Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study

Blair E. Wisco Ph.D., Brian P. Marx Ph.D., Casey L. May B.S., Brenda Martini M.A., and others
Depression and Anxiety

Abstract

Background

Combat exposure is associated with increased risk of mental disorders and suicidality. Moral injury, or persistent effects of perpetrating or witnessing acts that violate one's moral code, may contribute to mental health problems following military service. The pervasiveness of potentially morally injurious events (PMIEs) among U.S. combat veterans, and what factors are associated with PMIEs in this population remains unknown.
Methods

Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary and nationally representative survey of a population-based sample of U.S. veterans, including 564 combat veterans, collected September–October 2013. Types of PMIEs (transgressions by self, transgressions by others, and betrayal) were assessed using the Moral Injury Events Scale. Psychiatric and functional outcomes were assessed using established measures.
Results

A total of 10.8% of combat veterans acknowledged transgressions by self, 25.5% endorsed transgressions by others, and 25.5% endorsed betrayal. PMIEs were moderately positively associated with combat severity (β = .23, P < .001) and negatively associated with white race, college education, and higher income (βs = .11–.16, Ps < .05). Transgressions by self were associated with current mental disorders (OR = 1.65, P < .001) and suicidal ideation (OR = 1.67, P < .001); betrayal was associated with postdeployment suicide attempts (OR = 1.99, P < .05), even after conservative adjustment for covariates, including combat severity.
Conclusions

A significant minority of U.S combat veterans report PMIEs related to their military service. PMIEs are associated with risk for mental disorders and suicidality, even after adjustment for sociodemographic variables, trauma and combat exposure histories, and past psychiatric disorders.

The article is here.

As Trump Inquiries Flood Ethics Office, Director Looks To House For Action

By Marilyn Geewax and Peter Overby
npr.org
Originally published April 17, 2017

Office of Government Ethics Director Walter Shaub Jr. is calling on the chairman of House Oversight Committee to become more engaged in overseeing ethics questions in the Trump administration.

In an interview with NPR on Monday, Shaub said public inquiries and complaints involving Trump administration conflicts of interest and ethics have been inundating his tiny agency, which has only advisory power.

"We've even had a couple days where the volume was so huge it filled up the voicemail box, and we couldn't clear the calls as fast as they were coming in," Shaub said. His office is scrambling to keep pace with the workload.

But while citizens, journalists and Democratic lawmakers are pushing for investigations, Shaub suggested a similar level of energy is not coming from the House Oversight Committee, which has the power to investigate ethics questions, particularly those being raised now about reported secret ethics waivers for former lobbyists serving in the Trump administration.

The article is here.

Facebook plans ethics board to monitor its brain-computer interface work

Josh Constine
Tech Crunch
Originally posted April 19, 2017

Facebook will assemble an independent Ethical, Legal and Social Implications (ELSI) panel to oversee its development of a direct brain-to-computer typing interface it previewed today at its F8 conference. Facebook’s R&D department Building 8’s head Regina Dugan tells TechCrunch, “It’s early days . . . we’re in the process of forming it right now.”

Meanwhile, much of the work on the brain interface is being conducted by Facebook’s university research partners like UC Berkeley and Johns Hopkins. Facebook’s technical lead on the project, Mark Chevillet, says, “They’re all held to the same standards as the NIH or other government bodies funding their work, so they already are working with institutional review boards at these universities that are ensuring that those standards are met.” Institutional review boards ensure test subjects aren’t being abused and research is being done as safely as possible.

The article is here.

Individuals at High Risk for Suicide Are Categorically Distinct From Those at Low Risk.

Tracy K. Witte, Jill M. Holm-Denoma, Kelly L. Zuromski, Jami M. Gauthier, & John Ruscio
Psychological Assessment, Vol 29(4), Apr 2017, 382-393

Abstract

Although suicide risk is often thought of as existing on a graded continuum, its latent structure (i.e., whether it is categorical or dimensional) has not been empirically determined. Knowledge about the latent structure of suicide risk holds implications for suicide risk assessments, targeted suicide interventions, and suicide research. Our objectives were to determine whether suicide risk can best be understood as a categorical (i.e., taxonic) or dimensional entity, and to validate the nature of any obtained taxon. We conducted taxometric analyses of cross-sectional, baseline data from 16 independent studies funded by the Military Suicide Research Consortium. Participants (N = 1,773) primarily consisted of military personnel, and most had a history of suicidal behavior. The Comparison Curve Fit Index values for MAMBAC (.85), MAXEIG (.77), and L-Mode (.62) all strongly supported categorical (i.e., taxonic) structure for suicide risk. Follow-up analyses comparing the taxon and complement groups revealed substantially larger effect sizes for the variables most conceptually similar to suicide risk compared with variables indicating general distress. Pending replication and establishment of the predictive validity of the taxon, our results suggest the need for a fundamental shift in suicide risk assessment, treatment, and research. Specifically, suicide risk assessments could be shortened without sacrificing validity, the most potent suicide interventions could be allocated to individuals in the high-risk group, and research should generally be conducted on individuals in the high-risk group.

The article is here.

Victims, vectors and villains: are those who opt out of vaccination morally responsible for the deaths of others?

Euzebiusz Jamrozik, Toby Handfield, Michael J Selgelid
Journal of Medical Ethics 2016;42:762-768.

