Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Wednesday, April 8, 2020

How a Ship’s Coronavirus Outbreak Became a Moral Crisis for the Military

Navy fires USS Theodore Roosevelt captain over loss of confidence ...Helene Cooper,
Thomas Gibbons-Neff, & Eric Schmitt
The New York Times
Originally posted 6 April 20

Here is an excerpt:

In the close-knit world of the American military, the crisis aboard the Roosevelt — known widely as the “T.R.”— generated widespread criticism from men and women who are usually careful to steer clear of publicly rebuking their peers.

Mr. Modly’s decision to remove Captain Crozier without first conducting an investigation went contrary to the wishes of both the Navy’s top admiral, Michael M. Gilday, the chief of naval operations, and the military’s top officer, Gen. Mark A. Milley, the chairman of the Joint Chiefs of Staff.

“I am appalled at the content of his address to the crew,” retired Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff under Presidents George W. Bush and Barack Obama, said in a telephone interview, referring to Mr. Modly.

Mr. Modly, Admiral Mullen said, “has become a vehicle for the president. He basically has completely undermined, throughout the T.R. situation, the uniformed leadership of the Navy and the military leadership in general.”

Mr. Modly, Admiral Mullen said, “has become a vehicle for the president. He basically has completely undermined, throughout the T.R. situation, the uniformed leadership of the Navy and the military leadership in general.”

“At its core, this is about an aircraft carrier skipper who sees an imminent threat and is forced to make a decision that risks his career in the act of what he believes to be the safety of the near 5,000 members of his crew,” said Sean O’Keefe, a former Navy secretary under President George Bush. “That is more than enough to justify the Navy leadership rendering the benefit of the doubt to the deployed commander.”

The info is here.

The ethics of ordering non-essential items online during the coronavirus lockdown

imgLaura Steele
Originally posted 3 April 20

In response to the Coronavirus crisis, the UK government announced that all retail outlets, except for those considered to provide essential goods and services, were to close with immediate effect. Online retail is, however, 'still open and encouraged'.

So, does that mean we can click with a clear conscience?

Business academics Andrew Crane and Dirk Matten argue that a decision has an ethical dimension to it if it has a significant effect on others it is characterised by choice, and it is perceived as ethically relevant to one or more parties.

Most of us would likely agree that ordering essential items, such as food or medicine, is ethically acceptable. Especially if there is no alternative, as is currently the case for millions of people who have been deemed at high risk due to underlying health conditions, are self-isolating as the result symptoms of COVID-19, or are otherwise unable to shop in person.

But what about goods that are not absolutely necessary, such as clothing that is wanted but not needed, home decor, toys and games, garden furniture and accessories, beauty products or even, depending on your view on the matter, the humble Easter egg?

The info is here.

Tuesday, April 7, 2020

Four pieces of ethical advice for practitioners during COVID-19

Four pieces of ethical advice for practitioners during COVID-19Rebecca Schwartz-Mette
Originally posted 2 April 20

Are you transitioning to full-time telepsychology? Launching a virtual classroom? Want to expand your competence in the use of technology in practice? You can look to APA’s Ethics Committee for support in transforming your practice. Even in times of crisis, the Ethical Principles of Psychologists and Code of Conduct (hereafter “Ethics Code” or “Code;” 2002, Amended June 1, 2010 and Jan. 1, 2017) continues to guide psychologists’ actions based on our shared values. Here are four ways to practice in good faith while meeting the imminent needs of your community:

Lean in

Across the nation, rather than closing their practices and referring out, psychologists are accepting the challenge to diligently obtain training and expand their competence in telepsychology. Standard 2.02, “Providing Services in Emergencies,” allows psychologists to provide services for individuals for whom other services aren’t available through the duration of such emergencies, even if they have not obtained the necessary training. The Ethics Committee supports those psychologists working in good faith to meet the needs of patients, clients, supervisees and students.

Get training and support

Take advantage of the APA’s new (and often free) resources to develop and expand your competence, in line with Standard 2.03, “Maintaining Competence.” Expand your network by connecting with colleagues who can provide peer consultation and supervision to support your efforts.

