’ rather than ‘slash manips’.) Stedman contends that while many fan studies scholars are interested in remix, “studies commonly focus on examples of remixed objects rather than the compositional strategies used by remix composers themselves” (107). He advocates moving beyond an exclusive consideration of “text-centred approaches” to also consider “practice-” and “composer-centred” approaches. Such approaches offer insight into “the detailed choices composers actually make when composing” (107). He refers to recognition of the skills required by a remix composer as “remix literacy” (108). This article’s consideration of the various choices and skills that go into the composition of slash manips—what I term the ‘semiotic significance of selection’—is explored with respect to wandsinhand’s practice, coupling my reading—informed by my experience as a practitioner—with the interpretations of the artist himself. Jenkins defines slash as “reaction against” constructions of male sexuality in both popular media and pornography (189). By their very nature, slash manips also make clear the oft-overlooked connections between slash and gay pornography, and in turn the contributions of gay male participants, who are well represented by the form. This contrasts with a tendency within scholarship to compare slash with heterosexual female forms, such as the romance genre (Salmon and Symons). Gay pornography plays a visible role in slash manips—and slash vids, which often remix scenes from popular media with gay cinema and pornography. Slash as Romance, Slash as Pornography Early scholarship on slash (see Russ; Lamb and Veith) defines it as a form of erotica or pornography, by and for women; a reductive definition that fails to take into account men’s contribution, yet one that many researchers continue to adopt today. As stated above, there has also been a tendency within scholarship to align the practice with heterosexual female forms such as the romance genre. Such a tendency is by and large due to theorisation of slash as heterosexual female fantasy—and concerned primarily with romance and intimacy rather than sex (see Woledge). Weinstein describes slash as more a “fascination with” than a “representation of” homosexual relationships (615); while MacDonald makes the point that homosexuality is not a major political motivator for slash (28–9). There is no refuting that slash—along with most fannish practice—is female dominated, ethnographic work and fandom surveys reveal that is the case. However there is great need for research into male production of slash, particularly how such practices might challenge reigning definitions and assumptions of the practice. In similar Japanese practices, for example, gay male opposition to girls’ comics (shōjo) depicting love between ‘pretty boys’ (bishōunen) has been well documented (see Hori)—Men’s Love (or bara) is a subgenre of Boys’ Love (or shōnen’ai) predominately created by gay men seeking a greater connection with the lived reality of gay life (Lunsing). Dennis finds male slash fanart producers more committed to muscular representations and depiction of graphic male/male sex when compared with female-identifying artists (14, 16). He also observes that male fanart artists have a tendency of “valuing same-sex desire without a heterosexual default and placing it within the context of realistic gay relationships” (11). I have observed similar differences between male and female-identifying slash manip artists. Female-identifying Nicci Mac, for example, will often add trousers to her donor bodies, recoding them for a more romantic context. By contrast, male-identifying mythagowood is known for digitally enlarging the penises and rectums of his base models, exaggerating his work’s connection to the pornographic and the macabre. Consider, for example, mythagowood’s rationale for digitally enlarging and importing ‘lips’ for Sam’s (Supernatural) rectum in his work Ass-milk: 2012, which marks the third anniversary of the original: Originally I wasn’t going to give Sammy’s cunt any treatment (before I determined the theme) but when assmilk became the theme I had to go find a good set of lips to slap on him and I figured, it’s been three years, his hole is going to be MUCH bigger. (personal correspondence, used with permission) While mythagowood himself cautions against gendered romance/pornography slash arguments—“I find it annoying that people attribute certain specific aspects of my work to something ‘only a man’ would make.” (ibid.)—gay pornography occupies an important place in the lives of gay men as a means for entertainment, community engagement and identity-construction (see McKee). As one of the only cultural representations available to gay men, Fejes argues that gay pornography plays a crucial role in defining gay male desire and identity. This is confirmed by an Internet survey conducted by Duggan and McCreary that finds 98% of gay participants reporting exposure to pornographic material in the 30-day period prior to the survey. Further, the underground nature of gay pornographic film (see Dyer) aligns it with slash as a subcultural practice. I now analyse two Merlin slash manips with respect to the sexual positions of the pornographic base models, illustrating how gay pornography genres and ideologies referenced through these works enforce their intended meaning, as defined by the artist. A sexual act such as bukkake, as wandsinhand astutely notes, acts as a universal sign and “automatically generates a narrative for the image without anything really needing to be detailed”. Barthes argues that such a “relation between thing signified and image signifying in analogical representation” is unlike language, which has a much more ‘arbitrary’ relationship between signifier and signified (272). Bukkake and the Assertion of Masculine Power in Merlin Merlin (2008–12) is a BBC reimagining of the Arthurian legend that focuses on the coming-of-age of Arthur and his close bond with his manservant Merlin, who keeps his magical identity secret until Arthur’s final stand in the iconic Battle of Camlann. The homosexual potential of Merlin and Arthur’s story—and of magic as a metaphor for homosexuality—is something slash fans were quick to recognise. During question time at the first Merlin cast appearance at the London MCM Expo in October 2008—just one month after the show’s pilot first aired—a fan asked Morgan and James, who portray Merlin and Arthur, is Merlin “meant to be a love story between Arthur and Merlin?” James nods in jest. Wandsinhand, who is most active in the Teen Wolf (2011–present) fandom, has produced two Merlin slash manips to date, a 2013 Merlin/Arthur and a 2012 Arthur/Percival, both untitled. The Merlin/Arthur manip (see Figure 1) depicts Merlin bound and on his knees, Arthur ejaculating across his face and on his chest. Merlin is naked while Arthur is partially clothed in chainmail and armour. They are both bruised and dirty, Arthur’s injuries suggesting battle given his overall appearance, while Merlin’s suggesting abuse, given his subordinate position. The setting appears to be the royal stables, where we know Merlin spends much of his time mucking out Arthur’s horses. I am left to wonder if perhaps Merlin did not carry out this duty to Arthur’s satisfaction, and is now being punished for it; or if Arthur has returned from battle in need of sexual gratification and the endorsement of power that comes from debasing his manservant. Figure 1: wandsinhand, Untitled (Merlin/Arthur), 2013, photo montage. Courtesy the artist. Both readings are supported by Arthur’s ‘spent’ expression of disinterest or mild curiosity, while Merlin’s face emotes pain: crying and squinting through the semen obscuring his vision. The artist confirms this reading in our interview: “Arthur is using his pet Merlin to relieve some stress; Merlin of course not being too pleased about the aftermath, but obedient all the same.” The noun ‘pet’ evokes the sexual connotations of Merlin’s role as Arthur’s personal manservant, while also demoting Merlin even further than usual. He is, in Arthur’s eyes, less than human, a sexual plaything to use and abuse at will. The artist’s statement also confirms that Arthur is acting against Merlin’s will. Violence is certainly represented here, the base models having been ‘marked up’ to depict sexualisation of an already physically and emotionally abusive relationship, their relative positioning and the importation of semen heightening the humiliation. Wandsinhand’s work engages characters in sadomasochistic play, with semen and urine frequently employed to degrade and arouse—“peen wolf”, a reference to watersports, is used within his Teen Wolf practice. The two wandsinhand works analysed in this present article come without words, thus lacking a “linguistic message” (Barthes 273–6). However even so, the artist’s statement and Arthur’s stance over “his pet Merlin” mean we are still able to “skim off” (270) the meanings the image contains. The base models, for example, invite comparison with the ‘gay bukkake’ genre of gay pornography—admittedly with a single dominant male rather than a group. Gay bukkake has become a popular niche in North American gay pornography—it originated in Japan as a male–female act in the 1980s. It describes a ritualistic sexual act where a group of dominant men—often identifying as heterosexual—fuck and debase a homosexual, submissive male, commonly bareback (Durkin et al. 600). The aggression on display in this act—much like the homosocial insistency of men who partake in a ‘circle jerk’ (Mosher 318)—enables the participating men to affirm their masculinity and dominance by degrading the gay male, who is there to service (often on his knees) and receive—in any orifice of the group’s choosing—the men’s semen, and often urine as well. The equivalencies I have made here are based on the ‘performance’ of the bukkake fantasy in gay niche hazing and gay-for-pay pornography genres. These genres are fuelled by antigay sentiment, aggression and debasement of effeminate males (see Kendall). I wish here to resist the temptation of labelling the acts described above as deviant. As is a common problem with anti-pornography arguments, to attempt to fix a practice such as bukkake as deviant and abject—by, for example, equating it to rape (Franklin 24)—is to negate a much more complex consideration of distinctions and ambiguities between force and consent; lived and fantasy; where pleasure is, where it is performed and where it is taken. I extend this desire not to label the manip in question, which by exploiting the masculine posturing of Arthur effectively sexualises canon debasement. This began with the pilot when Arthur says: “Tell me Merlin, do you know how to walk on your knees?” Of the imported imagery—semen, bruising, perspiration—the key signifier is Arthur’s armour which, while torn in places, still ensures the encoding of particular signifieds: masculinity, strength and power. Doggystyle and the Subversion of Arthur’s ‘Armoured Self’ Since the romanticism and chivalric tradition of the knight in shining armour (see Huizinga) men as armoured selves have become a stoic symbol of masculine power and the benchmark for aspirational masculinity. For the medieval knight, armour reflects in its shiny surface the mettle of the man enclosed, imparting a state of ‘bodilessness’ by containing any softness beneath its shielded exterior (Burns 140). Wandsinhand’s Arthur/Percival manip (see Figure 2) subverts Arthur and the symbolism of armour with the help of arguably the only man who can: Arthur’s largest knight Percival. While a minor character among the knights, Percival’s physical presence in the series looms large, and has endeared him to slash manip artists, particularly those with only a casual interest in the series, such as wandsinhand: Why Arthur and Percival were specifically chosen had really little to do with the show’s plot, and in point of fact, I don’t really follow Merlin that closely nor am I an avid fan. […] Choosing Arthur/Percival really was just a matter of taste rather than being contextually based on their characterisations in the television show. Figure 2: wandsinhand, Untitled (Arthur/Percival), 2012, photo montage. Courtesy the artist. Concerning motivation, the artist explains: “Sometimes one’s penis decides to pick the tv show Merlin, and specifically Arthur and Percival.” The popularity of Percival among manip artists illustrates the power of physicality as a visual sign, and the valorisation of size and muscle within the gay community (see Sánchez et al.). Having his armour modified to display his muscles, the implication is that Percival does not need armour, for his body is already hard, impenetrable. He is already suited up, simultaneously man and armoured. Wandsinhand uses the physicality of this character to strip Arthur of his symbolic, masculine power. The work depicts Arthur with a dishevelled expression, his armoured chest pressed against the ground, his chainmail hitched up at the back to expose his arse, Percival threading his unsheathed cock inside him, staring expressionless at the ‘viewer’. The artist explains he “was trying to show a shift of power”: I was also hinting at some sign of struggle, which is somewhat evident on Arthur’s face too. […] I think the expressions work in concert to suggest […] a power reversal that leaves Arthur on the bottom, a position he’s not entirely comfortable accepting. There is pleasure to be had in seeing the “cocky” Arthur forcefully penetrated, “cut down to size by a bigger man” (wandsinhand). The two assume the ‘doggystyle’ position, an impersonal sexual position, without eye contact and where the penetrator sets the rhythm and intensity of each thrust. Scholars have argued that the position is degrading to the passive party, who is dehumanised by the act, a ‘dog’ (Dworkin 27); and rapper Snoop ‘Doggy’ Dogg exploits the misogynistic connotations of the position on his record Doggystyle (see Armstrong). Wandsinhand is clear in his intent to depict forceful domination of Arthur. Struggle is signified through the addition of perspiration, a trademark device used by this artist to symbolise struggle. Domination in a sexual act involves the erasure of the wishes of the dominated partner (see Cowan and Dunn). To attune oneself to the pleasures of a sexual partner is to regard them as a subject. To ignore such pleasures is to degrade the other person. The artist’s choice of pairing embraces the physicality of the male/male bond and illustrates a tendency among manip producers to privilege conventional masculine identifiers—such as size and muscle—above symbolic, nonphysical identifiers, such as status and rank. It is worth noting that muscle is more readily available in the pornographic source material used in slash manips—muscularity being a recurrent component of gay pornography (see Duggan and McCreary). In my interview with manip artist simontheduck, he describes the difficulty he had sourcing a base image “that complimented the physicality of the [Merlin] characters. […] The actor that plays Merlin is fairly thin while Arthur is pretty built, it was difficult to find one. I even had to edit Merlin’s body down further in the end.” (personal correspondence, used with permission) As wandsinhand explains, “you’re basically limited by what’s available on the internet, and even then, only what you’re prepared to sift through or screencap yourself”. Wandsinhand’s Arthur/Percival pairing selection works in tandem with other artistic decisions and inclusions—sexual position, setting, expressions, effects (perspiration, lighting)—to ensure the intended reading of the work. Antithetical size and rank positions play out in the penetration/submission act of wandsinhand’s work, in which only the stronger of the two may come out ‘on top’. Percival subverts the symbolic power structures of prince/knight, asserting his physical, sexual dominance over the physically inferior Arthur. That such a construction of Percival is incongruent with the polite, impeded-by-my-size-and-muscle-density Percival of the series speaks to the circumstances of manip production, much of which is on a taste basis, as previously noted. There are of course exceptions to this, the Teen Wolf ‘Sterek’ (Stiles/Derek) pairing being wandsinhand’s, but even in this case, size tends to couple with penetration. Slash manips often privilege physicality of the characters in question—as well as the base models selected—above any particular canon-supported slash reading. (Of course, the ‘queering’ nature of slash practice means at times there is also a desire to see such identifiers subverted, however in this example, raw masculine power prevails.) This final point is in no way representative—my practice, for example, combines manips with ficlets to offer a clearer connection with canon, while LJ’s zdae69 integrates manips, fiction and comics. However, common across slash manip artists driven by taste—and requests—rather than connection with canon—the best known being LJ’s tw-31988, demon48180 and Tumblr’s lwoodsmalestarsfakes, all of whom work across many fandoms—is interest in the ‘aesthetics of canon’, the blue hues of Teen Wolf or the fluorescent greens of Arrow (2012–present), displayed in glossy magazine format using services such as ISSUU. In short, ‘the look’ of the work often takes precedent over canonical implications of any artistic decisions. “Nothing Too Serious”: Slash Manips as Objects Worth Studying It had long been believed that the popular was the transient, that of entertainment rather than enlightenment; that which is manufactured, “an appendage of the machinery”, consumed by the duped masses and a product not of culture but of a ‘culture industry’ (Adorno and Rabinbach 12). Scholars such as Radway, Ang pioneered a shift in scholarly practice, advancing the cultural studies project by challenging elitism and finding meaning in traditionally devalued cultural texts and practices. The most surprising outcome of my interviews with wandsinhand was hearing how he conceived of his practice, and the study of slash: If I knew I could get a PhD by writing a dissertation on Slash, I would probably drop out of my physics papers! […] I don’t really think too highly of faking/manip-making. I mean, it’s not like it’s high art, is it? … or is it? I guess if Duchamp’s toilet can be a masterpiece, then so can anything. But I mainly just do it to pass the time, materialise fantasies, and disperse my fantasies unto others. Nothing too serious. Wandsinhand erects various binaries—academic/fan, important/trivial, science/arts, high art/low art, profession/hobby, reality/fantasy, serious/frivolous—as justification to devalue his own artistic practice. Yet embracing the amateur, personal nature of his practice frees him to “materialise fantasies” that would perhaps not be possible without self-imposed, underground production. This is certainly supported by his body of work, which plays with taboos of the unseen, of bodily fluids and sadomasochism. My intention with this article is not to contravene views such as wandsinhand’s. Rather, it is to promote slash manips as a form of remix culture that encourages new perspectives on how slash has been defined, its connection with male producers and its symbiotic relationship with gay pornography. I have examined the ‘semiotic significance of selection’ that creates meaning in two contrary slash manips; how these works actualise and resist canon dominance, as it relates to the physical and the symbolic. This examination also offers insight into this form’s connection to and negotiation with certain ideologies of gay pornography, such as the valorisation of size and muscle. 