Abstract

Mass vaccination has been a successful public health strategy for many contagious diseases. The immunity of the vaccinated also protects others who cannot be safely or effectively vaccinated—including infants and the immunosuppressed. When vaccination rates fall, diseases like measles can rapidly resurge in a population. Those who cannot be vaccinated for medical reasons are at the highest risk of severe disease and death. They thus may bear the burden of others' freedom to opt out of vaccination. It is often asked whether it is legitimate for states to adopt and enforce mandatory universal vaccination. Yet this neglects a related question: are those who opt out, where it is permitted, morally responsible when others are harmed or die as a result of their decision? In this article, we argue that individuals who opt out of vaccination are morally responsible for resultant harms to others. Using measles as our main example, we demonstrate the ways in which opting out of vaccination can result in a significant risk of harm and death to others, especially infants and the immunosuppressed. We argue that imposing these risks without good justification is blameworthy and examine ways of reaching a coherent understanding of individual moral responsibility for harms in the context of the collective action required for disease transmission. Finally, we consider several objections to this view, provide counterarguments and suggest morally permissible alternatives to mandatory universal vaccination including controlled infection, self-imposed social isolation and financial penalties for refusal to vaccinate.

The article is here.

White House may have violated its own ethics rules with Trump's executive-branch hires

Sonam Sheth
Business Insider
Originally published April 16, 2017

The Trump administration may be entangling itself in another ethical landmine.

In this case, the White House could have violated its own ethics rules with at least two hires, a New York Times and ProPublica investigation found.

One potential conflict involves Michael Catanzaro, who is the White House's top energy adviser. Until last year, The Times and ProPublica found, Catanzaro was working as a lobbyist for the fossil-fuel industry and had clients like Devon Energy of Oklahoma and Talen Energy of Pennsylvania.

Those two companies were stalwart opponents of President Barack Obama's environmental regulations, like the Clean Power Plan, which sought to promote the use of alternative energy sources. Trump signed an executive order undoing the plan in March. As the White House's top energy adviser, Catanzaro will handle many of those same issues.

The article is here.

Should Mental Disorders Be a Basis for Physician-Assisted Death?

Paul S. Appelbaum
Psychiatric Services
Volume 68, Issue 4, April 01, 2017, pp. 315-317

Abstract

Laws permitting physician-assisted death in the United States currently are limited to terminal conditions. Canada is considering whether to extend the practice to encompass intractable suffering caused by mental disorders, and the question inevitably will arise in the United States. Among the problems seen in countries that have legalized assisted death for mental disorders are difficulties in assessing the disorder’s intractability and the patient’s decisional competence, and the disproportionate involvement of patients with social isolation and personality disorders. Legitimate concern exists that assisted death could serve as a substitute for creating adequate systems of mental health treatment and social support.

The article is here.

Should healthcare professionals breach confidentiality when a patient is unfit to drive?

Daniel Sokol
The British Medical Journal
2017;356:j1505

Here are two excerpts:

The General Medical Council (GMC) has guidance on reporting concerns to the Driver and Vehicle Licensing Agency (DVLA). Doctors should explain to patients deemed unfit to drive that their condition may affect their ability to drive and that they—the patients—have a legal obligation to inform the DVLA about their condition.

(cut)

The trouble with this approach is that it relies on patients’ honesty. As far back as Hippocratic times, doctors were instructed to look out for the lies of patients. Two and a half thousand years later the advice still holds true. In a 1994 study on 754 adult patients, Burgoon and colleagues found that 85% admitted to concealing information from their doctors, and over a third said that they had lied outright. Many patients will lie to avoid the loss of their driving licence. They will falsely promise to inform the DVLA and to stop driving. And the chances of the doctor discovering that the patient is continuing to drive are slim.

The article is here.

Why Psychiatry Should Discard The Idea of Free Will

Steve Stankevicius
The Skeptical Shrink
Originally posted March 30, 2017

Here is an excerpt:

Neuroscience has continued to pile on the evidence that our thoughts are entirely dependent on the physical processes of the brain, whilst evidence for ‘something else’ is entirely absent. Despite this, mind-body dualism has endured as the predominant view to this day and the belief in free will is playing a crucial role. Free will would only make sense if we invoke at least some magical aspect of the mind. It would only make sense if we relinquish the mind from the bonds of the physical laws of the universe. It would only make sense if we imagine the mind as somewhat irrespective of the brain.

It is not surprising then that psychiatry, a medicine of the mind, is not seen as ‘real medicine’. Only 4% of medical graduates in the US apply for psychiatry, and in the UK psychiatry has the least applicants per vacancy of any specialty, about one applicant per vacancy (compared with over nine per vacancy in surgery). Psychiatry is seen as practise of the dark arts, accompanied by mind reading, talking to the dead, and fortune telling. It seems psychiatry deals with metaphysics, yet science is not in the game of metaphysics.

If psychiatry is medicine of the mind, but our common beliefs about the mind are wrong, where does that leave the medicine? In my view, free will is forcing a gap in our picture between physical processes and the mind. This gap forms a trash can where we throw all cases of mental illness we don’t yet understand. Does it seem like a trash can? No, because we feel comfortable in thinking “the mind is mysterious, there’s free will involved”. But if we resign ourselves to accept a mind with free will - a mind that is free - we resign ourselves to a psychiatric specialty that does not attempt to fully understand the underpinnings of mental illness.

The blog post is here.