Consider referrals

The decision to transition to telepsychology may not be for everyone. Competency concerns, lack of access to technology, and specific needs of particular clients may reflect good reasons to refer to practitioners who can provide telepsychology. Psychologists should assess each client’s needs in light of their own professional capacities and refer to others who can provide needed services in line with Standard 10.10(c), “Terminating Therapy.”

Take care of yourself

Psychologists are human and can feel lost in the ambiguity of this unprecedented time. It is your ethical mandate to also care for yourself. Practicing accurate self-assessment, leaning on colleagues when needed, and taking time to unplug from the news and practice to recharge helps to prevent burnout and is entirely consistent with 2.06, “Personal Problems and Conflicts.” Make self-care a verb and connect with your community of psychologists today.

Tavis Smiley Ordered To Pay PBS $1.5 Million For Violating Network's 'Morality' Clause

Vanessa Romo
Originally published 4 March 20

Here is an excerpt:

Throughout the three-week civil trial, jurors heard from six women who testified that Smiley subjected subordinates to unwanted sexual advances. "One woman who accused Smiley of sexual harassment left the show and received a $325,000 settlement," Variety reported.

The win for PBS may prove to be significant for other companies facing workplace suits stemming from sexual-misconduct allegations, who are seeking to break ties with accused individuals.

"In the midst of the #MeToo movement, he violated our morals clause... You can't have a consensual relationship between a manager and a subordinate because of the power dynamic. It's never consensual because that manager has power over all aspects of that person's employment," the network's lead attorney, Grace Speights, said in court.

Smiley's dismissal was one of many in the wake of the #MeToo movement which first gained global attention in 2017, after dozens of women accused movie producer Harvey Weinstein of sexual misconduct. Years later, a jury has convicted Weinstein of rape, Bill Cosby is behind bars for sexual assault, and popular hosts including Matt Lauer and Charlie Rose — who was fired by PBS in 2017 — have been removed from the airwaves amid accusations of misconduct.

The info is here.

Monday, April 6, 2020

JAIC launches pilot for implementing new DOD AI ethics principles

Jackson Barnett
Originally posted 2 April 20

Here is an excerpt:

The Department of Defense‘s Joint Artificial Intelligence Center is bringing together different types of engineers, policymakers and other DOD personnel to serve as “Responsible AI Champions” in support of the Pentagon’s new principles for AI ethics.

The pilot program brings together a “cross-functional group” of personnel from across the department to receive training on AI and DOD’s new ethical principles from JAIC staff who represent different parts of the AI development lifecycle. The intent is that when these trainees go back to their normal jobs, they will be “champions” for AI and the principles.

The model, which was announced through a JAIC blog post, is similar to a pilot Microsoft launched to implement its artificial intelligence governance structure. The JAIC did not say how many people will participate in the pilot program.

“The goal is to learn from this pilot so that we can develop a more robust and comprehensive program that can be implemented across the DOD,” Lt. Cmdr. Arlo Abrahamson, a JAIC spokesman, told FedScoop.

The info is here.

Life and death decisions of autonomous vehicles

Y. E. Bigman and K. Gray
Originally published 4 May 20

How should self-driving cars make decisions when human lives hang in the balance? The Moral Machine experiment (MME) suggests that people want autonomous vehicles (AVs) to treat different human lives unequally, preferentially killing some people (for example, men, the old and the poor) over others (for example, women, the young and the rich). Our results challenge this idea, revealing that this apparent preference for inequality is driven by the specific ‘trolley-type’ paradigm used by the MME. Multiple studies with a revised paradigm reveal that people overwhelmingly want autonomous vehicles to treat different human lives equally in life and death situations, ignoring gender, age and status—a preference consistent with a general desire for equality.

The large-scale adoption of autonomous vehicles raises ethical challenges because autonomous vehicles may sometimes have to decide between killing one person or another. The MME seeks to reveal people’s preferences in these situations and many of these revealed preferences, such as ‘save more people over fewer’ and ‘kill by inaction over action’ are consistent with preferences documented in previous research.