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Introduction The term monster might have its roots in the Latin word monere (to warn), but it has since evolved to have various symbolic meanings, from a terrifying mythical creature to a person of extreme cruelty. No matter the flexibility in use, the term is mostly meant to be derogatory (Asma). As Gilmore puts it, monsters “embody all that is dangerous and horrible in the human imagination” (1). However, it may be argued that monsters sometimes perform the much-needed work of defining and policing our norms (Mittman and Hensel). Since their archetype is predisposed to transgressing boundaries of human integrity (Gilmore), they help establish deviation between human and in-human. Their cognition and action are considered ‘other’ (Kearney) and a means with which people can understand what is right and wrong, and what is divergent from appropriate ways of being. The term monster need not even refer to the werewolves, ogres, vampires, zombies and the like that strike fear in audiences through their ‘immoral, heinous or unjust’ appearance or behaviours. Rather, the term monster can be, and has been, readily applied as a metaphor to describe the unthinkable, unethical, and brutal actions of human beings (Beville 5). Inadvertently, “through their bodies, words, and deeds, monsters show us ourselves” (Mittman and Hensel 2), or what we consider monstrous about ourselves. Therefore, humans acting in ways that deviate from societal norms and standards can be viewed as monstrous. This is evident in the representations of public relations practitioners in media offerings. In the practice of public relations, ethical standards are advocated as the norm, and deviating from them considered unprofessional (Fawkes), and as we contend: monstrous. However, the practice has long suffered a negative stereotypical perception of being deceptive, and with public relations roles receiving less screen time than shows and films about lawyers, accountants, teachers and the like, these few derogatory depictions can distort how audiences view the occupation (Johnston). Depictions of professions (lawyers, cops, journalists, etc.) tend to be cliché, but our contention is that fewer depictions of public relations practitioners on screen further limit the possibility for diverse depictions. The media can have a socialising impact and can influence audiences to view the content they consume as a reflection of the real world around them (Chandler). Television, in particular, with its capacity to prompt heuristic processing in audiences (Shurm), has messages that can be easily decoded by people of various literacies as they become immersed in the viewing experiences (Gerbner and Gross). These messages gain potency because, despite being set in fictional worlds, they can be understood as reflective of the world and audiences’ experiences of it (Gerbner and Gross). Tsetsura, Bentley, and Newcomb add that popular stories recounted in the media have authoritative power and can offer patterns of meaning that shape individual perceptions. Admittedly, as Stuart Hall suggests, media offerings can be encoded with ideologies and representations that are considered appropriate according to the dominant elite, but these may not necessarily be decoded as preferred meanings. In other words, those exposed to stories of monstrous public relations practitioners can agree with such a position, oppose this viewpoint, or remain neutral, but this is dependent on individual experiences. Without other frames of reference, it could be that viewers of negative portrayals of public relations accept the encoded representation that inevitably does a disservice to the profession. When the representations of the field of public relations suggest, inaccurately, that the industry is dominated by men (Johnston), and women practitioners are shown as slick dressers who control and care little about ethics (Dennison), the distortions can adversely impact on the identities of public relations practitioners and on how they are collectively viewed (Tsetsura et al.). Public relations practitioners view this portrayal as the ‘other’ and tend to distance the ideal self from it, continuing to be stuck in the dichotomy of saints and sinners (Fawkes). Our observation of television offerings such as Scandal, Flack, Call My Agent!, Absolutely Fabulous, Sex and the City, You’re the Worst, and Emily in Paris reveals how television programmes continue to perpetuate the negative stereotypes about public relations practice, where practitioners are anything but ethical—therefore monstrous. The characters, mostly well-groomed women, are shown as debased, liars and cheaters who will subvert ethical standards for personal and professional gain. Portrayals of Public Relations Practitioners in Television and Media According to Miller, the eight archetypical traits identified in media representations of public relations practitioners are: ditzy, obsequious, cynical, manipulative, money-minded, isolated, accomplished, or unfulfilled. In later research, Yoon and Black found that television representations of public relations tended to suggest that people in these roles were heartless, manipulative bullies, while Lambert and White contend that the depiction of the profession has improved to be more positive, but nonetheless continues to do a disservice to the practice by presenting female workers, especially, as “shallow but loveable” (18). We too find that public relations practitioners continue to be portrayed as morally ambiguous characters who are willing to break ethical codes of conduct to suit the needs of their clients. We discuss three themes prevalent as popular tropes in television programmes that characterise public relations practitioners as monstrous. To Be or Not to Be a Slick and Skilful Liar? Most television programmes present public relations practitioners as slick and skilful liars, who are shown as well-groomed and authoritative, convinced that they are lying only to protect their clients. In fact, in most cases the characters are shown to not only believe but also advocate to their juniors that ‘a little bit of lying’ is almost necessary to maintain client relationships and ensure campaign success. For example, in the British drama Flack, the main character of Robyn (played by Anna Paquin) is heard advising her prodigy “just assume we are lying to everyone”. The programmes also feature characters who are in dilemma about the monstrous expectations from their roles, struggling to accept that that they engage in deception as part of their jobs. However, most of them are presented as somewhat of an ugly duckling or the modest character in the programme, who is not always rational or in an explicit position of power. For example, Emily from Emily in Paris (played by Lily Collins), while working as a social media manager, regularly questions the approaches taken by the firm she works for. Her boss Sylvie Grateux (played by Philippine Leroy-Beaulieu), who embodies the status quo, is constantly disapproving of Emily’s lack of sophisticated self-presentation, among other aspects. In the episode ‘Faux Amis’, Sylvie quips “it’s not you personally. It’s everything you stand for. You’re the enemy of luxury because luxury is defined by sophistication and taste, not emilyinparis”. Similarly, in the first episode of Call My Agent!, Samuel Kerr (played by Alain Rimoux), the head of a film publicity firm, solves the conundrum faced by his anxious junior Gabriel (played by Grégory Montel) by suggesting that he lie to his client about the real reason why she lost the film. When a modestly dressed Gabriel questions how he can lie to someone he cares for, Samuel, towering over him in an impeccable suit and a confident demeanour, advises “who said anything about lying? Don’t lie. Simply don’t tell her the truth”. However, the subtext here is that the lie is to protect the client from unnecessary hurt and in doing so nurtures the client relationship. So, it lets the audience decide the morality of lying here. It may be argued that moral ambiguity may not necessarily be monstrous. Such grey characters are often crafted because they allow audiences to relate more readily to themselves by encouraging what Hawkins refers to as mental play. Audiences are less interested in the black and white of morality and veer towards shows such as Call My Agent! where storylines hone in on the need to do bad for the greater good. In these ways, public relations practitioners still transgress moral standards but are less likely to be considered monstrous because the impact and effect on others is utilitarian in nature. It is also interesting to note that in these programmes physical appearance is made to play a crucial role in showcasing the power and prestige of the senior public relations practitioner. This focus on attire can tend to further perpetuate unfavourable stereotypes about public relations practitioners being high income earners (Grandien) who are styled with branded apparel but lacking in substance and morals (Fröhlich and Peters). Promiscuous Women The urge to attract audiences to a female character can also lead to developing and cementing unfavourable stereotypes of public relations practitioners as uninhibited women who live on blurred lines between personal and professional. These characters are not portrayed as inherently bad, but instead are found to indulge in lives of excess. In her definition of the monstrous, Arumugam suggests that excess and insatiable appetites direct the monster’s behaviour, and Kearney outlines that this uncontainable excess is what signals the difference between humans and others. Such excess is readily identifiable in the character of Patsy Stone (played by Joanna Lumley) in Absolutely Fabulous. She is an alcoholic, regularly uses recreational drugs, is highly promiscuous, and chain-smokes throughout the series. She is depicted as prone to acting deceptively to maintain her vices. In Flack, Robyn is shown as regularly snorting cocaine and having sex with her clients. Those reviewing the show highlight how it will attract those interested in “its dark, acidic sense of humour” (Greene) while others condemn it because it emphasises the “depraved publicist” trope (Knibbs) and call it “one of the worst TV shows ever made” even though it is trying to highlight concerns raised in the MeToo movement about how men need to respect women (McGurk). Female characters such as Robyn, with her willingness to question why a client has not tried to sleep with her, appear to undermine the empowerment of the movement rather than support it, and continue to maintain the archetypes that those working in the field of public relations abhor. Similarly, Samantha Jones (played by Kim Cattrell) of Sex and the City is portrayed as sexually liberated, and in one episode another character describes Samantha’s vagina as “the hottest spot in town: it’s always open”. In many ways Samantha’s sexual behaviour reflects a post-feminist narrative of empowerment, agency, and choice, but it could also be read as a product of being a public relations practitioner frequenting parties and bars as she rubs shoulders with clients, celebrities, and high-profile businesspeople. To this end, Patsy, Samantha, and Robyn glamourise public relations and paint it as simply an extension of their liberated and promiscuous selves, with little care for any expectation of professionalism or work ethic. This is also in stark contrast to the reality, where women often tend to occupy technical roles that see much of their time spent in doing the hard yards of publicity and promotion (Krugler). Making Others Err Public relations practitioners are not just shown as being morally ambiguous themselves, but often quite adept at making others do deceitful acts on their behalf, thus nonchalantly oppressing others to get their way. For example, although lauded for elevating an African-American woman to the lead role despite the show maintaining misrepresentations of race (Lambert), the main character of Olivia Pope (played by Kerry Washington) in the television programme Scandal regularly subverts the law for her clients despite considering herself one of the “good guys” and wearing a “white hat”. Over the course of seven seasons, Olivia Pope is found to rig elections, plant listening devices in political figures’ offices, bribe, threaten, and conduct an affair with the President. In some cases, she calls on the services of her colleague Huck to literally, and figuratively, get rid of the barriers in the way of protecting her clients. For example, in season one’s episode Crash and Burn she asks Huck to torture a suspect for information about a dead client. Her willingness to request such actions of her friend and colleague, regardless of perceived good motivations, reinforces Mittman’s categorisation that monsters are identified by their effect and impact on others. Here, the impact includes the torturing of a suspect and the revisiting of psychological trauma by Huck’s character. Huck struggles to overcome his past as a killer and spends much of the show trying to curb his monstrous tendencies which are often brought on by PR woman Olivia’s requests. Although she is sometimes striving for justice, Olivia’s desire for results can lead her to act monstrously, which inadvertently contributes to the racist and sexist ideologies that have long been associated with monsters and perceptions of the Other. Across time and space, certain ethnic groups, such as those of African descent, have been associated with the demonic (Cohen). Similarly, all that is feminine often needs to be discarded as the monster to conform to the patriarchal order of society (Creed). Therefore, Olivia Pope’s monstrous behaviour not only does a disservice to representations of public relations practitioners, but also inadvertently perpetuates negative and inaccurate stereotypes about women of African American descent. Striving to be Ethical The majority of public relations practitioners are encouraged, and in some cases expected, to conform to ethical guidelines to practice and gain respect, admiration, and in-group status. In New Zealand, those who opt to become members of the Public Relations Institute of New Zealand (PRINZ) are required to abide by the association’s code of ethics. The code stipulates that members are bound to act in ways that serve public interests by ensuring they are honest, disclose conflict of interests, follow the law, act with professionalism, ensure openness and privacy are maintained, and uphold values of loyalty, fairness, and independence (PRINZ). Similarly, the Global Alliance of Public Relations and Communication Management that binds practitioners together identifies nine guiding principles that are to be adhered to to be recognised as acting ethically. These include obeying laws, working in the public’s interest, ensuring freedom of speech and assembly, acting with integrity, and upholding privacy in sensitive matters (to name a few). These governing principles are designed to maintain ethical practice in the field. Of course, the trouble is that not all who claim to practice public relations become members of the local or global governing bodies. This implies that professional associations like PRINZ are not able to enforce ethics across the board. In New Zealand alone, public relations consultants have had to offer financial reparations for acting in defamatory ways online (Fisher), or have been alleged to have bribed an assault victim to prevent the person giving evidence in a court case (Hurley). Some academics have accused the industry of being engaged in organised lying (Peacock), but these are not common, nor are these moral transgressors accepted into ethical bodies that afford practitioners authenticity and legitimacy. In most cases, public relations practitioners view their role as acting as the moral conscience of the organisations they support (Schauster, Neill, Ferrucci, and Tandoc). Furthermore, they rated better than the average adult when it came to solving ethical dilemmas through moral reasoning (Schuaster et al.). Additionally, training of practitioners through guidance of mentors has continued to contribute to the improved ethical ratings of public relations. What these findings suggest is that the monsters of public relations portrayed on our television screens are exaggerations that are not reflective of most of the practice. Women of Substance, But Not Necessarily Power Exploring the role of women in public relations, Topic, Cunha, Reigstad, Jele-Sanchez, and Moreno found that female practitioners were subordinated to their male counterparts but were found to be more inclined to practice two-way communication, offer balanced perspectives, opt to negotiate, and build relationships through cooperation. The competitiveness, independence, and status identified in popular media portrayals were found to be exhibited more by male practitioners, despite there being more women in the public relations industry than men. As Fitch argues, popular culture continues to suggest that men dominate public relations, and their preferred characteristics end up being those elements that permeate the media messages, regardless of instances where the lead character is a woman or the fact that feminist values of “loyalty, ethics, morality, [and] fairness” are advocated by female practitioners in real life (Vardeman-Winter and Place 333). Additionally, even though public relations is a feminised field, female practitioners struggle to break the glass ceiling, with male practitioners dominating executive positions and out-earning women (Pompper). Interestingly, in public relations, power is not just limited due to gender but also area of practice. In her ethnographic study of the New Zealand practice, Sissons found that practitioners who worked in consultancies were relatively powerless vis-à-vis their clients, and often this asymmetry negatively affected the practitioner’s decision-making. This implies that in stark contrast to the immoral, glamourous, and authoritative depiction of public relations women in television programmes, in reality they are mired by the struggles of a gendered occupation. Accordingly, they are not in fact in a position to have monstrous power over and impact on others. Therefore, one of the only elements the shows seem to capture and emphasise is that public relations is an occupation that specialises in image management; but what these shows contribute to is an ideology that women are expected to look and carry themselves in particular ways, ultimately constructing aesthetic standards that can diminish women’s power and self-esteem. Conclusion Miller’s archetypes may be over twenty years old, but the trend towards obsequious, manipulative, and cynical television characters remains. Although there have been identifiable shifts to loveable, yet shallow, public relations practitioners, such as Alexis Rose on Schitt’s Creek, the appeal of monstrous public relations practitioners remains. As Cohen puts it, monsters reveal to audiences “what a member of that society can become when those same dictates are rejected, when the authority of leaders or customs disintegrates and the subordination of individual to hierarchy is lost” (68). In other words, audiences enjoy watching the stories of metaphorical monsters because they exhibit the behaviours that are expected to be repressed in human beings; they depict what happens when the social norms of society are disturbed (Levina and Bui). At the very least, these media representations can act, much as monster narratives do, as a cautionary tale on how not to think and act to remain accepted as part of the in-group rather than being perceived as the Other. As Mittman and Hensel argue, society can learn much from monsters because monsters exist within human beings. According to Cohen, they offer meaning about the world and can teach audiences so they can learn, in this case, how to be better. Although the representations of public relations in television can offer insights into roles that are usually most effective when they are invisible (Chorazy and Harrington), the continued negative stereotypes of public relations practitioners can adversely impact on the industry if people are unaware of the practices of the occupation, because lacking a reference point limits audiences’ opportunities to critically evaluate the media representations. This will certainly harm the occupation by perpetuating existing negative stereotypes of charming and immoral practitioners, and perhaps add to its struggles with gendered identity and professional legitimacy. References Absolutely Fabulous. Created by Jennifer Saunders and Dawn French. Saunders and French Productions, 1992-1996. Arumugam, Indira. “Gods as Monsters: Insatiable Appetites, Exceeding Interpretations and a Surfeit of Life.” Monster Anthropology. Eds. Yasmine Musharbash and Geir Henning Presterudstuen. Routledge, 2020. 44-58. Asma, Stephen, T. On Monsters: An Unnatural History of Our Worst Fear. Oxford UP, 2009. Beville, Maria. The Unnameable Monster in Literature and Film. Routledge, 2013. Call My Agent! Created by Fanny Herrero. France Televisions, 2015-2020. Chandler, Daniel. Cultivation Theory. Aberystwyth U, 1995. 5 Aug. 2021 <http://visual-memory.co.uk/daniel//Documents/short/cultiv.html>. Chorazy, Ella, and Stephen Harrington. “Fluff, Frivolity, and the Fabulous Samantha Jones: Representations of Public Relations in Entertainment.” Entertainment Values. Ed. Stephen Harrington. Palgrave, 2017. Cohen, Jeffrey J. Monster Theory. U of Minnesota P, 1996. Creed, Barbara. The Monstrous-Feminine: Film, Feminism, Psychoanalysis. Routledge, 1993. Dennison, Mikela. An Analysis of Public Relations Discourse and Its Representations in Popular Culture. Masters Thesis. Auckland: Auckland University of Technology, 2012. Emily in Paris. Created by Darren Starr. Darren Starr Productions, 2020-present. Fawkes, Johanna. “A Jungian Conscience: Self-Awareness for Public Relations Practice.” Public Relations Review 41.5 (2015): 726-33. Fisher, David. “’Hit’ Jobs Case: PR Consultant Apologises and Promises Cash to Settle Defamation Case That Came from Dirty Politics”. New Zealand Herald, 3 Mar. 2021. 