However, the MME also concludes that people want autonomous vehicles to make decisions about who to kill on the basis of personal features, including physical fitness, age, status and gender (for example, saving women and killing men). This conclusion contradicts well-documented ethical preferences for equal treatment across demographic features and identities, a preference enshrined in the US Constitution, the United Nations Universal Declaration of Human Rights and in the Ethical Guideline 9 of the German Ethics Code for Automated and Connected Driving.

The info is here.

Sunday, April 5, 2020

Why your brain is not a computer

Matthew Cobb
Originally posted 27 Feb 20

Here is an excerpt:

The processing of neural codes is generally seen as a series of linear steps – like a line of dominoes falling one after another. The brain, however, consists of highly complex neural networks that are interconnected, and which are linked to the outside world to effect action. Focusing on sets of sensory and processing neurons without linking these networks to the behaviour of the animal misses the point of all that processing.

By viewing the brain as a computer that passively responds to inputs and processes data, we forget that it is an active organ, part of a body that is intervening in the world, and which has an evolutionary past that has shaped its structure and function. This view of the brain has been outlined by the Hungarian neuroscientist György Buzsáki in his recent book The Brain from Inside Out. According to Buzsáki, the brain is not simply passively absorbing stimuli and representing them through a neural code, but rather is actively searching through alternative possibilities to test various options. His conclusion – following scientists going back to the 19th century – is that the brain does not represent information: it constructs it.

The metaphors of neuroscience – computers, coding, wiring diagrams and so on – are inevitably partial. That is the nature of metaphors, which have been intensely studied by philosophers of science and by scientists, as they seem to be so central to the way scientists think. But metaphors are also rich and allow insight and discovery. There will come a point when the understanding they allow will be outweighed by the limits they impose, but in the case of computational and representational metaphors of the brain, there is no agreement that such a moment has arrived. From a historical point of view, the very fact that this debate is taking place suggests that we may indeed be approaching the end of the computational metaphor. What is not clear, however, is what would replace it.

Scientists often get excited when they realise how their views have been shaped by the use of metaphor, and grasp that new analogies could alter how they understand their work, or even enable them to devise new experiments. Coming up with those new metaphors is challenging – most of those used in the past with regard to the brain have been related to new kinds of technology. This could imply that the appearance of new and insightful metaphors for the brain and how it functions hinges on future technological breakthroughs, on a par with hydraulic power, the telephone exchange or the computer. There is no sign of such a development; despite the latest buzzwords that zip about – blockchain, quantum supremacy (or quantum anything), nanotech and so on – it is unlikely that these fields will transform either technology or our view of what brains do.

The info is here.

Saturday, April 4, 2020

Suicide attempt survivors’ recommendations for improving mental health treatment for attempt survivors.

Melanie A. Hom and others
Psychological Services. 
Advance online publication.


Research indicates that connection to mental health care services and treatment engagement remain challenges among suicide attempt survivors. One way to improve suicide attempt survivors’ experiences with mental health care services is to elicit suggestions directly from attempt survivors regarding how to do so. This study aimed to identify and synthesize suicide attempt survivors’ recommendations for how to enhance mental health treatment experiences for attempt survivors. A sample of 329 suicide attempt survivors (81.5% female, 86.0% White/Caucasian, mean age = 35.07 ± 12.18 years) provided responses to an open-ended self-report survey question probing how treatment might be improved for suicide attempt survivors. Responses were analyzed utilizing both qualitative and quantitative techniques. Analyses identified four broad areas in which mental health treatment experiences might be improved for attempt survivors: (a) provider interactions (e.g., by reducing stigma of suicidality, expressing empathy, and using active listening), (b) intake and treatment planning (e.g., by providing a range of treatment options, including nonmedication treatments, and conducting a thorough assessment), (c) treatment delivery (e.g., by addressing root problems, bolstering coping skills, and using trauma-informed care), and (d) structural issues (e.g., by improving access to care and continuity of care). Findings highlight numerous avenues by which health providers might be able to facilitate more positive mental health treatment experiences for suicide attempt survivors. Research is needed to test whether implementing the recommendations offered by attempt survivors in this study might lead to enhanced treatment engagement, retention, and outcomes among suicide attempt survivors at large.

Here is an excerpt from the Discussion:

On this point, this study revealed numerous recommendations for how providers might be able to improve their interactions with attempt survivors. Suggestions in this domain aligned with prior studies on treatment experiences among suicide attempt survivors. For instance, recommendations that providers not stigmatize attempt survivors and, instead, empathize with them, actively listen to them, and humanize them, are consistent with aforementioned studies (Berglund et al., 2016; Frey et al., 2016; Shand et al., 2018; Sheehan et al., 2017; Taylor et al., 2009). This study’s findings regarding the importance of a collaborative therapeutic relationship are also consistent with previous work (Shand et al., 2018). Though each of these factors has been identified as salient to treatment engagement efforts broadly (see Barrett et al., 2008, for review), several suggestions that emerged in this study were more specific to attempt survivors. For example, ensuring that patients feel comfortable openly discussing suicidal thoughts and behaviors and taking disclosures of suicidality seriously are suggestions specifically applicable to the care of at-risk individuals. These recommendations not only support research indicating that asking about suicidality is not iatrogenic (see DeCou & Schumann, 2018, for review), but they also underscore the importance of considering the unique needs of attempt survivors. Indeed, given that most participants provided a recommendation in this area, the impact of provider-related factors should not be overlooked in the provision of care to this group.

Friday, April 3, 2020

Treating “Moral” Injuries

Anna Harwood-Gross
Scientific American
Originally posted 24 March 20

Here is an excerpt:

Though PTSD symptoms such as avoidance of reminders of the traumatic event and intrusive thought patterns may also be present in moral injury, they appear to serve different purposes, with PTSD sufferers avoiding fear and moral injury sufferers avoiding shame triggers. Few comparison studies of PTSD and moral injury exist, yet there has been research that indirectly compares the two conditions by differentiating between fear-based and non-fear-based (i.e., moral injury) forms of PTSD, which have been demonstrated to have different neurobiological markers. In the context of the military, there are countless examples of potentially morally injurious events (PMIEs), which can include killing or wounding others, engaging in retribution or disproportionate violence, or failing to save the life of a comrade, child or civilian. The experience of PMIEs has been demonstrated to lead to a larger range of psychological distress symptoms, including higher levels of guilt, anger, shame, depression and social isolation, than those seen in traditional PTSD profiles.

Guilt is difficult to address in therapy and often lingers following standardized PTSD treatment (that is, if the sufferer is able to access therapy). It may, in fact, be a factor in the more than 49 percent of veterans who drop out of evidence-based PTSD treatment or in why, at times, up to 72% of sufferers, despite meaningful improvement in their symptoms, do not actually recover enough after such treatment for their PTSD diagnosis to be removed. Most often, moral injury symptoms that are present in the clinic are addressed through traditional PTSD treatments, with thoughts of guilt and shame treated similarly to other distorted cognitions. When guilt and the events it relates to are treated as “a feeling and not a fact,” as psychologist Lisa Finlay put it in a 2015 paper, there is an attempt to lessen or relieve such emotions while taking a shortcut to avoid experiencing those that are legitimate and reasonable after-wartime activities. Continuing, Finlay stated that “the idea that we might get good, as a profession, at talking people out of guilt following their involvement in traumatic incidents is frighteningly short-sighted in more ways than one.”

The info is here.

Managing mental health challenges faced by healthcare workers during COVID-19 pandemic

Greenberg N., & others
BMJ 2020; 368 :m1211

Here is an excerpt:

Moral injury

Moral injury, a term that originated in the military, can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code.1 Unlike formal mental health conditions such as depression or post-traumatic stress disorder, moral injury is not a mental illness. But those who develop moral injuries are likely to experience negative thoughts about themselves or others (for example, “I am a terrible person” or “My bosses don’t care about people’s lives”) as well as intense feelings of shame, guilt, or disgust. These symptoms can contribute to the development of mental health difficulties, including depression, post-traumatic stress disorder, and even suicidal ideation. Equally, some people who have to contend with significant challenges, moral or traumatic, experience a degree of post-traumatic growth,3 a term used to describe a bolstering of psychological resilience, esteem, outlook, and values after exposure to highly challenging situations. Whether someone develops a psychological injury or experiences psychological growth is likely to be influenced by the way that they are supported before, during, and after a challenging incident.