7 July 2021 <https://www.nzherald.co.nz/nz/hit-jobs-case-pr-consultant-apologises-and-promises-cash-to-settle-defamation-case-that-came-from-dirty-politics/C4KN5H42UUOCSXD7OFXGZ6YCEA/>. Fiske, John. Television Culture. Routledge, 2010. Fitch, Kate. “Promoting the Vampire Rights Amendment: Public Relations, Postfeminism and True Blood”. Public Relations Review 41.5 (2015): 607-14. Flack. Created by Oliver Lansley. Hat Trick Productions, 2019-2021. Fröhlich, Romy, and Sonja B. Peters. “PR Bunnies Caught in the Agency Ghetto? Gender Stereotypes, Organizational Factors, and Women’s Careers in PR Agencies.” Journal of Public Relations Research 19.3 (2007): 229-54. Gerbner, George, and Larry Gross. “Living with Television: The Violence Profile”. Journal of Communication 26.2 (1976): 172-99. Gilmore, David D. Monsters: Evil Beings, Mythical Beasts, and All Manner of Imaginary Terrors. U of Pennsylvania P. Global Alliance for Public Relations and Communication Management. Code of Ethics. 14 Mar. 2021. <https://www.globalalliancepr.org/code-of-ethics>. Greene, Steve. “Flack: Amazon Resurfaced the Show’s First Season at Just the Right Time.” IndieWire, 22 Jan. 2021. 7 July 2021 <https://www.indiewire.com/2021/01/flack-review-amazon-prime-video-anna-paquin-1234610509/>. Hall, Stuart. “Encoding/Decoding”. Culture, Media, Language. Eds. Stuart Hall, Doothy Hobson, Andrew Lowe, and Paul Willis. Routledge, 1980. 128-138. Hawkins, Gay. “The Ethics of Television”. International Journal of Cultural Studies 4.4 (2001): 412-26. Hurley, Sam. “The PR Firm Hired to Do a Rich-Lister’s Dirty Work”. New Zealand Herald, 30 Mar. 2021. 5 July 2021 <https://www.nzherald.co.nz/business/inside-story-the-pr-firm-hired-to-do-a-rich-listers-dirty-work-and-make-a-court-case-disappear/7FKKEADHWIBT64POKDH3ADEDE4/>. Johnston, Jane. “Girls on Screen: How Film and Television Depict Women in Public Relations.” PRism 7.4 (2010): 1-16. Kearney, Richard. Strangers, Gods and Monsters: Interpreting Otherness. London: Routledge, 2003. Knibbs, Kate. “A Brief Pop Cultural History of the Publicist.” The Ringer 27 Feb. 2019. 7 July 2021 <https://www.theringer.com/tv/2019/2/27/18241636/flack-publicists-pop-culture>. Krugler, Elizabeth. Women in Public Relations: The Influence of Gender on Women Leaders in Public Relations. Masters Thesis. Iowa State University, 2017. Lambert, Cheryl Ann. “Post-Racial Public Relations on Primetime Television: How Scandal Represents Olivia Pope.” Public Relations Review 43.4 (2017): 750-54. Lambert, Cheryl Ann, and Candace White. “Feminization of the film? Occupational Roles of Public Relations Characters in Movies.” Public Relations Journal 6.4 (2012): 1-24. Levina, Marina, and Diem-My Bui. “Introduction”. In Monster Culture in the 21st Century. Eds. Marina Levina and Diem-My Bui. Bloomsbury, 2013. 1-13. McGurk, Stuart. “PR Drama Flack Might Be One of the Worst TV Shows Ever Made.” GQ Magazine 19 Feb. 2019. 7 July 2021 <https://www.gq-magazine.co.uk/article/flack-tv-show-review>. Miller, Karen S. “Public Relations in Film and Fiction: 1930 to 1995.” Journal of Public Relations Research 11.1 (1999): 3-28. Mittman, Asa Simon. “Introduction: The Impact of Monsters and Monster Studies.” The Ashgate Research Companion to Monsters and the Monstrous. Eds. Asa Simon Mittman and Peter Dendle. London: Ashgate, 2012. 1-14. Mittman, Asa Simon, and Marcus Hensel. “Introduction: A Marvel of Monsters.” Primary Sources on Monsters: Demonstrare Volume Two. Eds. Asa Simon Mittman and Marcus Hensel. Leeds: Arc Humanities P, 2018. 1-6. Peacock, Colin. “Expert Says PR Needs an Ethical Upgrade.” Radio New Zealand 22 Sep. 2019. 7 July 2021 <https://www.rnz.co.nz/national/programmes/mediawatch/audio/2018713710/expert-says-pr-needs-an-ethical-upgrade\ >. Pompper, Donnalyn. “Interrogating Inequalities Perpetuated in a Feminized Field: Using Critical Race Theory and the Intersectionality Lens to Render Visible That Which Should Not Be Disaggregated.” Gender and Public Relations: Critical Perspectives on Voice, Image and Identity. Eds. Christine Daymon and Kristin Demetrious. London: Routledge, 2013. 67-86. Public Relations Institute of New Zealand. Code of Ethics. 14 March 2021. <https://prinz.org.nz/wp-content/uploads/2020/11/PRINZ-Code-of-Ethics-2020.pdf>. Scandal. Created by Shonda Rimes. ABC Studios, 2012-2018 Sex and the City. Created by Darren Starr. HBO Entertainment, 1998-2004. Schitt’s Creek. Created by Eugene and Dan Levy. Not a Real Company Productions, 2015-2020. Schauster, Erin, Marlene S. Neill, Patrick Ferrucci, and Edson Tandoc. “Public Relations Primed: An Update on Practitioners’ Moral Reasoning, from Moral Development to Moral Maintenance.” Journal of Media Ethics 35.3 (2019): 164-79. Shrun, L.J. “Processing Strategy Moderates the Cultivation Effect.” Human Communication Research 27.1 (2001): 94-120. Sissons, Helen. “Lifting the Veil on the PRP-Client Relationship.” Public Relations Inquiry 4.3 (2015): 263-86. Topić, Martina, Maria Joäo Chunha, Amelia Reigstad, Alenka Jele-Sanchez, and Ángeles Moreno. “Women in Public Relations (1982-2019).” Journal of Communication Management 24.4 (2020): 391-407. 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A same-but-different dichotomy has recently been encapsulated within the US Food and Drug Administration’s ill-defined concept of “substantial equivalence” (USFDA, FDA). By invoking this concept the genetically modified organism (GMO) industry has escaped the rigors of safety testing that might otherwise apply. The curious concept of “substantial equivalence” grants a presumption of safety to GMO food. This presumption has yet to be earned, and has been used to constrain labelling of both GMO and non-GMO food. It is an idea that well serves corporatism. It enables the claim of difference to secure patent protection, while upholding the contrary claim of sameness to avoid labelling and safety scrutiny. It offers the best of both worlds for corporate food entrepreneurs, and delivers the worst of both worlds to consumers. The term “substantial equivalence” has established its currency within the GMO discourse. As the opportunities for patenting food technologies expand, the GMO recruitment of this concept will likely be a dress rehearsal for the developing debates on the labelling and testing of other techno-foods – including nano-foods and clone-foods. “Substantial Equivalence” “Are the Seven Commandments the same as they used to be, Benjamin?” asks Clover in George Orwell’s “Animal Farm”. By way of response, Benjamin “read out to her what was written on the wall. There was nothing there now except a single Commandment. It ran: ALL ANIMALS ARE EQUAL BUT SOME ANIMALS ARE MORE EQUAL THAN OTHERS”. After this reductionist revelation, further novel and curious events at Manor Farm, “did not seem strange” (Orwell, ch. X). Equality is a concept at the very core of mathematics, but beyond the domain of logic, equality becomes a hotly contested notion – and the domain of food is no exception. A novel food has a regulatory advantage if it can claim to be the same as an established food – a food that has proven its worth over centuries, perhaps even millennia – and thus does not trigger new, perhaps costly and onerous, testing, compliance, and even new and burdensome regulations. On the other hand, such a novel food has an intellectual property (IP) advantage only in terms of its difference. And thus there is an entrenched dissonance for newly technologised foods, between claiming sameness, and claiming difference. The same/different dilemma is erased, so some would have it, by appeal to the curious new dualist doctrine of “substantial equivalence” whereby sameness and difference are claimed simultaneously, thereby creating a win/win for corporatism, and a loss/loss for consumerism. This ground has been pioneered, and to some extent conquered, by the GMO industry. The conquest has ramifications for other cryptic food technologies, that is technologies that are invisible to the consumer and that are not evident to the consumer other than via labelling. Cryptic technologies pertaining to food include GMOs, pesticides, hormone treatments, irradiation and, most recently, manufactured nano-particles introduced into the food production and delivery stream. Genetic modification of plants was reported as early as 1984 by Horsch et al. The case of Diamond v. Chakrabarty resulted in a US Supreme Court decision that upheld the prior decision of the US Court of Customs and Patent Appeal that “the fact that micro-organisms are alive is without legal significance for purposes of the patent law”, and ruled that the “respondent’s micro-organism plainly qualifies as patentable subject matter”. This was a majority decision of nine judges, with four judges dissenting (Burger). It was this Chakrabarty judgement that has seriously opened the Pandora’s box of GMOs because patenting rights makes GMOs an attractive corporate proposition by offering potentially unique monopoly rights over food. The rear guard action against GMOs has most often focussed on health repercussions (Smith, Genetic), food security issues, and also the potential for corporate malfeasance to hide behind a cloak of secrecy citing commercial confidentiality (Smith, Seeds). Others have tilted at the foundational plank on which the economics of the GMO industry sits: “I suggest that the main concern is that we do not want a single molecule of anything we eat to contribute to, or be patented and owned by, a reckless, ruthless chemical organisation” (Grist 22). The GMO industry exhibits bipolar behaviour, invoking the concept of “substantial difference” to claim patent rights by way of “novelty”, and then claiming “substantial equivalence” when dealing with other regulatory authorities including food, drug and pesticide agencies; a case of “having their cake and eating it too” (Engdahl 8). This is a clever slight-of-rhetoric, laying claim to the best of both worlds for corporations, and the worst of both worlds for consumers. Corporations achieve patent protection and no concomitant specific regulatory oversight; while consumers pay the cost of patent monopolization, and are not necessarily apprised, by way of labelling or otherwise, that they are purchasing and eating GMOs, and thereby financing the GMO industry. The lemma of “substantial equivalence” does not bear close scrutiny. It is a fuzzy concept that lacks a tight testable definition. It is exactly this fuzziness that allows lots of wriggle room to keep GMOs out of rigorous testing regimes. Millstone et al. argue that “substantial equivalence is a pseudo-scientific concept because it is a commercial and political judgement masquerading as if it is scientific. It is moreover, inherently anti-scientific because it was created primarily to provide an excuse for not requiring biochemical or toxicological tests. It therefore serves to discourage and inhibit informative scientific research” (526). “Substantial equivalence” grants GMOs the benefit of the doubt regarding safety, and thereby leaves unexamined the ramifications for human consumer health, for farm labourer and food-processor health, for the welfare of farm animals fed a diet of GMO grain, and for the well-being of the ecosystem, both in general and in its particularities. “Substantial equivalence” was introduced into the food discourse by an Organisation for Economic Co-operation and Development (OECD) report: “safety evaluation of foods derived by modern biotechnology: concepts and principles”. It is from this document that the ongoing mantra of assumed safety of GMOs derives: “modern biotechnology … does not inherently lead to foods that are less safe … . Therefore evaluation of foods and food components obtained from organisms developed by the application of the newer techniques does not necessitate a fundamental change in established principles, nor does it require a different standard of safety” (OECD, “Safety” 10). This was at the time, and remains, an act of faith, a pro-corporatist and a post-cautionary approach. The OECD motto reveals where their priorities lean: “for a better world economy” (OECD, “Better”). The term “substantial equivalence” was preceded by the 1992 USFDA concept of “substantial similarity” (Levidow, Murphy and Carr) and was adopted from a prior usage by the US Food and Drug Agency (USFDA) where it was used pertaining to medical devices (Miller). Even GMO proponents accept that “Substantial equivalence is not intended to be a scientific formulation; it is a conceptual tool for food producers and government regulators” (Miller 1043). And there’s the rub – there is no scientific definition of “substantial equivalence”, no scientific test of proof of concept, and nor is there likely to be, since this is a ‘spinmeister’ term. And yet this is the cornerstone on which rests the presumption of safety of GMOs. Absence of evidence is taken to be evidence of absence. History suggests that this is a fraught presumption. By way of contrast, the patenting of GMOs depends on the antithesis of assumed ‘sameness’. Patenting rests on proven, scrutinised, challengeable and robust tests of difference and novelty. Lightfoot et al. report that transgenic plants exhibit “unexpected changes [that] challenge the usual assumptions of GMO equivalence and suggest genomic, proteomic and metanomic characterization of transgenics is advisable” (1). GMO Milk and Contested Labelling Pesticide company Monsanto markets the genetically engineered hormone rBST (recombinant Bovine Somatotropin; also known as: rbST; rBGH, recombinant Bovine Growth Hormone; and the brand name Prosilac) to dairy farmers who inject it into their cows to increase milk production. This product is not approved for use in many jurisdictions, including Europe, Australia, New Zealand, Canada and Japan. Even Monsanto accepts that rBST leads to mastitis (inflammation and pus in the udder) and other “cow health problems”, however, it maintains that “these problems did not occur at rates that would prohibit the use of Prosilac” (Monsanto). A European Union study identified an extensive list of health concerns of rBST use (European Commission). The US Dairy Export Council however entertain no doubt. In their background document they ask “is milk from cows treated with rBST safe?” and answer “Absolutely” (USDEC). Meanwhile, Monsanto’s website raises and answers the question: “Is the milk from cows treated with rbST any different from milk from untreated cows? No” (Monsanto). Injecting cows with genetically modified hormones to boost their milk production remains a contested practice, banned in many countries. It is the claimed equivalence that has kept consumers of US dairy products in the dark, shielded rBST dairy farmers from having to declare that their milk production is GMO-enhanced, and has inhibited non-GMO producers from declaring their milk as non-GMO, non rBST, or not hormone enhanced. This is a battle that has simmered, and sometimes raged, for a decade in the US. Finally there is a modest victory for consumers: the Pennsylvania Department of Agriculture (PDA) requires all labels used on milk products to be approved in advance by the department. The standard issued in October 2007 (PDA, “Standards”) signalled to producers that any milk labels claiming rBST-free status would be rejected. This advice was rescinded in January 2008 with new, specific, department-approved textual constructions allowed, and ensuring that any “no rBST” style claim was paired with a PDA-prescribed disclaimer (PDA, “Revised Standards”). However, parsimonious labelling is prohibited: No labeling may contain references such as ‘No Hormones’, ‘Hormone Free’, ‘Free of Hormones’, ‘No BST’, ‘Free of BST’, ‘BST Free’,’No added BST’, or any statement which indicates, implies or could be construed to mean that no natural bovine somatotropin (BST) or synthetic bovine somatotropin (rBST) are contained in or added to the product. (PDA, “Revised Standards” 3) Difference claims are prohibited: In no instance shall any label state or imply that milk from cows not treated with recombinant bovine somatotropin (rBST, rbST, RBST or rbst) differs in composition from milk or products made with milk from treated cows, or that rBST is not contained in or added to the product. If a product is represented as, or intended to be represented to consumers as, containing or produced from milk from cows not treated with rBST any labeling information must convey only a difference in farming practices or dairy herd management methods. (PDA, “Revised Standards” 3) The PDA-approved labelling text for non-GMO dairy farmers is specified as follows: ‘From cows not treated with rBST. No significant difference has been shown between milk derived from rBST-treated and non-rBST-treated cows’ or a substantial equivalent. Hereinafter, the first sentence shall be referred to as the ‘Claim’, and the second sentence shall be referred to as the ‘Disclaimer’. (PDA, “Revised Standards” 4) It is onto the non-GMO dairy farmer alone, that the costs of compliance fall. These costs include label preparation and approval, proving non-usage of GMOs, and of creating and maintaining an audit trail. In nearby Ohio a similar consumer versus corporatist pantomime is playing out. This time with the Ohio Department of Agriculture (ODA) calling the shots, and again serving the GMO industry. The ODA prescribed text allowed to non-GMO dairy farmers is “from cows not supplemented with rbST” and this is to be conjoined with the mandatory disclaimer “no significant difference has been shown between milk derived from rbST-supplemented and non-rbST supplemented cows” (Curet). These are “emergency rules”: they apply for 90 days, and are proposed as permanent. Once again, the onus is on the non-GMO dairy farmers to document and prove their claims. GMO dairy farmers face no such governmental requirements, including no disclosure requirement, and thus an asymmetric regulatory impost is placed on the non-GMO farmer which opens up new opportunities for administrative demands and technocratic harassment. Levidow et al. argue, somewhat Eurocentrically, that from its 1990s adoption “as the basis for a harmonized science-based approach to risk assessment” (26) the concept of “substantial equivalence” has “been recast in at least three ways” (58). It is true that the GMO debate has evolved differently in the US and Europe, and with other jurisdictions usually adopting intermediate positions, yet the concept persists. Levidow et al. nominate their three recastings as: firstly an “implicit redefinition” by the appending of “extra phrases in official documents”; secondly, “it has been reinterpreted, as risk assessment processes have … required more evidence of safety than before, especially in Europe”; and thirdly, “it has been demoted in the European Union regulatory procedures so that it can no longer be used to justify the claim that a risk assessment is unnecessary” (58). Romeis et al. have proposed a decision tree approach to GMO risks based on cascading tiers of risk assessment. However what remains is that the defects of the concept of “substantial equivalence” persist. Schauzu identified that: such decisions are a matter of “opinion”; that there is “no clear definition of the term ‘substantial’”; that because genetic modification “is aimed at introducing new traits into organisms, the result will always be a different combination of genes and proteins”; and that “there is no general checklist that could be followed by those who are responsible for allowing a product to be placed on the market” (2). Benchmark for Further Food Novelties? The discourse, contestation, and debate about “substantial equivalence” have largely focussed on the introduction of GMOs into food production processes. GM can best be regarded as the test case, and proof of concept, for establishing “substantial equivalence” as a benchmark for evaluating new and forthcoming food technologies. This is of concern, because the concept of “substantial equivalence” is scientific hokum, and yet its persistence, even entrenchment, within regulatory agencies may be a harbinger of forthcoming same-but-different debates for nanotechnology and other future bioengineering. The appeal of “substantial equivalence” has been a brake on the creation of GMO-specific regulations and on rigorous GMO testing. The food nanotechnology industry can be expected to look to the precedent of the GMO debate to head off specific nano-regulations and nano-testing. As cloning becomes economically viable, then this may be another wave of food innovation that muddies the regulatory waters with the confused – and ultimately self-contradictory – concept of “substantial equivalence”. Nanotechnology engineers particles in the size range 1 to 100 nanometres – a nanometre is one billionth of a metre. This is interesting for manufacturers because at this size chemicals behave differently, or as the Australian Office of Nanotechnology expresses it, “new functionalities are obtained” (AON). Globally, government expenditure on nanotechnology research reached US$4.6 billion in 2006 (Roco 3.12). While there are now many patents (ETC Group; Roco), regulation specific to nanoparticles is lacking (Bowman and Hodge; Miller and Senjen). The USFDA advises that nano-manufacturers “must show a reasonable assurance of safety … or substantial equivalence” (FDA). A recent inventory of nano-products already on the market identified 580 products. Of these 11.4% were categorised as “Food and Beverage” (WWICS). This is at a time when public confidence in regulatory bodies is declining (HRA). In an Australian consumer survey on nanotechnology, 65% of