Moral injury has already been described in medical students, who report great difficulty coping with working in prehospital and emergency care,4 where they were exposed to trauma that they felt unprepared for. This may be similar to the unprecedented nature of the challenges healthcare staff are currently facing. In the UK, most NHS staff may have felt, with some justification, that with all its faults, the NHS gives the sickest people the greatest chance of recovery. As such, staff should and usually do feel that it is something to be proud of.

The huge current effort to ensure adequate staffing and resources may be successful, but it looks likely that during the covid-19 outbreak many healthcare workers will encounter situations where they cannot say to a grieving relative, “We did all we could” but only, “We did our best with the staff and resources available, but it wasn’t enough.” That is the seed of a moral injury. Not all staff members will be adversely affected by the challenges ahead (table 1) but no one is invulnerable, and some healthcare workers will hurt, perhaps for a long time, unless we begin now to prepare and support our staff.

The info is here.

Thursday, April 2, 2020

Intelligence, Surveillance, and Ethics in a Pandemic

Jessica Davis
Originally posted 31 March 20

Here is an excerpt:

It is imperative that States and their citizens question how much freedom and privacy should be sacrificed to limit the impact of this pandemic. It is also not sufficient to ask simply “if” something is legal; we should also ask whether it should be, and under what circumstances. States should consider the ethics of surveillance and intelligence, specifically whether it is justified, done under the right authority, if it can be done with intentionality and proportionality and as a last resort, and if targets of surveillance can be separated from non-targets to avoid mass surveillance. These considerations, combined with enhanced transparency and sunset clauses on the use of intelligence and surveillance techniques, can allow States to ethically deploy these powerful tools to help stop the spread of the virus.

States are employing intelligence and surveillance techniques to contain the spread of the illness because these methods can help track and identify infected or exposed people and enforce quarantines. States have used cell phone data to track people at risk of infection or transmission and financial data to identify places frequented by at-risk people. Social media intelligence is also ripe for exploitation in terms of identifying social contacts. This intelligence, is increasingly being combined with health data, creating a unique (and informative) picture of a person’s life that is undoubtedly useful for virus containment. But how long should States have access to this type of information on their citizens, if at all? Considering natural limits to the collection of granular data on citizens is imperative, both in terms of time and access to this data.

The info is here.

Social Distancing as a Moral Dilemma

E. Litvack
U. A. News
Originally posted 31 March 20

Here is an excerpt:

Q: At this point, is social distancing a moral imperative?

This is an interesting philosophical question. A moral imperative is a command to act in a certain way, which everyone should follow, and, in order to invoke one, we need to explain what makes a particular action right or morally good.

A: In the context of the current health crisis, we can plausibly make the claim that it is a morally good state of affairs if we save the greatest number of lives possible. Not everyone would agree with that claim, but I'll leave that argument aside for now and return to it later. For now, let's assume that promoting health and saving lives is a morally good goal for society. Given that premise – if we also accept the empirical evidence, which suggests that social distancing is a means to halt the spread of the virus – it's easy to see how one would defend their judgment that it is morally wrong not to practice social distancing.

Q: How might someone argue that saving lives isn't a moral imperative?

A: Some people might argue that there is a naturalistic and evolutionary reason to let the virus take its course. It would reduce human population, which, in the long run, could be a good thing in terms of having more resources for fewer people. Notice one thing this view entails, though: The person who holds it must be willing to accept that they or their loved ones might be among those who contribute to the population reduction.

Likewise, some might argue that certain people have more value than others and therefore deserve to live while others do not. This would require a set of criteria by which to judge the value of a life, and unless someone – or some entity – creates that criteria by fiat, then to define "a valuable life" requires us to circle right back around to our original premise.

The info is here.

Wednesday, April 1, 2020

How Trump failed the biggest test of his life

Ed Pilkington & Tom McCarty
The Guardian
Originally posted 29 Mar 20

Here is an excerpt:

Those missing four to six weeks are likely to go down in the definitive history as a cautionary tale of the potentially devastating consequences of failed political leadership. Today, 86,012 cases have been confirmed across the US, pushing the nation to the top of the world’s coronavirus league table – above even China.

More than a quarter of those cases are in New York City, now a global center of the coronavirus pandemic, with New Orleans also raising alarm. Nationally, 1,301 people have died.

Most worryingly, the curve of cases continues to rise precipitously, with no sign of the plateau that has spared South Korea.

“The US response will be studied for generations as a textbook example of a disastrous, failed effort,” Ron Klain, who spearheaded the fight against Ebola in 2014, told a Georgetown university panel recently. “What’s happened in Washington has been a fiasco of incredible proportions.”

Jeremy Konyndyk, who led the US government’s response to international disasters at USAid from 2013 to 2017, frames the past six weeks in strikingly similar terms. He told the Guardian: “We are witnessing in the United States one of the greatest failures of basic governance and basic leadership in modern times.”

In Konyndyk’s analysis, the White House had all the information it needed by the end of January to act decisively. Instead, Trump repeatedly played down the severity of the threat, blaming China for what he called the “Chinese virus” and insisting falsely that his partial travel bans on China and Europe were all it would take to contain the crisis.

The info is here.

The Ethics of Quarantine

The Ethics of Quarantine | Journal of Ethics | American Medical ...Ross Upshur
Virtual Mentor. 2003;5(11):393-395.

Here are two excerpts:

There are 2 independent ethical considerations to consider here: whether the concept of quarantine is justified ethically and whether it is effective. It is also important to make a clear distinction between quarantine and isolation. Quarantine refers to the separation of those exposed individuals who are not yet symptomatic for a period of time (usually the known incubation period of the suspected pathogen) to determine whether they will develop symptoms. Quarantine achieves 2 goals. First, it stops the chain of transmission because it is less possible to infect others if one is not in social circulation. Second, it allows the individuals under surveillance to be identified and directed toward appropriate care if they become symptomatic. This is more important in diseases where there is presymptomatic shedding of virus. Isolation, on the other hand, is keeping those who have symptoms from circulation in general populations.

Justification of quarantine and quarantine laws stems from a general moral obligation to prevent harm to (infection of) others if this can be done. Most democracies have public health laws that do permit quarantine. Even though quarantine is a curtailment of civil liberties, it can be broadly justified if several criteria can be met.


Secondly, the proportionality, or least-restrictive-means, principle should be observed. This holds that public health authorities should use the least restrictive measures proportional to the goal of achieving disease control. This would indicate that quarantine be made voluntary before more restrictive means and sanctions such as mandatory orders or surveillance devices, home cameras, bracelets, or incarceration are contemplated. It is striking to note that in the Canadian SARS outbreak in the Greater Toronto area, approximately 30,000 persons were quarantined at some time. Toronto Public Health reports writing only 22 orders for mandatory detainment [3]. Even if the report is a tenfold underestimate, the remaining instances of voluntary quarantine constitute an impressive display of civic-mindedness.

Thirdly, reciprocity must be upheld. If society asks individuals to curtail their liberties for the good of others, society has a reciprocal obligation to assist them in the discharge of their obligations. That means providing individuals with adequate food and shelter and psychological support, accommodating them in their workplaces, and not discriminating against them. They should suffer no penalty on account of discharging their obligations to society.

The info is here.

Tuesday, March 31, 2020

Pregnant and shackled: why inmates are still giving birth cuffed and bound

23 states do not have laws against shackling of incarcerated pregnant women.Lori Teresa Yearwood
Originally posted 24 Feb 20

Here is an excerpt:

To convolute matters more, the federal government does not require prisons or jails to collect data on pregnancy and childbirth among female inmates. A bill introduced in September 2018 would have required such data collection. However, no action was taken on the bill.