respondents indicated they were concerned about “unknown and long term side effects”, and 71% agreed that it is important “to know if products are made with nanotechnology” (MARS 22). Cloned animals are currently more expensive to produce than traditional animal progeny. In the course of 678 pages, the USFDA Animal Cloning: A Draft Risk Assessment has not a single mention of “substantial equivalence”. However the Federation of Animal Science Societies (FASS) in its single page “Statement in Support of USFDA’s Risk Assessment Conclusion That Food from Cloned Animals Is Safe for Human Consumption” states that “FASS endorses the use of this comparative evaluation process as the foundation of establishing substantial equivalence of any food being evaluated. It must be emphasized that it is the food product itself that should be the focus of the evaluation rather than the technology used to generate cloned animals” (FASS 1). Contrary to the FASS derogation of the importance of process in food production, for consumers both the process and provenance of production is an important and integral aspect of a food product’s value and identity. Some consumers will legitimately insist that their Kalamata olives are from Greece, or their balsamic vinegar is from Modena. It was the British public’s growing awareness that their sugar was being produced by slave labour that enabled the boycotting of the product, and ultimately the outlawing of slavery (Hochschild). When consumers boycott Nestle, because of past or present marketing practices, or boycott produce of USA because of, for example, US foreign policy or animal welfare concerns, they are distinguishing the food based on the narrative of the food, the production process and/or production context which are a part of the identity of the food. Consumers attribute value to food based on production process and provenance information (Paull). Products produced by slave labour, by child labour, by political prisoners, by means of torture, theft, immoral, unethical or unsustainable practices are different from their alternatives. The process of production is a part of the identity of a product and consumers are increasingly interested in food narrative. It requires vigilance to ensure that these narratives are delivered with the product to the consumer, and are neither lost nor suppressed. Throughout the GM debate, the organic sector has successfully skirted the “substantial equivalence” debate by excluding GMOs from the certified organic food production process. This GMO-exclusion from the organic food stream is the one reprieve available to consumers worldwide who are keen to avoid GMOs in their diet. The organic industry carries the expectation of providing food produced without artificial pesticides and fertilizers, and by extension, without GMOs. Most recently, the Soil Association, the leading organic certifier in the UK, claims to be the first organisation in the world to exclude manufactured nonoparticles from their products (Soil Association). There has been the call that engineered nanoparticles be excluded from organic standards worldwide, given that there is no mandatory safety testing and no compulsory labelling in place (Paull and Lyons). The twisted rhetoric of oxymorons does not make the ideal foundation for policy. Setting food policy on the shifting sands of “substantial equivalence” seems foolhardy when we consider the potentially profound ramifications of globally mass marketing a dysfunctional food. If there is a 2×2 matrix of terms – “substantial equivalence”, substantial difference, insubstantial equivalence, insubstantial difference – while only one corner of this matrix is engaged for food policy, and while the elements remain matters of opinion rather than being testable by science, or by some other regime, then the public is the dupe, and potentially the victim. “Substantial equivalence” has served the GMO corporates well and the public poorly, and this asymmetry is slated to escalate if nano-food and clone-food are also folded into the “substantial equivalence” paradigm. Only in Orwellian Newspeak is war peace, or is same different. It is time to jettison the pseudo-scientific doctrine of “substantial equivalence”, as a convenient oxymoron, and embrace full disclosure of provenance, process and difference, so that consumers are not collateral in a continuing asymmetric knowledge war. References Australian Office of Nanotechnology (AON). Department of Industry, Tourism and Resources (DITR) 6 Aug. 2007. 24 Apr. 2008 < http://www.innovation.gov.au/Section/Innovation/Pages/ AustralianOfficeofNanotechnology.aspx >.Bowman, Diana, and Graeme Hodge. “A Small Matter of Regulation: An International Review of Nanotechnology Regulation.” Columbia Science and Technology Law Review 8 (2007): 1-32.Burger, Warren. “Sidney A. Diamond, Commissioner of Patents and Trademarks v. Ananda M. Chakrabarty, et al.” Supreme Court of the United States, decided 16 June 1980. 24 Apr. 2008 < http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court=US&vol=447&invol=303 >.Curet, Monique. “New Rules Allow Dairy-Product Labels to Include Hormone Info.” The Columbus Dispatch 7 Feb. 2008. 24 Apr. 2008 < http://www.dispatch.com/live/content/business/stories/2008/02/07/dairy.html >.Engdahl, F. William. Seeds of Destruction. Montréal: Global Research, 2007.ETC Group. Down on the Farm: The Impact of Nano-Scale Technologies on Food and Agriculture. Ottawa: Action Group on Erosion, Technology and Conservation, November, 2004. European Commission. Report on Public Health Aspects of the Use of Bovine Somatotropin. Brussels: European Commission, 15-16 March 1999.Federation of Animal Science Societies (FASS). Statement in Support of FDA’s Risk Assessment Conclusion That Cloned Animals Are Safe for Human Consumption. 2007. 24 Apr. 2008 < http://www.fass.org/page.asp?pageID=191 >.Grist, Stuart. “True Threats to Reason.” New Scientist 197.2643 (16 Feb. 2008): 22-23.Hochschild, Adam. Bury the Chains: The British Struggle to Abolish Slavery. London: Pan Books, 2006.Horsch, Robert, Robert Fraley, Stephen Rogers, Patricia Sanders, Alan Lloyd, and Nancy Hoffman. “Inheritance of Functional Foreign Genes in Plants.” Science 223 (1984): 496-498.HRA. Awareness of and Attitudes toward Nanotechnology and Federal Regulatory Agencies: A Report of Findings. Washington: Peter D. Hart Research Associates, 25 Sep. 2007.Levidow, Les, Joseph Murphy, and Susan Carr. “Recasting ‘Substantial Equivalence’: Transatlantic Governance of GM Food.” Science, Technology, and Human Values 32.1 (Jan. 2007): 26-64.Lightfoot, David, Rajsree Mungur, Rafiqa Ameziane, Anthony Glass, and Karen Berhard. “Transgenic Manipulation of C and N Metabolism: Stretching the GMO Equivalence.” American Society of Plant Biologists Conference: Plant Biology, 2000.MARS. “Final Report: Australian Community Attitudes Held about Nanotechnology – Trends 2005-2007.” Report prepared for Department of Industry, Tourism and Resources (DITR). Miranda, NSW: Market Attitude Research Services, 12 June 2007.Miller, Georgia, and Rye Senjen. “Out of the Laboratory and on to Our Plates: Nanotechnology in Food and Agriculture.” Friends of the Earth, 2008. 24 Apr. 2008 < http://nano.foe.org.au/node/220 >.Miller, Henry. “Substantial Equivalence: Its Uses and Abuses.” Nature Biotechnology 17 (7 Nov. 1999): 1042-1043.Millstone, Erik, Eric Brunner, and Sue Mayer. “Beyond ‘Substantial Equivalence’.” Nature 401 (7 Oct. 1999): 525-526.Monsanto. “Posilac, Bovine Somatotropin by Monsanto: Questions and Answers about bST from the United States Food and Drug Administration.” 2007. 24 Apr. 2008 < http://www.monsantodairy.com/faqs/fda_safety.html >.Organisation for Economic Co-operation and Development (OECD). “For a Better World Economy.” Paris: OECD, 2008. 24 Apr. 2008 < http://www.oecd.org/ >.———. “Safety Evaluation of Foods Derived by Modern Biotechnology: Concepts and Principles.” Paris: OECD, 1993.Orwell, George. Animal Farm. Adelaide: ebooks@Adelaide, 2004 (1945). 30 Apr. 2008 < http://ebooks.adelaide.edu.au/o/orwell/george >.Paull, John. “Provenance, Purity and Price Premiums: Consumer Valuations of Organic and Place-of-Origin Food Labelling.” Research Masters thesis, University of Tasmania, Hobart, 2006. 24 Apr. 2008 < http://eprints.utas.edu.au/690/ >.Paull, John, and Kristen Lyons. “Nanotechnology: The Next Challenge for Organics.” Journal of Organic Systems (in press).Pennsylvania Department of Agriculture (PDA). “Revised Standards and Procedure for Approval of Proposed Labeling of Fluid Milk.” Milk Labeling Standards (2.0.1.17.08). Bureau of Food Safety and Laboratory Services, Pennsylvania Department of Agriculture, 17 Jan. 2008. ———. “Standards and Procedure for Approval of Proposed Labeling of Fluid Milk, Milk Products and Manufactured Dairy Products.” Milk Labeling Standards (2.0.1.17.08). Bureau of Food Safety and Laboratory Services, Pennsylvania Department of Agriculture, 22 Oct. 2007.Roco, Mihail. “National Nanotechnology Initiative – Past, Present, Future.” In William Goddard, Donald Brenner, Sergy Lyshevski and Gerald Iafrate, eds. Handbook of Nanoscience, Engineering and Technology. 2nd ed. Boca Raton, FL: CRC Press, 2007.Romeis, Jorg, Detlef Bartsch, Franz Bigler, Marco Candolfi, Marco Gielkins, et al. “Assessment of Risk of Insect-Resistant Transgenic Crops to Nontarget Arthropods.” Nature Biotechnology 26.2 (Feb. 2008): 203-208.Schauzu, Marianna. “The Concept of Substantial Equivalence in Safety Assessment of Food Derived from Genetically Modified Organisms.” AgBiotechNet 2 (Apr. 2000): 1-4.Soil Association. “Soil Association First Organisation in the World to Ban Nanoparticles – Potentially Toxic Beauty Products That Get Right under Your Skin.” London: Soil Association, 17 Jan. 2008. 24 Apr. 2008 < http://www.soilassociation.org/web/sa/saweb.nsf/848d689047 cb466780256a6b00298980/42308d944a3088a6802573d100351790!OpenDocument >.Smith, Jeffrey. Genetic Roulette: The Documented Health Risks of Genetically Engineered Foods. Fairfield, Iowa: Yes! Books, 2007.———. Seeds of Deception. Melbourne: Scribe, 2004.U.S. Dairy Export Council (USDEC). Bovine Somatotropin (BST) Backgrounder. Arlington, VA: U.S. Dairy Export Council, 2006.U.S. Food and Drug Administration (USFDA). Animal Cloning: A Draft Risk Assessment. Rockville, MD: Center for Veterinary Medicine, U.S. Food and Drug Administration, 28 Dec. 2006.———. FDA and Nanotechnology Products. U.S. Department of Health and Human Services, U.S. Food and Drug Administration, 2008. 24 Apr. 2008 < http://www.fda.gov/nanotechnology/faqs.html >.Woodrow Wilson International Center for Scholars (WWICS). “A Nanotechnology Consumer Products Inventory.” Data set as at Sep. 2007. Woodrow Wilson International Center for Scholars, Project on Emerging Technologies, Sep. 2007. 24 Apr. 2008 < http://www.nanotechproject.org/inventories/consumer >.

Photo by National Cancer Institute on Unsplash ABSTRACT Medical professionals sometimes perform intimate tasks while prepping patients for surgical procedures. These tasks may include urinary catheterization, underwear or gown removal, pubic hair removal, and groin sanitization. The intimate nature of these tasks calls for informed consent. Performed without consent, these intimate functions can result in long-term psychological harm. Given the parallels in the arguments for regulating unauthorized sensitive exams, like pelvic exams under anesthesia, policymakers and legislators should expand their efforts to require express consent for all intimate encounters that occur before, during, and after elective medical procedures to protect all patients. INTRODUCTION Healthcare facilities should be safe places where individuals seek healing without fear of assault on their personal dignity, bodily sanctity, autonomy, and humanity. Patients who have undergone non-consensual pelvic, rectal, prostate, and other sensitive exams and procedures – whether for diagnostic or educational purposes – have discovered that this is not always the case after emerging from the experience with a sense of violation and betrayal. Proponents of requiring explicit consent for these invasive exams have likened them to sexual abuse, which disempowers, humiliates, and degrades victims, resulting in long-lasting psychological harm. However, these sensitive exams and procedures are not the only sources of traumatic, unauthorized intimate experiences in medical settings. Indeed, both male and female patients who have endured urinary catheterization, underwear or gown removal that resulted in intimate exposure, pubic hair removal, groin sanitization, and other such intimately invasive preparatory practices without their knowledge or explicit consent have expressed the same sense of bodily violation and psychological harm as patients who have undergone non-consensual sensitive exams. While some patients have no concern over these invasive ancillary procedures, others take issue with medical staff manipulating their private spaces without express consent. This paper explores how to resolve the issues that cause harm in some patients due to nonconsensual intimate tasks associated with procedures. I. Background Some surgeries include prepping private areas of a patient’s body that are not directly involved in the procedure to mitigate contingencies that would require access to veins and arteries.[1] Given that physicians commonly exclude information about prep and that medical staff perform these tasks after anesthesia, some patients may be initially unaware of these intimate functions and have not provided express consent. While the media have begun to share the accounts of individuals, mostly women, who have spoken up about their unwanted medical exams,[2] the voices of those suffering the same psychological harm after experiencing other non-consensual intimate encounters in medical settings have remained largely unheard. Yet, there are some who have shared their accounts anonymously on the website of Medical Patient Modesty (MPM), a non-profit organization that seeks to educate patients about potential privacy issues that may occur in medical settings. A survey of these accounts suggests a wide array of bodily violations. In addition to women, a significant number of men submitted their stories. The following are a few excerpts: [3] “John” from Iowa stated that he was traumatized after discovering that staff had removed the disposable underwear they had given him and clipped his pubic hair while he was sedated for a procedure that involved incisions around his knee. He claimed that nobody ever mentioned his groin. John asserts that medical personnel deceived him into believing they were protecting his bodily privacy by providing him with disposable underwear and then removing it when he was sedated. Jeffrey Fox from Virginia said that he suffers from PTSD as a result of a female nurse clipping his pubic hair for open heart surgery. He noted that staff instructed him not to shave his chest, implying that they would perform the task. But nobody mentioned anything about his groin. Kevin reported that his sister sexually abused him at a young age and that he was retraumatized as an adult when he awakened from hernia surgery to discover that staff had clipped his pubic hair and inserted a urinary catheter without his knowledge or consent. Due to anxiety as a result of trauma from an incident involving genital exposure, RM from Pennsylvania made multiple appeals to the doctor to leave his underwear on during an angiogram centering around his wrist. After the doctor denied his request, he unwillingly relented and ultimately suffered further trauma when staff clipped his pubic hair and left him exposed. RM stated that clipping his pubic hair for a procedure centering around his wrist was “completely unnecessary” and an “unforgivable violation” of his privacy. Beth from Oklahoma submitted an account on behalf of her husband who was traumatized after awakening during hand surgery to discover that staff had stripped him naked. “Man Who Had Carpal Tunnel Surgery” refused to remove his underwear only for staff to take them off after he had been anesthetized. “Lynn” from Mississippi stated that she suffers from PTSD after a dermatologist lifted the waistband of her shorts, peered down, and placed his hand against her groin for the stated purpose of taking her pulse. The event occurred when she was a young girl, and she was retraumatized decades later when medical staff subjected her husband to a similar unwanted intimate encounter while he was sedated for a procedure involving his knee. She says that both she and her husband have suffered a sharp decline in their mental health as a result of their medical experiences. Marie stated that she unsuccessfully appealed to medical staff to leave her underwear on and then was traumatized when they exposed her genitals while positioning her for knee surgery. “Concerned human being” from Kentucky relayed the account of his wife, an RN who had expressed concerns to him over witnessing unnecessary intimate exposure of patients only to find herself on the receiving end of a dignity violation when she awoke after her procedure to fix a tendon in her finger to find staff had removed her gown and laid it across her during transport out of the OR. These accounts are just a few of the first-hand narratives on the MPM website. I do not use them to make assumptions about the scope of the problem. Instead, this paper suggests these narratives are an important source for any advocates for changes that better respect patient dignity. II. Consent It is apparent that medical professionals did not inform these patients of the intimate encounters they would experience. As many attest, patients often begrudgingly remove their underwear when medical professionals instruct them to do so before procedures. Patients such as the ones from the MPM website may not understand why they must remove their underwear and may not wish to ask. Some acquiesce to the requests for underwear removal because they do not wish to reschedule a long-awaited procedure or appointment. Thus, they may experience duress after unsuccessfully appealing to leave their underwear on. While medical professionals may argue that there are medical reasons for these intimate functions, such as access to arteries, these explanations do not account for a lack of consent. Simply declaring that a task or procedure is routine and necessary does not render clinicians' actions ethical or less of a violation.[4] Patients have a right to know if their private areas will be involved at any point during a medical experience so they can determine for themselves if these intimate procedures and tasks are reasonable. Some patients may not agree that underwear removal is essential, that clipping pubic hair and cleansing the groin is necessary, or that urinary catheters are required. Multiple patients from the website appear to share this sentiment and expressed feelings of confusion and distress over the fact that their providers had never informed them of these intimate preparatory tasks. Assuredly, they believe they never truly consented to the experiences medical staff ultimately subjected them to. III. Informed Consent Informed consent is a shared decision-making process by which practitioners discuss the benefits and risks of undergoing or rejecting an invasive procedure. Providers must disclose sufficient information to enable patients to make informed decisions and then document consent in a consent form.[5] Ultimately, clinicians do not know what patients find important. They document consent in a vague form that the medical community can interpret to the disadvantage of patients. But informed consent transcends a signature on a form.[6] As one bioethicist notes regarding intimate medical exams, “Clearly, standard consent forms fail to give patients the granularity they need to properly consent.”[7] I argue that consent forms should name the ancillary intimate tasks that doctors and medical staff plan to perform, especially those that patients might not expect, and when staff will conduct such tasks under anesthesia without the opportunity for patients to verbally consent at the moment. Obtaining informed consent for intimate preparatory steps should be a requirement, just as obtaining informed consent for the procedure is. Consents are a version of waivers that patients present as right holders of their bodies for medical workers to access limited body parts for a limited amount of time.[8] When a violation of this waiver occurs, a patient’s bodily autonomy and sanctity is violated. Informed consent is the cornerstone of patients’ rights, and understanding is the cornerstone of informed consent. A patient can only understand – and consent to – a procedure as a physician explains it. Due to the knowledge asymmetry in medical settings, patients rely on the fiduciary relationship with their physician to safeguard their physical and psychological well-being. To adhere to ethical standards, medical professionals should include details about surgical prep when the tasks required are intimately invasive. For example, medical professionals should disclose tasks like removing undergarments and shaving intimate areas in advance to allow patients to ask any questions about the necessity of those tasks and then properly consent or withhold consent. Deliberately withholding information patients would find important is tantamount to lying because a deceptive person “acts in such a way that the other person can never agree with how she or he is being treated.”[9] Therefore, it is understandable – and expected – that the patients from the MPM website, like individuals who have experienced a non-consensual sensitive medical exam, could feel betrayed. These intimate tasks involved in preparing patients for procedures should be included in the informed consent process. Some ethicists and medical professionals contend that convenience is a reason why providers exclude information about sensitive procedures and suggest that hospitals are concerned that patients would decline procedures if they were aware of ancillary sensitive exams and tasks, prompting them to change their practices.[10] Maggie from the MPM website, who was distressed over learning that an anesthesiologist had administered an amnesiac drug and then discovered from her records that her surgical team consisted mostly of men after her provider assured her beforehand that all the staff would be female, reported that her doctor and hospital responded to her complaints with, “that's why people are sedated. Hospitals/surgeons don't want patients to know what's happening during surgery—it's not necessary. Most patients like you would just object, so sedation helps everyone.”[11] This approach is paternalistic, insulting, and harmful. Performing a procedure after choosing not to seek consent out of fear that a patient would reject it “violates the very concepts of consent, patient autonomy, and individual rights.”[12] IV. Implied Consent Implied consent is another reason why medical community members believe that express consent for preparatory procedures is unnecessary. They allege patients implicitly consent to these tasks when consenting to the general procedure. Implied consent assumes that the patient possesses prior knowledge and expectations that medical personnel could perform a specific task, and thus, there is a presumption of consent. Medical staff are presuming consent, yet patients may feel they have done nothing to imply consent.[13] Not all patients anticipate medical staff accessing intimate areas of their body while prepping for a non-intimate procedure. Relying on implied consent undermines the well-documented right to refuse treatment because of the lack of information. Medical personnel deprive patients like the individuals from the MPM website of the right to determine what happens to their bodies, particularly their most private parts. Assuming that patients have implicitly consented to intimate preparatory tasks for a non-intimate procedure denies them the right to safeguard their bodily sanctity themselves and forces patients to adhere to the provider’s concept of dignity. Relying on implied consent is an abuse of a provider's privileged position of power. Medical harm results from “not only … a physical perpetration but as an act of power of one person over another'' and that “Patients [and] family members [are] burdened…by the thoughtless and insensitive exercise of power."[14] Abusing a privileged position of power creates an intimidating and unwelcoming environment, especially for modest individuals and vulnerable members of society, such as sexual assault victims who are hyper-protective of their bodily privacy, sanctity, and autonomy. In the context of sexual assault, “A sleeping, unconscious, or incompetent person cannot consent.”[15] Federal law, state laws, and university policies address consent, also in the context of sexual assault. For example, the University of Iowa’s sexual misconduct policy defines consent as “knowing, voluntary, and clear permission by word or unambiguous action.”[16] This provides a clear definition of consent as it applies specifically to intimate areas of the body the policy defines as “breasts, buttock, groin, or genitals.” As with sexual consent, patients must be informed of the activity to which they are consenting when they are conscious. Federal and state law, along with university policy that also governs associated teaching hospitals, do not allow implied consent regarding a patient’s private parts in the context of rape or sexual assault. I suggest that they should extend this prohibition on implied consent to medicine, with the exception of emergency situations. Federal and state laws criminalize non-consensual sexual contact either directly or through clothing with intimate areas of the body, specifically the “anus, groin, breast, inner thigh, or buttocks.”[17] Medical professionals would not generally view pre-surgical hair clipping and gown and undergarment removal as sexual in nature. Yet some patients feel otherwise. This paper highlights their perspective rather than assessing the reasonableness of their feelings. I argue that informed consent would protect individuals like those who reported being personally harmed by nonconsensual intimate contact ancillary to medical procedures. Some patients do not think of their private areas in a detached or neutral manner.[18] For example, outside the medical context, research suggests that individuals equate clipping pubic hair to sexual activity.[19] One might argue that in the medical context, the patient may feel hair removal has a sexual aspect, and its removal is a violation. Hair removal is an example of the inability of medical practice to “abstract itself from the culture in which it operates.”[20] Providers cannot expect or force a sudden paradigm shift in how patients view and value their intimate boundaries simply because they enter a medical environment. V. Patient Psychological Harm Malicious intent does not have to be present for a medical professional to inflict damage given that that medical harm is “not necessarily the intention, but the byproduct of action.”[21] The patient narratives cited on the MPM website describe various harms that patients experienced due to ancillary medical tasks that involved exposing or touching intimate body parts for non-intimate procedures. In a study of women undergoing gynecological procedures, a “lack of information given to the patient…and a lack of clearly understood consent” led some women to develop PTSD.[22] I assert that these nonconsensual ancillary tasks evoke similar reactions. Multiple patients from the MPM website expressed feelings of humiliation, embarrassment, and disrespect after staff exposed their genitals, clipped their pubic hair, and inserted a urinary catheter without their prior knowledge. Several patients from the MPM website stated that they had experienced some form of previous intimate violations and were retraumatized by their medical encounters. Lynn’s account, in particular, of second-hand re-traumatization via her husband’s experience illustrates that the damage caused by non-consensual intimate exposure and contact in medical settings is far-reaching. Some argue that medical staff cannot harm the psyche of patients who are anesthetized.[23] The Association of periOperative Registered Nurses (AORN) even notes that “Our current protocol seems to be ‘what they don't know won't hurt them.’"[24] But patients have awakened naked during procedures that began with their underwear and gown on. And the patients from the MPM website relayed a sense of trauma when they learned afterward that a staff member had clipped their pubic hair or inserted a urinary catheter. A patient’s conscious state should not dictate what is ethically appropriate when it comes to viewing and contacting private areas. Studies show that patients who feel violated after they experience nonconsensual intimate exposure and contact have strong convictions regarding their rights and values and ultimately forsake medical care as a result of their concerns.[25] The patients from the MPM website claimed they lost their faith, trust, and respect for the medical community due to their intimate medical experiences. Therefore, the frame of reference should not center around how medical professionals perceive their actions but that patients may feel that nonconsensual intimate encounters are sexual violations.[26] VI. Discussion and Recommendations Some have acknowledged a need to preserve patient modesty and dignity better, resulting in improvements in gown design and the development of surgical undergarments.[27] Additionally, some medical organizations have called for clipping hair only when necessary.[28] However, these improvements would be more effective if all hospitals and doctors followed more rigorous modesty protocols. For instance, providing improved gowns and surgical undergarments to patients is pointless if medical staff remove them without the patient’s knowledge, such as in the case of John. The issue is informed consent. It appears that medical professionals do not need permission to visually and physically access intimate areas of their patients’ bodies. The medical community ignored sustained calls for explicit consent for sensitive medical exams for years.[29] Eventually, public awareness and scrutiny of the issues surrounding non-consensual pelvic, rectal, and other sensitive exams led to an increasing number of states passing laws requiring express consent for pelvic exams and other invasive actions. These and others should consider requiring express consent for all intimate functions, not just exams for the sake of uniformity and consistency. It is understandable that clinicians need to access private areas for serious medical reasons. But medical professionals should explain their rationale, include this information on consent forms, and give patients the opportunity to question their validity and consider all key aspects of a medical procedure – including intimately invasive preparatory functions – prior to consenting. CONCLUSION The core issue patients from the MPM website expressed is a loss of autonomy. From the viewpoint of the patients whose narratives are included on the MPM website, the nonconsensual intimate tasks related to medical procedures caused harm. Patients should be able to learn about all intimate functions that staff may perform while preparing for surgery. The patient would then determine whether to refuse the ancillary task or the entire procedure. While some argue attaining informed consent for such tasks is impractical, I suggest that it is an ethical imperative. When patients undergo intimate tasks that they did not expect, some experience significant psychological harm, sometimes exacerbated by re-traumatization. Another effect is distrust of the medical community. Trust is the foundation of medical care. Patients must have confidence in a provider’s expertise, professionalism, communication, and procedural technique. The loss of any of these elements results in a breakdown of the doctor-patient relationship. Clinicians who touch a patient’s body without proper consent “risk violating the trust that forms the foundation of medical practice.”[30] Patients could forsake important medical care if patients cannot trust members of the medical community to abide by their personal notion of dignity, which includes respecting their intimate boundaries. The goal of this piece is to illustrate the need for explicit consent for intimate, invasive preparatory functions for the benefit of patients and providers alike. - [1] U.F.O. Themes, “Preoperative Skin Preparation.” Nurse Key. July 21, 2016. https://nursekey.com/preoperative-skin-preparation/. [2] L.R. Wilson, C. Tanner, and S.L. Wong, “A New Layer of Informed Consent: Discussions and Documentation Regarding Sensitive Examinations in Surgery,” Annals of Surgery Open: Perspectives of Surgical History, Education, and Clinical Approaches 3 (1): e120, (March 2022). https://doi.org/10.1097/as9.0000000000000120. [3] Bodily Privacy Violation Cases. Medical Patient Modesty. (2023). http://www.patientmodesty.org/modesty.aspx [4] M. Valencia, “Providers Are Sexually Assaulting Patients — and It’s Legal,” Healthline. August 30, 2019. https://www.healthline.com/health/nonconsensual-internal-exams-sexual-assault. [5]B. Murray, “Informed Consent: What Must a Physician Disclose to a Patient?” AMA Journal of Ethics 14 (7): 563–66, (July 2012). https://doi.org/10.1001/virtualmentor.2012.14.7.hlaw1-1207. [6] “Quick Safety 21: Informed Consent: More than Getting a Signature,” (Updated: April 2022). Jointcommission.org. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-21-informed--consent-more-than-getting-a-signature/informed-consent-more-than-getting-a-signature/. [7] L. Bruce, “A Pot Ignored Boils on: Sustained Calls for Explicit Consent of Intimate Medical Exams.” HEC Forum: An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues 32 (2): 125–45, (March 9, 2020). https://doi.org/10.1007/s10730-020-09399-4 [8] P. Friesen, “Educational Pelvic Exams on Anesthetized Women: Why Consent Matters,” Bioethics 32 (5): 298–307, (April 23, 2018). https://doi.org/10.1111/bioe.12441. [9] S.L. Seybold, “Not Just ‘Bodies with Vaginas’: A Kantian Defense of Pelvic Exam Consent Laws,” Bioethics 36 (9): 940–47, (September 6, 2022). https://doi.org/10.1111/bioe.13084 [10] Seybold , “Not Just Bodies with Vaginas,”Bruce, “A Pot Ignored Boils On”; Valencia, “Providers Are Sexually Assaulting Patients;” P. Hsieh, “Pelvic Exams On Anesthetized Women Without Consent: A Troubling And Outdated Practice,” Forbes. (May 14, 2018). https://www.forbes.com/sites/paulhsieh/2018/05/14/pelvic-exams-on-anesthetized-women-without-consent-a-troubling-and-outdated-practice/?sh=7f0b5bcb7846; D. S. Davis, “Pelvic Exams Performed on Anesthetized Women,” AMA Journal of Ethics 5 (5): 193–94, (May 2003). https://doi.org/10.1001/virtualmentor.2003.5.5.oped1-0305. [11] Medical Patient Modesty, “Bodily Privacy Violation Cases,” www.patientmodesty.org/modesty.aspx [12] Hsieh, “Pelvic Exams On Anesthetized Women Without Consent.” [13] Robert M. Veatch “Implied, Presumed and Waived Consent: The Relative Moral Wrongs of Under- and Over-Informing,” The American Journal of Bioethics, 7:12, 39-41, (December 19, 2007). DOI: 10.1080/15265160701710253 (noting differences between implied and presumed consent) [14] J. Shapiro, “Violence’ in Medicine: Necessary and Unnecessary, Intentional and Unintentional,” Philosophy, Ethics, and Humanities in Medicine: PEHM 13 (1), (June 11, 2018). https://doi.org/10.1186/s13010-018-0059-y. [15] “10 U.S. Code § 920 - Art. 120. Rape and Sexual Assault Generally,” n.d. LII / Legal Information Institute. https://www.law.cornell.edu/uscode/text/10/920. [16] “Prohibited Conduct,” n.d. Uiowa.edu. https://opsmanual.uiowa.edu/community-policies/sexual-harassment-and-sexual-misconduct/prohibited-conduct. [17]Department of Justice, “Sexual Assault”; “18 USC 2246: Definitions for Chapter,” n.d. House.gov. https://uscode.house.gov/view.xhtml?req=(title:18%20section:2246%20edition:prelim). [18] Bruce, “A Pot Ignored Boils On.” [19] S. Ramsey, C. Sweeney, M. Fraser, and G. Oades, “Pubic Hair and Sexuality: A Review.” The Journal of Sexual Medicine 6 (8): 2102–10, (August 2009). https://doi.org/10.1111/j.1743-6109.2009.01307.x. [20] Davis, “Pelvic Exams.” [21] Shapiro, “Violence in Medicine.” [22] J. Menage, “Post-Traumatic Stress Disorder in Women Who Have Undergone Obstetric and/or Gyneacological Procedures: A Consecutive Series of 30 Cases of PTSD,” Journal of Reproductive and Infant Psychology 11 (4): 221–28, (December 11, 2007). https://doi.org/10.1080/02646839308403222. [23] Seybold, “Not Just Bodies with Vaginas”; Bruce, “A Pot Ignored Boils On.” [24] D. O’Connor, “We got blasted for June's cover photo. Did we deserve it?” Outpatient Surgery. July 10, 2013. https://www.aorn.org/outpatient-surgery/article/2013-July-editors-page-another-photo-bomb [25] M.C. Jacofsky, R. L. Auran, A. Williams, S. Mauro, and D. Sietsema, “Exposure-Related Anxiety and Improving Patient Satisfaction with Medical Undergarments during Surgery: A Randomized Controlled Trial,” The Journal of Bone and Joint Surgery. American Volume 104 (15): 1380–85, (August 3, 2022). https://doi.org/10.2106/jbjs.22.00126. [26] Bruce, “A Pot Ignored Boils On.” [27] Jacofsky, et. al. “Exposure-Related Anxiety”; P. Arunachalam and B. D’Souza, “Patient-Centered Hospital Gowns: A Novel Redesign of Inpatient Attire to Improve Both the Patient and Provider Experience,” Frontiers in Biomedical Devices 84815 (April 11, 2022),. V001T04A008, https://doi.org/10.1115/dmd2022-1058. [28] C. E. Edmiston Jr, D. Leaper, S. Barnes, H. B. Johnson, M. Barnden, M. Paulson, J. L. Wolfe, K. Truitt, “Revisiting Perioperative Hair Removal Practices.” AORN Journal. (April 26, 2019), https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12662; Association of Surgical Technologists, “AST Standards of Practice for Skin Prep of the Surgical Patient,” n.d,, https://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Skin_Prep.pdf [29] Bruce, “A Pot Ignored Boils on” [30] Friesen, “Why Consent Matters.”

Introduction In an era of upheaval and uncertainty for higher education institutions around the world, scholars, like those in many in other professions, are increasingly using social media to build communities around mutual support and professional development. These communities appear to offer opportunities for participants to exert more positive influence over the types of interactions they engage in with colleagues, in many cases being valued as more altruistic, transformational, or supportive than established academic structures (Gibson, and Gibbs; Mewburn, and Thomson; Maitzen). What has been described as ‘digital scholarship’ applies social media to “different facets of scholarly activity in a helpful and productive way” (Carrigan 5), with online scholarly communities being likened to evolutions of face-to-face practices including peer mentoring (Ferguson, and Wheat) or a “virtual staffroom” (Mewburn, and Thomson). To a large extent, these accounts of scholarly practice adapted for digital media have resonance. From writing groups (O’Dwyer, McDonough, Jefferson, Goff, and Redman-MacLaren) to conference attendance (Spilker, Silva, and Morgado) and funding (Osimo, Priego, and Vuorikari), the transformational possibilities of social media have been applied to almost every facet of existing academic practices. These practices have increasingly attracted scrutiny from higher education institutions, with social media profiles of staff both a potential asset and risk to institutions’ brands. Around the world, institutions use social media for marketing, student recruitment, student support and alumni communication (Palmer). As such, social media policies have emerged in recent years in attempts to ensure staff engage in ways that align with the interests of their employers (Solberg; Carrigan). However, engagement via social media is also still largely considered “supplementary to ‘real’ scholarly work” (Mussell 347).Paralleling this trend, guides to effectively managing an online profile as a component of professional reputation have also become increasingly common (e.g. Carrigan). While public relations and management literatures have approached reputation management in terms of how an organisation is regarded by its multiple stakeholders (Fombrun) this is increasingly being applied to individuals on social media. According to Gandini a “reputation economy” (22) has come to function for knowledge workers who seek to cultivate a reputation as a good community member through sociality in order to secure more (or better) work.The popularity of professional social media communities and scrutiny of participants raises questions about the work involved in building and participating in them. This article explores these questions through analysis of tweets from the first year of #ECRchat, a Twitter group for early career researchers (ECRs). The group was established in 2012 to provide an opportunity for ECRs (typically within five years of PhD completion) to discuss career-related issues. Since it was founded, the group has been administered through partnerships between early career scholars using a Twitter account (@ECRchat) and a blog. Tweets, the posts of 140 characters or fewer, which appear on a user’s profile and in followers’ feeds (Twitter) are organised into a ‘chat’ by participants through the use of the hashtag ‘#ECRchat’. Participants vote on chat topics and take on the role of hosting on a volunteer basis. The explicit career focus of this group provides an ideal case study to explore how work is represented in an online professionally-focused community, in order to reflect on what this might mean for the norms of knowledge work.Digital Labour The impact of Internet Communication Technologies (ICT), including social media, on the lives of workers has long been a source of both concern and hope. Mobile devices, wireless Internet and associated communications software enable increasing numbers of people to take work home. This flexibility has been welcomed as the means by which workers might more successfully access jobs and manage competing commitments (Raja, Imaizumi, Kelly, Narimatsu, and