Even the definition of shackling varies. Some states, such as Maryland and New York, ban all restraints immediately before and after birth, though there are exceptions in extraordinary circumstances. Other states, such as Ohio, allow pregnant women to be handcuffed in the front of their bodies, as opposed to behind their bodies, which is thought to be more destabilizing.

Then there is the delineation between shackling during pregnancy, active delivery and postpartum. Individual state laws are filled with nuances. As of 2017, Rhode Island is the only state that has what is called “a private right of action”, an enforcement mechanism allowing the illegally shackled woman to sue for monetary compensation.

The one constant: the acute psychological trauma that shackling inflicts.

“Women subjected to restraint during childbirth report severe mental distress, depression, anguish, and trauma,” states a 2017 report from the American Psychological Association.

“Women who get locked up, tend on average to have suffered many more childhood traumas, says Terry Kupers, MD, a psychiatrist and the author of the book Solitary: The Inside Story of Supermax Isolation and How We Can Abolish It. He implores prison staffs “to be very careful that we do not re-traumatize them. Because re-traumatization makes conditions like post-traumatic stress disorder much worse.”

Amy Ard, executive director of Motherhood Beyond Bars, a not-for-profit in Georgia, worries that the trauma of shackling takes a toll on the self-image of new mothers. Inevitably, this question looms in the minds of the women Ard works with: if I am someone who needs to be chained, how can I expect to also see myself as someone capable of protecting my child?

The info is here.

How Should We Judge Whether and When Mission Statements Are Ethically Deployed?

K. Schuler & D. Stulberg
AMA J Ethics. 2020;22(3):E239-247.
doi: 10.1001/amajethics.2020.239.


Mission statements communicate health care organizations’ fundamental purposes and can help potential patients choose where to seek care and employees where to seek employment. They offer limited benefit, however, when patients do not have meaningful choices about where to seek care, and they can be misused. Ethical implementation of mission statements requires health care organizations to be truthful and transparent about how their mission influences patient care, to create environments that help clinicians execute their professional obligations to patients, and to amplify their obligations to communities.

Ethics, Mission, Standard of Care

Mission statements have long been used to communicate an organization’s values, priorities, and goals; serve as a moral compass for an organization; guide institutional decision making; and align efforts of employees. They can also be seen as advertising to prospective patients and employees. Although health care organizations’ mission statements serve these beneficial purposes, ethical questions (especially about business practices seen as motivating profit by rewarding underutilization) arise when mission implementation conflicts with acting in the best interests of patients. Ethical questions also arise when religiously affiliated organizations deny clinically indicated care in order to uphold their religiously based mission. For example, a Catholic organization’s mission statement might include phrases such as “faithful,” “honoring our sponsor’s spirit,” or “promoting reverence for life” and likely accords the Ethical and Religious Directives for Catholic Health Care Services, which Catholic organizations’ clinicians are required to follow as a condition of employment or privileges.

When strictly followed, these directives restrict health care service delivery, such that patients—particularly those seeking contraception, pregnancy termination, miscarriage management, end-of-life care, or other services perceived as conflicting with Catholic teaching—are not given the standard of care. Federal and state laws protect conscience rights of organizations, allowing them to refuse to provide services that conflict with the deeply held beliefs and values that drive their mission.6 Recognizing the potential for conflict between mission statements and patients’ autonomy or best interests, we maintain that health care organizations have fundamental ethical and professional obligations to patients that should not be superseded by a mission statement.

The info is here.

Monday, March 30, 2020

The Trump administration’s botched coronavirus response

PressTVGerman Lopez
Updated 25 March 20

Here is an excerpt:

It’s also something that the federal government has done well before — recently, with H1N1 and Zika. “It’s been surprising to me that the administration’s had a hard time executing on some of these things,” Ashish Jha, director of the Harvard Global Health Institute, previously told me.

But it’s the kind of thing that the Trump administration has screwed up, while instead trying to downplay the threat of Covid-19. Trump himself has tweeted comparisons of Covid-19 to the common flu — which Jha describes as “really unhelpful,” because the novel coronavirus appears to be much worse. Trump also called concerns about the virus a “hoax.” He said on national television that, based on nothing more than a self-admitted “hunch,” the death rate of the disease is much lower than public health officials projected.