Paradi-Guilford). However, hours worked from home are often unpaid and carry with them a strong likelihood of interfering with rest, recreation and family time (Pocock and Skinner). Melissa Gregg describes this as “presence bleed” (2): the dilutions of focus from everyday activities as workers increasingly use electronic devices to ‘check in’ during non-work time. Moving beyond the limitations of this work-life balance approach, which tends to over-state divisions between employment and other everyday life practices, a growing literature seeks to address work in online environments by analysing the types of labour being practiced, rather than seeing such practices as adjunct to physical workplaces. Responding to claims that digital communication heralds a new age of greater freedom, creativity and democratic participation, this work draws attention to the reliance of such networks on unpaid labour (e.g. Hearn; Hesmondhalgh) with ratings, reviews and relationship maintenance serving business’ economic ends alongside the individual interests which motivate participants. The immaterial, affective, and often precarious labour that has been observed is “simultaneously voluntarily given and unwaged, enjoyed and exploited” (Terranova). This work builds particularly on feminist analysis of work (see McRobbie for a discussion of this), with behind the scenes moderator, convenor, and community builder roles largely female and largely unrecognised, be they activist (Gleeson), creative (Duffy) or consumer (Arcy) groups. For some, this suggests the emergence of a new ‘women’s work’ of affective immaterial labour which goes into building transformational communities (Jarrett). Yet, digital labour has not yet been foregrounded within research into higher education, where it is largely practiced in the messy intersections of employment, unpaid professional development, and leisure. Joyce Goggin argues that convergence of these spheres is a feature of digital labour. Consequently, this article seeks to add a consideration of digital labour, specifically the cultural politics of work that emerge in these spaces, to the literature on digital practices as a translation of existing academic responsibilities online. In the context of widespread concerns over academic workload and job market (Bentley, Coates, Dobson, Goedegebuure, and Meek) and the growing international engagement and impact agenda (Priem, Piwowar, and Hemminger), it raises questions about the implications of these practices. Researching Twitter Communities This article analyses tweets from the publicly available Twitter timeline, containing the hashtag #ECRchat, during scheduled chats, from 1 July 2012 to 31 July 2013 (the first year of operation). Initially, all tweets in this time period were analysed in anonymised form to determine the most commonly mentioned topics during chats. This content analysis removed the most common English language words, such as: the; it; I; and RT (which stands for retweet), which would otherwise appear as top results in almost any content analysis regardless of the community of interest. This was followed by qualitative analysis of tweets, to explore in more depth how important issues were articulated and rationalised within the group. This draws on Catherine Driscoll’s and Melissa Gregg’s idea of “sympathetic online cultural studies” which seeks to explore online communities first and foremost as communities rather than as exemplars of online communications (15-20). Here, a narrative approach was undertaken to analyse how participants curated, made sense of, and explained their own career stories (drawing on Pamphilon). Although I do not claim that participants are representative of all ECRs, or that the ideas given the most attention during chats are representative of the experiences of all participants, representations of work articulated here are suggestive of the kinds of public utterances that were considered reasonable within this open online space. Participants are identified according to the twitter handle and user name they had chosen to use for the chats being analysed. This is because the practical infeasibility of guaranteeing online anonymity (readers need only to Google the text of any tweet to associate it with a particular user, in most cases) and the importance of actively involving participants as agents in the research process, in part by identifying them as authors of their own stories, rather than informants (e.g. Butz; Evans; Svalastog and Eriksson).Representations of Work in #ECRchat The co-creation of the #ECRchat community through participant hosts and community votes on chat topics gave rise to a discussion group that was heavily focused on ‘the work’ of academia, including its importance in the lives of participants, relative appeal over other options, and negative effects on leisure time. I was clear that participants regarded participation as serving their professional interests, despite participation not being paid or formally recognised by employers. With the exception of two discussions focused on making decisions about the future of the group, #ECRchat discussions during the year of analysis focused on topics designed to help participants succeed at work such as “career progression and planning”, “different routes to postdoc funding”, and “collaboration”. At a micro-level, ‘work’ (and related terms) was the most frequently used term in #ECRchat, with its total number of uses (1372) almost double that of research (700), the next most used term. Comments during the chats reiterated this emphasis: “It’s all about the work. Be decent to people and jump through the hoops you need to, but always keep your eyes on the work” (Magennis).The depth of participants’ commitment comes through strongly in discussions comparing academic work with other options: “pretty much everyone I know with ‘real jobs’ hates their work. I feel truly lucky to say that I love mine #ECRchat” (McGettigan). This was seen in particular in the discussion about ‘careers outside academia’. Hashtags such as #altac (referring to alternative-academic careers such as university research support or learning and teaching administration roles) and #postac (referring to PhD holders working outside of universities in research or non-research roles) used both alongside the #ECRchat hashtag and separately, provide an ongoing site of these kinds of representations. While participants in #ECRchat sought to shift this perception and were critically aware that it could lead to undesirable outcomes: “PhDs and ECRs in Humanities don’t seem to consider working outside of academia – that limits their engagement with training #ECRchat” (Faculty of Humanities at the University of Manchester), such discussions frequently describe alternative academic careers as a ‘backup plan’, should academic employment not be found. Additionally, many participants suggested that their working hours were excessive, extending the professional into personal spaces and times in ways that they did not see as positive. This was often described as the only way to achieve success: “I hate to say it, but one of the best ways to improve track record is to work 70+ hours a week, every week. Forever. #ecrchat” (Dunn). One of the key examples of this dynamic was the scheduling of the chat itself. When founded in 2012, #ECRchat ran in the Australian evening and UK morning, eliding the personal/work distinction for both its coordinators and participants. While considerable discussion was concerned with scheduling the chat during times when a large number of international participants could attend, this discussion centred on waking rather than working hours. The use of scheduled tweets and shared work between convenors in different time zones (Australia and the United Kingdom) maintained an around the clock online presence, extending well beyond the ordinary working hours of any individual participant.Personal Disclosure The norms that were articulated in #ECRchat are perhaps not surprising for a group of participants seeking to establish themselves in a profession where a long-hours culture and work-life interference are common (Bentley, Coates, Dobson, Goedegebuure, and Meek). However, what is notable is that participation frequently involved the extension of the personal into the professional and in support of professional aims. In the chat’s first year, an element of personal disclosure and support for others became key to acting as a good community member. Beyond the well-established norms of white collar workers demonstrating professionalism by deploying “courtesy, helpfulness, and kindness” (Mills xvii), this community building relied on personal disclosure which to some extent collapsed personal and professional boundaries.By disclosing individual struggles, anxieties, and past experiences participants contributed to a culture of support. This largely functioned through discussions of work stress rather than leisure: “I definitely don’t have [work-life balance]. I think it’s because I don’t have a routine so work and home constantly blend into one another” (Feely). Arising from these discussions, ideas to help participants better navigate and build academic careers was one of the main ways this community support and concern was practiced: “I think I’m often more productive and less anxious if I'm working on a couple of things in parallel, too #ecrchat” (Brian).Activities such as preparing meals, caring for family, and leisure activities, became part of the discussion. “@snarkyphd Sorry, late, had to deal with toddler. Also new; currently doing casual teaching/industry work & applying for postdocs #ecrchat” (Ronald). Exclusively professional profiles were considered less engaging than the combination of personal and professional that most participants adopted: “@jeanmadams I’ve answered a few queries on ResearchGate, but agree lack of non-work opinions / personality makes them dull #ecrchat” (Tennant). However, this is not to suggest that these networks become indistinguishable from more informal, personal, or leisurely uses of social media: “@networkedres My ‘professional’ online identity is slightly more guarded than my ‘facebook’ id which is for friends and family #ECRchat” (Wheat). Instead, disclosure of certain kinds of work struggles came to function as a positive contribution to a more reflexive professionalism. In the context of work-focused discussion, #ECRchat opens important spaces for scholars to question norms they considered damaging or at least make these tacit norms explicit and receive support to manage them. Affective Labour The professional goals and focus of #ECRchat, combined with the personal support and disclosure that forms the basis for the supportive elements in this group is arguably one of its strongest and most important elements. Mark Carrigan suggests that the practices of revealing something of the struggles we experience could form the basis for a new collegiality, where common experiences which had previously not been discussed publicly are for the first time recognised as systemic, not individual challenges. However, there is work required to provide context and support for these emotional experiences which is largely invisible here, as has typically been the case in other communities. Such ‘affective labour’ “involves the production and manipulation of affect and requires (virtual or actual) human contact, labour in the bodily mode … the labour is immaterial, even if it is corporeal and affective, in the sense that its products are intangible, a feeling of ease, well-being, satisfaction, excitement or passion” (Hardt, and Negri 292). In #ECRchat, this ranges from managing the schedule and organising discussions – which involves following up offers to help, assisting people to understand the task, and then ensuring things go ahead as planned –to support offered by members of the group within discussions. This occurs in the overlaps between personal and professional representations, taking a variety of forms from everyday reassurance, affirmation, and patience: “Sorry to hear - hang in there. Hope you have a good support network. #ECRchat” (Galea) to empathy often articulated alongside the disclosure discussed earlier: “The feeling of guilt over not working sounds VERY familiar! #ecrchat” (Vredeveldt).The point here is not to suggest that this work is not sufficiently valued by participants, or that it does not parallel the kinds of work undertaken in more formal job roles, including in academia, where management, conference convening or participation in professional societies, and teaching, as just a few examples, involve degrees of affective labour. However, as a consequence of the (semi)public nature of these groups, the interactions observed here appear to represent a new inflection of professional reputation work, where, in building online professional communities, individuals peg their professional reputations to these forms of affective labour. Importantly, given the explicitly professional nature of the group, these efforts are not counted as part of the formal workload of those involved, be they employed (temporarily or more securely) inside or outside universities, or not in the paid workforce. Conclusion A growing body of literature demonstrates that online academic communities can provide opportunities for collegiality, professional development, and support: particularly among emerging scholars. These accounts demonstrate the value of digital scholarly practices across a range of academic work. However, this article’s discussion of the work undertaken to build and maintain #ECRchat in its first year suggests that these practices at the messy intersections of employment, unpaid professional development, and leisure constitute a new inflection of professional reputation and service work. This work involves publicly building a reputation as a good community member through a combination of personal disclosure and affective labour.In the context of growing emphasis on the economic, social, and other impacts of academic research and concerns over work intensification, this raises questions about possible scope for, and impact of, formal recognition of digital academic labour. While institutions’ work planning and promotion processes may provide opportunities to recognise work developing professional societies or conferences as a leadership or service to a discipline, this new digital service work remains outside the purview of such recognition and reward systems. Further research into the relationships between academic reputation and digital labour will be needed to explore the implications of this for institutions and academics alike. 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IntroductionDespite claims that the importance of distance has been reduced due to technological and communications improvements (Cairncross; Friedman; O’Brien), the ‘power of place’ still resonates, often intensifying the role of geography (Christopherson et al.; Morgan; Pratt; Scott and Storper). Within the film industry, there has been a decentralisation of production from Hollywood, but there remains a spatial logic which has preferenced particular centres, such as Toronto, Vancouver, Sydney and Prague often led by a combination of incentives (Christopherson and Storper; Goldsmith and O’Regan; Goldsmith et al.; Miller et al.; Mould). The emergence of high end television, television programming for which the production budget is more than £1 million per television hour, has presented new opportunities for screen hubs sharing a very similar value chain to the film industry (OlsbergSPI with Nordicity).In recent years, interventions have proliferated with the aim of capitalising on the decentralisation of certain activities in order to attract international screen industries production and embed it within local hubs. Tools for building capacity and expertise have proliferated, including support for studio complex facilities, infrastructural investments, tax breaks and other economic incentives (Cucco; Goldsmith and O’Regan; Jensen; Goldsmith et al.; McDonald; Miller et al.; Mould). Yet experience tells us that these will not succeed everywhere. There is a need for a better understanding of both the capacity for places to build a distinctive and competitive advantage within a highly globalised landscape and the relative merits of alternative interventions designed to generate a sustainable production base.This article first sets out the rationale for the appetite identified in the screen industries for co-location, or clustering and concentration in a tightly drawn physical area, in global hubs of production. It goes on to explore the latest trends of decentralisation and examines the upturn in interventions aimed at attracting mobile screen industries capital and labour. Finally it introduces the Scottish screen industries and explores some of the ways in which Scotland has sought to position itself as a recipient of screen industries activity. The paper identifies some key gaps in infrastructure, most notably a studio, and calls for closer examination of the essential ingredients of, and possible interventions needed for, a vibrant and sustainable industry.A Compulsion for ProximityIt has been argued that particular spatial and place-based factors are central to the development and organisation of the screen industries. The film and television sector, the particular focus of this article, exhibit an extraordinarily high degree of spatial agglomeration, especially favouring centres with global status. It is worth noting that the computer games sector, not explored in this article, slightly diverges from this trend displaying more spatial patterns of decentralisation (Vallance), although key physical hubs of activity have been identified (Champion). Creative products often possess a cachet that is directly associated with their point of origin, for example fashion from Paris, films from Hollywood and country music from Nashville – although it can also be acknowledged that these are often strategic commercial constructions (Pecknold). The place of production represents a unique component of the final product as well as an authentication of substantive and symbolic quality (Scott, “Creative cities”). Place can act as part of a brand or image for creative industries, often reinforcing the advantage of being based in particular centres of production.Very localised historical, cultural, social and physical factors may also influence the success of creative production in particular places. Place-based factors relating to the built environment, including cheap space, public-sector support framework, connectivity, local identity, institutional environment and availability of amenities, are seen as possible influences in the locational choices of creative industry firms (see, for example, Drake; Helbrecht; Hutton; Leadbeater and Oakley; Markusen).Employment trends are notoriously difficult to measure in the screen industries (Christopherson, “Hollywood in decline?”), but the sector does contain large numbers of very small firms and freelancers. This allows them to be flexible but poses certain problems that can be somewhat offset by co-location. The findings of Antcliff et al.’s study of workers in the audiovisual industry in the UK suggested that individuals sought to reconstruct stable employment relations through their involvement in and use of networks. The trust and reciprocity engendered by stable networks, built up over time, were used to offset the risk associated with the erosion of stable employment. These findings are echoed by a study of TV content production in two media regions in Germany by Sydow and Staber who found that, although firms come together to work on particular projects, typically their business relations extend for a much longer period than this. Commonly, firms and individuals who have worked together previously will reassemble for further project work aided by their past experiences and expectations.Co-location allows the development of shared structures: language, technical attitudes, interpretative schemes and ‘communities of practice’ (Bathelt, et al.). Grabher describes this process as ‘hanging out’. Deep local pools of creative and skilled labour are advantageous both to firms and employees (Reimer et al.) by allowing flexibility, developing networks and offsetting risk (Banks et al.; Scott, “Global City Regions”). For example in Cook and Pandit’s study comparing the broadcasting industry in three city-regions, London was found to be hugely advantaged by its unrivalled talent pool, high financial rewards and prestigious projects. As Barnes and Hutton assert in relation to the wider creative industries, “if place matters, it matters most to them” (1251). This is certainly true for the screen industries and their spatial logic points towards a compulsion for proximity in large global hubs.Decentralisation and ‘Sticky’ PlacesDespite the attraction of global production hubs, there has been a decentralisation of screen industries from key centres, starting with the film industry and the vertical disintegration of Hollywood studios (Christopherson and Storper). There are instances of ‘runaway production’ from the 1920s onwards with around 40 per cent of all features being accounted for by offshore production in 1960 (Miller et al., 133). This trend has been increasing significantly in the last 20 years, leading to the genesis of new hubs of screen activity such as Toronto, Vancouver, Sydney and Prague (Christopherson, “Project work in context”; Goldsmith et al.; Mould; Miller et al.; Szczepanik). This development has been prompted by a multiplicity of reasons including favourable currency value differentials and economic incentives. Subsidies and tax breaks have been offered to secure international productions with most countries demanding that, in order to qualify for tax relief, productions have to spend a certain amount of their budget within the local economy, employ local crew and use domestic creative talent (Hill). Extensive infrastructure has been developed including studio complexes to attempt to lure productions with the advantage of a full service offering (Goldsmith and O’Regan).Internationally, Canada has been the greatest beneficiary of ‘runaway production’ with a state-led enactment of generous film incentives since the late 1990s (McDonald). Vancouver and Toronto are the busiest locations for North American Screen production after Los Angeles and New York, due to exchange rates and tax rebates on labour costs (Miller et al., 141). 80% of Vancouver’s production is attributable to runaway production (Jensen, 27) and the city is considered by some to have crossed a threshold as:It now possesses sufficient depth and breadth of talent to undertake the full array of pre-production, production and post-production services for the delivery of major motion pictures and TV programmes. (Barnes and Coe, 19)Similarly, Toronto is considered to have established a “comprehensive set of horizontal and vertical media capabilities” to ensure its status as a “full function media centre” (Davis, 98). These cities have successfully engaged in entrepreneurial activity to attract production (Christopherson, “Project Work in Context”) and in Vancouver the proactive role of provincial government and labour unions are, in part, credited with its success (Barnes and Coe). Studio-complex infrastructure has also been used to lure global productions, with Toronto, Melbourne and Sydney all being seen as key examples of where such developments have been used as a strategic priority to take local production capacity to the next level (Goldsmith and O’Regan).Studies which provide a historiography of the development of screen-industry hubs emphasise a complex interplay of social, cultural and physical conditions. In the complex and global flows of the screen industries, ‘sticky’ hubs have emerged with the ability to attract and retain capital and skilled labour. Despite being principally organised to attract international production, most studio complexes, especially those outside of global centres need to have a strong relationship to local or national film and television production to ensure the sustainability and depth of the labour pool (Goldsmith and O’Regan, 2003). Many have a broadcaster on site as well as a range of companies with a media orientation and training facilities (Goldsmith and O’Regan, 2003; Picard, 2008). The emergence of film studio complexes in the Australian Gold Coast and Vancouver was accompanied by an increasing role for television production and this multi-purpose nature was important for the continuity of production.Fostering a strong community of below the line workers, such as set designers, locations managers, make-up artists and props manufacturers, can also be a clear advantage in attracting international productions. For example at Cinecitta in Italy, the expertise of set designers and experienced crews in the Barrandov Studios of Prague are regarded as major selling points of the studio complexes there (Goldsmith and O’Regan; Miller et al.; Szczepanik). Natural and built environments are also considered very important for film and television firms and it is a useful advantage for capturing international production when cities can double for other locations as in the cases of Toronto, Vancouver, Prague for example (Evans; Goldsmith and O’Regan; Szczepanik). Toronto, for instance, has doubled for New York in over 100 films and with regard to television Due South’s (1994-1998) use of Toronto as Chicago was estimated to have saved 40 per cent in costs (Miller et al., 141).The Scottish Screen Industries Within mobile flows of capital and labour, Scotland has sought to position itself as a recipient of screen industries activity through multiple interventions, including investment in institutional frameworks, direct and indirect economic subsidies and the development of physical infrastructure. Traditionally creative industry activity in the UK has been concentrated in London and the South East which together account for 43% of the creative economy workforce (Bakhshi et al.). In order, in part to redress this imbalance and more generally to encourage the attraction and retention of international production a range of policies have been introduced focused on the screen industries. A revised Film Tax Relief was introduced in 2007 to encourage inward investment and prevent offshoring of indigenous production, and this has since been extended to high-end television, animation and children’s programming. Broadcasting has also experienced a push for decentralisation led by public funding with a responsibility to be regionally representative. The BBC (“BBC Annual Report and Accounts 2014/15”) is currently exceeding its target of 50% network spend outside London by 2016, with 17% spent in Scotland, Wales and Northern Ireland. Channel 4 has similarly committed to commission at least 9% of its original spend from the nations by 2020. Studios have been also developed across the UK including at Roath Lock (Cardiff), Titanic Studios (Belfast), MedicaCity (Salford) and The Sharp Project (Manchester).The creative industries have been identified as one of seven growth sectors for Scotland by the government (Scottish Government). In 2010, the film and video sector employed 3,500 people and contributed £120 million GVA and £120 million adjusted GVA to the economy and the radio and TV sector employed 3,500 people and contributed £50 million GVA and £400 million adjusted GVA (The Scottish Parliament). Beyond the direct economic benefits of sectors, the on-screen representation of Scotland has been claimed to boost visitor numbers to the country (EKOS) and high profile international film productions have been attracted including Skyfall (2012) and WWZ (2013).Scotland has historically attracted international film and TV productions due to its natural locations (VisitScotland) and on average, between 2009-2014, six big budget films a year used Scottish locations both urban and rural (BOP Consulting, 2014). In all, a total of £20 million was generated by film-making in Glasgow during 2011 (Balkind) with WWZ (2013) and Cloud Atlas (2013), representing Philadelphia and San Francisco respectively, as well as doubling for Edinburgh for the recent acclaimed Scottish films Filth (2013) and Sunshine on Leith (2013). Sanson (80) asserts that the use of the city as a site for international productions not only brings in direct revenue from production money but also promotes the city as a “fashionable place to live, work and visit. Creativity makes the city both profitable and ‘cool’”.Nonetheless, issues persist and it has been suggested that Scotland lacks a stable and sustainable film industry, with low indigenous production levels and variable success from year to year in attracting inward investment (BOP Consulting). With regard to crew, problems with an insufficient production base have been identified as an issue in maintaining a pipeline of skills (BOP Consulting). Developing ‘talent’ is a central aspect of the Scottish Government’s Strategy for the Creative Industries, yet there remains the core challenge of retaining skills and encouraging new talent into the industry (BOP Consulting).With regard to film, a lack of substantial funding incentives and the absence of a studio have been identified as a key concern for the sector. For example, within the film industry the majority of inward investment filming in Scotland is location work as it lacks the studio facilities that would enable it to sustain a big-budget production in its entirety (BOP Consulting). The absence of such infrastructure has been seen as contributing to a drain of Scottish talent from these industries to other areas and countries where there is a more vibrant sector (BOP Consulting). The loss of Scottish talent to Northern Ireland was attributed to the longevity of the work being provided by Games of Thrones (2011-) now having completed its six series at the Titanic Studios in Belfast (EKOS) although this may have been stemmed somewhat recently with the attraction of US high-end TV series Outlander (2014-) which has been based at Wardpark in Cumbernauld since 2013.Television, both high-end production and local broadcasting, appears crucial to the sustainability of screen production in Scotland. Outlander has been estimated to contribute to Scotland’s production spend figures reaching a historic high of £45.8 million in 2014 (Creative Scotland ”Creative Scotland Screen Strategy Update”). The arrival of the program has almost doubled production spend in Scotland, offering the chance for increased stability for screen industries workers. Qualifying for UK High-End Television Tax Relief, Outlander has engaged a crew of approximately 300 across props, filming and set build, and cast over 2,000 supporting artist roles from within Scotland and the UK.Long running drama, in particular, offers key opportunities for both those cutting their teeth in the screen industries and also by providing more consistent and longer-term employment to existing workers. BBC television soap River City (2002-) has been identified as a key example of such an opportunity and the programme has been credited with providing a springboard for developing the skills of local actors, writers and production crew (Hibberd). This kind of pipeline of production is critical given the work patterns of the sector. According to Creative Skillset, of the 4,000 people in Scotland are employed in the film and television industries, 40% of television workers are freelance and 90% of film production work in freelance (EKOS).In an attempt to address skills gaps, the Outlander Trainee Placement Scheme has been devised in collaboration with Creative Scotland and Creative Skillset. During filming of Season One, thirty-eight trainees were supported across a range of production and craft roles, followed by a further twenty-five in Season Two. Encouragingly Outlander, and the books it is based on, is set in Scotland so the authenticity of place has played a strong component in the decision to locate production there. Producer David Brown began his career on Bill Forsyth films Gregory’s Girl (1981), Local Hero (1983) and Comfort and Joy (1984) and has a strong existing relationship to Scotland. He has been very vocal in his support for the trainee program, contending that “training is the future of our industry and we at Outlander see the growth of talent and opportunities as part of our mission here in Scotland” (“Outlander fast tracks next generation of skilled screen talent”).ConclusionsThis article has aimed to explore the relationship between place and the screen industries and, taking Scotland as its focus, has outlined a need to more closely examine the ways in which the sector can be supported. Despite the possible gains in terms of building a sustainable industry, the state-led funding of the global screen industries is contested. The use of tax breaks and incentives has been problematised and critiques range from use of public funding to attract footloose media industries to the increasingly zero sum game of competition between competing places (Morawetz; McDonald). In relation to broadcasting, there have been critiques of a ‘lift and shift’ approach to policy in the UK, with TV production companies moving to the nations and regions temporarily to meet the quota and leaving once a production has finished (House of Commons). Further to this, issues have been raised regarding how far such interventions can seed and develop a rich production ecology that offers opportunities for indigenous talent (Christopherson and Rightor).Nonetheless recent success for the screen industries in Scotland can, at least in part, be attributed to interventions including increased decentralisation of broadcasting and the high-end television tax incentives. This article has identified gaps in infrastructure which continue to stymie growth and have led to production drain to other centres. 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Photo 190773207 / Transplant Medicine © Victor Moussa | Dreamstime.com ABSTRACT Xenotransplant research offers hope to individuals waiting for vital organ transplants. Nascent first-in-human xenotransplantation research trials present unique ethical challenges which may translate into obligations for researchers and special considerations for institutional review boards (IRBs). Contextual vulnerability is an important consideration in reviewing proposed subject selection methods. Some recipients are uniquely prone to receiving an unfair offer to enroll in an experimental clinical trial when excluded from allograft waitlists due to psychosocial or compliance evaluations. These exclusions represent an allocational injustice. Enrolling research subjects subjectively excluded from allotransplantation into xenotransplant research is not a mechanism of fair access but rather an exploitation of an unjustly option-constrained vulnerable group by the clinical transplant system. Carefully considering contextual vulnerability can help researchers and IRBs clarify eligibility criteria for xenograft clinical trials. A requirement for simultaneous allograft co-listing can safeguard the interests of vulnerable potential subjects. INTRODUCTION In the United States, the supply of allogeneic, or human-derived, organs and tissues from living donors and cadavers available for transplant into critically ill individuals is inadequate.[i] Physicians refer only half of potentially eligible patients for transplant evaluation, and the clinical transplant team ultimately waitlists less than 30 percent.[ii] Waitlists are lengthy for those who make it through the evaluation process, and many individuals die while waiting for a transplant.[iii] In contrast to allogeneic transplants, xenotransplantation, from the prefix, xeno- meaning foreign, is the process of taking live organs or tissues from an animal for surgical placement into a human recipient. Xenografts are typically sourced from porcine animals (domestic pigs) or non-human primates (baboons) and range from simple tissues like corneas to complex vital organs like hearts, lungs, or kidneys. Scientists have explored xenotransplantation methods for decades, but research with vital organ xenotransplants has been in largely haphazard and non-controlled studies, which demonstrated only short-duration survival for recipients.[iv] Recent advances using gene modification and improved immunosuppression in single-patient attempts to transplant porcine organs into brain-dead human recipients have presented more realistic human-environment models; however, these modified xenografts have still functioned only for very short durations.[v] The limited bioethics discourse on xenotransplantation centers primarily on the ethical use of high-order animals and the risks of zoonotic infectious disease spread.[vi] Bioethics pays insufficient attention to the potential for exploitation of vulnerable individuals in need of a transplant amid growing interest in phase I clinical trials in living human subjects. Clinician-investigators in contemporary literature repeatedly recommend that these trials enroll subjects who are medically eligible for, but effectively excluded or outright denied access to, an allograft.[vii] The Food & Drug Administration (FDA) recommends xenotransplants be limited to subjects with serious or life-threatening diseases for whom adequately safe and effective alternative therapies are not available.[viii] The ethically salient difference between the investigator and the regulatory recommendations is why alternatives are not available to potential subjects: because transplant centers have subjectively denied access or because there is a clinical contraindication that proves prohibitively risky. In a notable single-patient emergency use authorization, physician-investigators offered a genetically modified porcine heart to a living male recipient after denying him access to the waitlist for a human-donor heart, citing a history of non-compliance.[ix] This case suggests that a person denied access to a transplant waitlist due to subjective compliance criteria is an appropriate research subject. The physician-investigators failed to acknowledge how offering a xenotransplant to a contextually vulnerable subject is potentially unfair. Contextual vulnerability is a specific feature of a research environment that increases a subject’s risk of harm. Bioethics discourse must address this vulnerability within the transplant research environment. This paper describes the current transplant system’s use of subjective evaluation criteria, particularly psychosocial support and compliance. Subjective evaluation criteria perpetuate discriminatory medical biases rather than advance the transplant system’s goal of additional life-years gained. Researchers designing controlled human subject trials and institutional review boards (IRBs) reviewing and approving proposed protocols must consider how disparate waitlisting practices unjustly preclude some patients from a fair opportunity to access an allograft and impacts their participation in research. It is unethical for physician-investigators to intentionally take advantage of this vulnerability, creating an exploitative and unethical transaction.[x] Protocol inclusion criteria requiring proof of simultaneous allograft listing is a feasible procedural safeguard to protect research subjects’ interests. I. Injustices in Organ Allocation Solid organ allocation systems are varied but aim for equity and efficiency in granting individuals with similar claims a fair opportunity to access the scarce resource. Allocation decisions attempt to maximize the common good of additional life-years gained.[xi] The federal oversight of allograft allocation in the US uses objective clinical metrics like blood type, immune compatibility, body size, and geographic distance to match organs to recipients to increase both graft and patient survival.[xii] Transplant centers additionally use their own evaluations to waitlist patients. Although variation exists between transplant center criteria across more objective measurements, such as lab values and concurrent diseases, significant inconsistencies arise in how they incorporate subjective factors like compliance with medical recommendations, psychosocial support, and intellectual disability into the review process.[xiii] Only 7 percent of renal transplant programs use formal criteria for subjective psychosocial assessments, while no pediatric solid organ transplant programs use formal, explicit, or uniform review to assess developmental delays and psychosocial support.[xiv] Failing to establish uniform definitions and inconsistently applying evaluation criteria in the review of potential transplant candidates introduce bias into listing practices.[xv] The center they present to and the variable evaluative criteria the center uses may discount an individual’s claim to a fair opportunity to access a scarce resource. Labeling a patient non-compliant can preclude both a referral to and placement on a waitlist for potentially suitable recipients. Compliance considerations presuppose that graft longevity will be jeopardized by an individual’s failure to adhere to pre- and post-transplant regimens. It is necessary to distinguish individuals who are intentionally non-adherent to treatment regimens and demonstrate willful disregard for medical recommendations from those who are involuntarily non-adherent due to barriers that limit full participation in care plans. The former would not be offered a spot on the waitlist for an allograft, nor would investigators offer them a spot in a xenotransplantation research study. Significant and repeated refusals to participate in treatment plans would confound the ability of researchers to collect necessary data and perform the safety monitoring required by early-phase clinical trials. Enrolling subjects who are medically eligible for a traditional transplant but denied access requires a population that is suitably compliant to participate in a clinical trial reliably and safely yet judged not worthy of receipt of a standard allograft during the evaluation process. The latter population is most disadvantaged by compliance judgments and unsubstantiated outcome predictions. Multi-center research studies have found that moderate non-adherence to immunosuppression regimens is not directly associated with poor kidney transplant outcomes.[xvi] Nor are intellectual and developmental disabilities, conditions for which transplant centers may categorically refuse evaluation, clear indicators of an individual’s ability to comply with treatment regimens.[xvii] Large cohort studies of both pediatric kidney and liver transplant recipients found no correlation between intellectual disability and graft or patient survival.[xviii] Rather, it is the perpetuation of medical biases and quality-of-life judgments that presumptively label specific populations poor transplant candidates or label their support systems insufficient, notwithstanding data demonstrating their ability to achieve successful transplant outcomes.[xix] Variability in compliance assessments and psychosocial support criteria allows medical biases to persist and disproportionately impedes waitlist access to patients from underserved populations.[xx] Low-income Medicaid patients are 2.6 times more likely to be labelled non-compliant as privately insured patients.[xxi] Additionally, the medical records of Black patients are 2.5 times more likely to contain negative descriptors like non-compliant, non-adherent, aggressive, unpleasant, and hysterical than those of white patients.[xxii] The higher prevalence of stigmatizing, compliance-based language in the medical records of minority, economically disadvantaged, and disabled persons decreases the likelihood that they will be recommended for a transplant, referred for an evaluation, placed on a waiting list, or ultimately receive a transplant.[xxiii] These populations are at heightened risk of being used in ethically inappropriate ways by xenograft research that capitalizes on this precluded access. II. Defining Vulnerability Subjective evaluation criteria in allograft waitlisting disproportionately impact some populations. This precluded access to waitlists increases their vulnerability to experience harm in experimental xenotransplant research. Fair subject selection requires the development of specific and appropriate inclusion and exclusion criteria designed to address and minimize known subject vulnerabilities.[xxiv] This process begins with physician-investigators designing research trials and IRB review of proposed trials in which some or all potential subjects are vulnerable.[xxv] The literature has no consensus on defining vulnerability in the clinical or research setting.[xxvi] Prominent guidelines such as the Common Rule and the Declaration of Helsinki focus on a categorical, consent-based approach to assessing vulnerability. The capacity to provide freely given consent is a necessary prerequisite for ethical human subject research. Still, consent alone is insufficient to establish ethical permissibility or assure that a research transaction is fair.[xxvii] Harm can occur even with informed consent if it results from coercion, undue influence, or exploitation.[xxviii] Subjects have limited ability to avoid exploitation and act as an autonomous moral agents under such circumstances. Categorical assessments label groups whose members share salient features, such as prisoners or children, as vulnerable. This shared characteristic may compromise their capacity for free consent and autonomous ability to protect their interests. Although widely used, broad categorizations create monolithic views of populations but lack clarity as to why a particular feature makes one vulnerable or what a given characteristic decidedly renders one vulnerable to.[xxix] Individuals broadly vulnerable in society, such as the severely economically disadvantaged or incarcerated, are not necessarily vulnerable as research subjects in a given proposed trial.[xxx] Categorical vulnerability is insufficient to recognize that research-related harm is specific to a particular subject potentially participating in a given protocol at a definite time and place. III. Assessing for Contextual Vulnerability Ensuring ethical consent, therefore, requires more than an accounting of capacity, competency, and freedom from coercion. This requires looking beyond voluntariness to ask whether the research offer is fair. Contextual vulnerability recognizes and addresses how some subjects are at a heightened risk of being used in ethically inappropriate ways due to research-specific situations and environments.[xxxi] Contextual vulnerability derives from a specific feature of the research environment that increases a subject’s risk of harm rather than an intrinsic categorical condition of that subject. Accounting for contextual vulnerabilities is necessary because it is ethically unsound for a competent subject to give voluntary consent to an offer that is nonetheless unfair or exploitative.[xxxii] Potential subjects excluded from accessing an allograft are contextually vulnerable in a research environment that may view their diminished range of choice as an opportunity for experimental research enrollment. Proposals to exploit or take advantage of this vulnerability places these individuals at a heightened risk of research-related harm. IV. Exploitative Transactions in Xenotransplant Research In the landmark single-patient case in Maryland, a genetically modified porcine heart was offered to the subject only because he was denied access to the allograft waitlist due to a history of noncompliance with a recommended medical regimen.[xxxiii] Physician-investigators did not define how they evaluated compliance, nor did they elaborate on how this claim demonstrated the subject’s clear and convincing contraindication to receive a conventional cardiac allograft. The subject was presented with a so-called Hobson’s choice, in which there is the illusion of free choice but ultimately there is no real choice as only one outcome, the acceptance of the experimental xenograft, is permitted; access to other choices, such as pursuing standard of care waitlisting, have been removed.[xxxiv] This case set a precedent for researchers and IRBs to view individuals denied access to conventional allografts as an appropriate subject population without acknowledgment of how this transaction is consensually exploitative. Consensual exploitation occurs when researchers intentionally and wrongfully take advantage of a subject’s vulnerability.[xxxv] In the cardiac xenotransplant case, the application of subjective evaluation criteria created a unique contextual vulnerability specific to transplant waitlist practices. Investigators took advantage of the subject’s diminished ability to access the heart transplant waitlist to obtain consent for the xenotransplant procedure. Researchers have no obligation to repair unjust conditions that they bear no responsibility for causing.[xxxvi] The wrongfulness in this case is how subjective compliance-based waitlisting criteria precluded the subject from accessing the heart transplant waitlist and denied him fair consideration in accessing the standard clinical option. Then, the transplantation team exploited this disadvantage they were morally responsible for creating. The subject agreed to the terms for an experimental and high-risk xenograft from a place of vulnerability due to the diminished range of choice specifically constructed by the policy and actions of the transplant center. The options offered by the physician-investigators to the patient were manipulated to promote the research system’s interests through the production of new scientific knowledge, not necessarily the subject’s conception of his own good.[xxxvii] V. Recommendation for Simultaneous Allograft Listing Ethical research design calls for assessments of which vulnerabilities and in which contexts researchers and IRBs ought to offer additional safeguards. Subjects should be clinically suitable to produce robust, reliable, and generalizable scientific knowledge and be presented with a fair research offer. Researchers and IRBs can achieve this through an inclusion criterion requiring that a subject has previously been placed on and maintains a spot on a waitlist for a conventional allograft. Investigators and IRBs must ensure that subjects are selected based on scientific rationale, not because they are easy to recruit due to a compromised or vulnerable position.[xxxviii] Evidence of simultaneous allograft listing would provide verification that a researcher expects a potential subject to survive the burdens of an experimental xenotransplant procedure. Individuals of advanced age or with severe life-limiting comorbidities separate from their end-stage organ failure are less likely to survive after receiving an allograft or a research xenograft. These subjects would not produce valuable data in service to the study’s endpoints or knowledge generalizable to broader patient populations. Requiring evidence of simultaneous allograft listing fulfills the ethical requirement that subjects who withdraw consent are not worse off than if they had not pursued research enrollment.[xxxix] If a subject withdraws consent before receiving a xenograft, their continued place on a waitlist ensures that their fair opportunity claim to an allograft has been maintained. Simultaneous allograft waitlisting excludes contextually vulnerable subjects clinically suitable to receive a graft but denied access to a waitlist. This inclusion criteria provides an additional safeguard against unfairly capitalizing on a subject’s marginalized status. Requiring simultaneous allograft listing will narrow the potential subject population to those clinically suitable and well situated to receive a fair opportunity to enroll in research: individuals listed for an allograft but significantly unlikely to receive or to benefit from that allograft. This potential subject population includes individuals with broadly reactive antibodies who are unlikely to match to a donor organ and individuals with anatomical contraindications who face prohibitive risks with standard allografts or bridging therapies.[xl] This subject population aligns with the FDA recommendation to enroll subjects for whom safe and effective alternatives are not available.[xli] These individuals have not had their claim to a fair opportunity transgressed by a subjective evaluation process, nor has their interest in accessing a scarce resource been unjustly discounted.[xlii] Neither the individual nor the transplant clinicians are responsible for creating a clinical or statistical disadvantage to receiving a standard allograft. An offer of research enrollment extended to this population has not been manipulated to favor one party over the other, but rather appropriately considers the interests of both parties.[xliii] Researchers have an interest in identifying subjects capable of producing scientifically valuable knowledge. Potential subjects have an interest in exploring alternatives to the high morbidity of a traditional allograft. This subject population retains the autonomous choice to pursue a standard-of-care allograft or to enroll in xenograft research. Having few treatment options available does not inexorably undermine the voluntariness of research consent or increase vulnerability.[xliv] The consent transaction is not exploitative or unfair because the transplant system is not responsible for creating this diminished range of choice. Simultaneous allograft listing represents an eligibility criterion that responds to and limits the products of subjective decisions from unjustly impacting trial enrollment. VI. Counterargument: Is Something Better Than Nothing? Some may argue that for medically exigent individuals in need of a transplant, any option to participate in research is better than no option. Autonomy and dignity, however, are not advanced when an inability to access the standard of care compels a subject’s decision to pursue experimental research. An offer of research enrollment that is unfair or exploitative remains unethical regardless of whether the subject stands to benefit. Nor should benefit be expected in early-phase research. The goals of phase I research are primarily to collect short-term safety, toxicity, dosing, and pharmacologic data, not to provide efficacious treatment.[xlv] Expanding access to experimental research trials cannot be conflated with fair access to equitable health care.[xlvi] Broadened access alone does not produce a more ethical research environment. Excluding contextually vulnerable subjects from research should not be the end goal, but rather a necessary interim to call attention to the need to redress biases and existing injustices in transplant access. Research that targets a population’s vulnerability serves to enable the continuation of unjust systems. CONCLUSION In summary, the urgent and significant clinical need for transplantable organs cannot undermine the requirements of ethical research design and conduct. Fair subject selection is a requirement of ethical clinical research.[xlvii] Potential subjects enrolled in upcoming xenograft research must be selected for their ability to answer the scientific objectives of a proposed study and must have the capacity to provide freely given informed consent within a fair research environment. Denying access to allotransplants for subjective psychosocial or compliance-based claims creates contextual vulnerability specific to transplant research that perpetuates the unfairness of the organ allocation system. Ethical research that produces valuable scientific knowledge cannot exploit the rights or interests of subjects in the process. A look beyond categorical vulnerability to contextual vulnerability highlights this currently overlooked area of exploitation. - [i] “Organ Donation Statistics,” Health Resources and Services Administration, accessed April 18, 2022, https://www.organdonor.gov/learn/organ-donation-statistics. [ii] Schold, J.D. et al., “Barriers to Evaluation and Wait Listing for Kidney Transplantation,” Clinical Journal of the American Society of Nephrology 6, no. 7 (2011): 1760-67. [iii] Abouna, G.M. “Ethical Issues in Organ Transplantation,” Medical Principles and Practice 12, no. 1 (2003): 54-69. [iv] Anderson, M. “Xenotransplantation: A Bioethical Evaluation,” Journal of Medical Ethics 32, no. 4 (2006): 205-8. [v] Lambert, J. “What Does the First Successful Test of a Pig-to-Human Kidney Transplant Mean?,” ScienceNews, October 22, 2021, https://www.sciencenews.org/article/xenotransplantation-pig-human-kidney-transplant.; Koplon, S. “Xenotransplantation: What It Is, Why It Matters and Where It Is Going,” UAB News, February 17, 2022, https://www.uabmedicine.org/-/xenotransplantation-what-it-is-why-it-matters-and-where-it-is-going. [vi] Anderson, supra; Daar, A.S. “Ethics of Xenotransplantation: Animal Issues, Consent, and Likely Transformation of Transplant Ethics,” World Journal of Surgery 21, no. 9 (1997): 975-82.; Kim, M.K., et al., “The International Xenotransplantation Association Consensus Statement on Conditions for Undertaking Clinical Trials of Xenocorneal Transplantation,” Xenotransplantation 21, no. 5 (2014): 420-30. [vii] Abouna, supra; Pierson, R.N., et al., “Pig-to-Human Heart Transplantation: Who Goes First?,” American Journal of Transplantation 20, no. 10 (2020): 2669-74. [viii] Food and Drug Administration, Source Animal, Product, Preclinical, and Clinical Issues Concerning the Use of Xenotransplantation Products in Humans (Silver Spring, MD, 2016), 43, https://www.fda.gov/media/102126/download. [ix] Wang, W., et al., “First Pig-to-Human Heart Transplantation,” Innovation (Camb) 3, no. 2 (2022): 100223. [x] Carse, A.L. and Little, M.O. “Exploitation and the Enterprise of Medical Research,” in Exploitation and Developing Countries, ed. J. S. Hawkins and E. J. Emanuel (Princeton, NJ: Princeton University Press, 2008), 206-45. [xi] Halpern, S.D. and Goldberg, D.“Allocating Organs to Cognitively Impaired Patients,” New England Journal of Medicine 376, no. 4 (2017): 299-301. [xii] “How We Match Organs,” United Network for Organ Sharing, accessed April 18, 2022, https://unos.org/transplant/how-we-match-organs/. [xiii] UW Medicine Harborview Medical Center – UW Medical Center University of Washington Physicians, Selection Criteria: Kidney Transplant Recipient (Seattle, WA, 2019), 1-3, https://www.uwmedicine.org/sites/stevie/files/2020-11/UW-Medicine-Kidney-Selection-Criteria-UH2701.pdf; Penn Medicine, Kidney Transplant Selection Criteria (Philadelphia, PA: Hospital of the University of Pennsylvania), 1-2. https://www.pennmedicine.org/media/documents/instructions/transplant/kidney_transplant_selection_criteria.ashx. [xiv] Dudzinski, D.M. “Shifting to Other Justice Issues: Examining Listing Practices,” American Journal of Bioethics 4, no. 4 (2004): 35-37.; Richards, C.T., et al., “Use of Neurodevelopmental Delay in Pediatric Solid Organ Transplant Listing Decisions: Inconsistencies in Standards Across Major Pediatric Transplant Centers,” Pediatric Transplant 13, no. 7 (2009): 843-50. [xv] Dudzinski, supra. [xvi] Israni, A.K., et al., “Electronically Measured Adherence to Immunosuppressive Medications and Kidney Function after Deceased Donor Kidney Transplantation,” Clinical Transplantation 25, no. 2 (2011): 124-31. [xvii] National Council on Disability, Organ Transplant Discrimination against People with Disabilities (Washington, DC, 2019), 25-35, https://ncd.gov/sites/default/files/NCD_Organ_Transplant_508.pdf.; Halpern and Goldberg, supra. [xviii] Wightman, A., et al., “Prevalence and Outcomes of Renal Transplantation in Children with Intellectual Disability,” Pediatric Transplantation 18, no. 7 (2014): 714-19.; Wightman, A., et al., “Prevalence and Outcomes of Liver Transplantation in Children with Intellectual Disability,” Journal of Pediatric Gastroenterology and Nutrition 62, no. 6 (2016): 808-12. [xix] Richards et al., supra; Godown, J., et al., “Heart Transplantation in Children with Down Syndrome,” Journal of the American Heart Association 11, no. 10 (2022): e024883. [xx] Silverman, H. and Odonkor, P.N. “Reevaluating the Ethical Issues in Porcine-to-Human Heart Xenotransplantation,” Hastings Center Report 52, no. 5 (2022): 32-42. [xxi] Sun, M., et al., “Negative Patient Descriptors: Documenting Racial Bias in the Electronic Health Record,” Health Affairs 41, no. 2 (2022): 203-11. [xxii] Ibid. [xxiii] Dudzinski, supra; Garg, P.P., et al., “Reducing Racial Disparities in Transplant Activation: Whom Should We Target?,” American Journal of Kidney Diseases 37, no. 5 (2001): 921-31. [xxiv] Emanuel, E.J., et al., “What Makes Clinical Research Ethical?,” JAMA 283, no. 20 (2000): 2701-11. [xxv] 45 C.F.R. 46.111(b). [xxvi] Hurst, S.A. “Vulnerability in Research and Health Care; Describing the Elephant in the Room?,” Bioethics 22, no. 4 (2008): 191-202. [xxvii] The Nuremberg Code, Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law 2, no. 10: 181-2 (Washington, DC: U.S. Government Printing Office, 1949); Kipnis, K. “Vulnerability in Research Subjects: A Bioethical Taxonomy. Ethical and Policy Issues in Research Involving Human Participants.,” in Ethical and Policy Issues in Research Involving Human Participants, (Bethesda, MD: National Bioethics Advisory Commission, August 2001), G1-G13. [xxviii] Dickert, N. and Grady, C. “Incentives for Research Participants,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 386-96. [xxix] Gordon, B.G. “Vulnerability in Research: Basic Ethical Concepts and General Approach to Review,” Ochsner Journal 20, no. 1 (2020): 34-38. [xxx] Kipnis, supra. [xxxi] Hurst, supra. [xxxii] Lamkin, M. and Elliott, C. “Avoiding Exploitation in Phase I Clinical Trials: More Than (Un)Just Compensation,” Journal of Law, Medicine & Ethics 46, no. 1 (2018): 52-63.; Jansen, L.A. “A Closer Look at the Bad Deal Trial: Beyond Clinical Equipoise,” Hastings Center Report 35, no. 5 (2005): 29-36. [xxxiii] Wang et al., supra; Silverman and Odonkor, supra. [xxxiv] Silverman and Odonkor, supra. [xxxv] Carse and Little, supra. [xxxvi] Wertheimer, A. “Exploitation in Clinical Research,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 201-210. [xxxvii] Brock, D.W. “Philosophical Justifications of Informed Consent in Research,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 606-612. [xxxviii] Council for International Organizations of Medical Sciences, International Ethical Guidelines for Health-Related Research Involving Humans (Geneva: World Health Organization, 2016), https://cioms.ch/wp-content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf. [xxxix] Ibid. [xl] Pierson et al., supra. [xli] Food and Drug Administration, supra. [xlii] Hurst, supra. [xliii] Kipnis, supra. [xliv] Hawkins, J.S. and Emanuel, E.J. “Introduction: Why Exploitation?,” in Exploitation and Developing Countries, ed. J. S. Hawkins and E. J. Emanuel (Princeton, NJ: Princeton Universiy Pres, 2008), 1-20. [xlv] Muglia, J.J. and DiGiovanna, J.J. “Phase 1 Clinical Trials,” Journal of Cutaneous Medicine and Surgery 2, no. 4 (1998): 236-41. [xlvi] Dresser, R. “The Role of Patient Advocates and Public Representatives in Research,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 231-41. [xlvii] MacKay, D. and Saylor, K.W. “Four Faces of Fair Subject Selection,” The American Journal of Bioethics 20, no. 2 (2020): 5-19.