And Trump has rejected any accountability for the botched testing process: “I don’t take responsibility at all,” he said this month.

Jha described the Trump administration’s messaging so far as “deeply disturbing,” adding that it’s “left the country far less prepared than it needs to be for what is a very substantial challenge ahead.”

Even as the Trump administration has tried to escalate its efforts to combat the pandemic, Trump has continued to downplay concerns. Recently, he’s suggested that social distancing measures — asking people to stay home and keep their physical distance from one another — could be lifted within weeks, instead of the months experts say is likely necessary. “What a great timeline that would be,” Trump said.

The info is here.

The race to develop coronavirus treatments pushes the ethics of clinical trials

Olivia Goldhill
Originally posted 28 March 20

Here is an excerpt:

But others are more pragmatic. Arthur Caplan, director of NYU Langone’s Division of Medical Ethics says that when doctors are faced with suffering patients, it’s ethical for them to use drugs that have been approved for other health conditions as treatments. This happened with Ebola, swine flu, Zika, and now coronavirus, he says.

Some of the first coronavirus patients in China, for example, were experimentally given the HIV treatment lopinavir–ritonavir and the rheumatoid arthritis drug Actemra. Now, as the virus continues its rampage around the globe, doctors are eyeballing an increasing number of treatment possibilities—and dealing with the challenging ethics of testing their efficacy while making the safest choices for their patients.

Controlled trials—with caveats

When choosing to use an experimental treatment, doctors have to be as methodical as possible—taking careful note of how sick patients are when given treatment, the dose and timing of medication, and how they fared. “It’s not a study, not controlled, but you want observations to be systematic,” says Caplan.

If, after a couple of weeks and 10 or 20 patients the drug doesn’t seem to cause active harm, Caplan says scientists can quickly move to the first stage of clinical research.

Many of the current coronavirus clinical trials are based on those early experimental treatments. Early research on lopinavir–ritonavir suggests that the drug is not effective, though as the first study was small, researchers plan to investigate further. There are also ongoing trials into arthritis medication Actemra,  antimalarial chloroquine, and Japanese flu drug favipiravir.

While clinical trials typically take months to years to get started, Li believes the current coronavirus trials will set records for speed: “I don’t think they could go any faster,” she says. It helps that there are a lot of coronavirus patients, so it’s easy to quickly enroll study participants.

The info is here.

Sunday, March 29, 2020

Who gets the ventilator in the coronavirus pandemic?

A group of doctors pictured during a surgical operation, with a heart rate monitor in the foreground.Julian Savulescu & Dominic Wilkinson
Updated on 17 March 20

Here is an excerpt:

4. Flatten the curve: the 'too little, too late' approach

There are two wishful-thinking approaches that try to make the problem go away.

The first is that we need more liberty to impose restrictions on the movement of citizens in an effort to "flatten the curve", reduce the number of coronavirus cases and pressure on hospitals, and allow everyone who needs a ventilator to get one.

That may have been possible early on (Singapore and Taiwan adopted severe liberty restriction and seemed to have controlled the epidemic).

However, that horse has bolted and it is now inevitable that there will be a shortage of life-saving medical supplies, as there is in Italy.

This approach is a case of too little, too late.

5. Paternalism: the 'greater harm' myth

The second wishful-thinking approach is that some people try to argue that it is harmful to ventilate older patients, or patients with a poorer prognosis.

One intensive care consultant wrote an open letter to older patients claiming that he and his colleagues would not discriminate against them:

"But we won't use the things that won't work. We won't use machines that can cause harm."

But all medical treatments can cause harm. It is simply incorrect that intensive care "would not work" in a patient with COVID-19 who is older than 60, or who has comorbidities.

Is a 1/1,000 chance of survival worth the discomfort of a month on a ventilator? That is a complex value judgement and people may reasonably differ. I would take the chance.

The claim that intensive care doctors will only withhold treatment that is harmful is either paternalistic or it is confused.

If the doctor claims that they will withhold ventilation when it is harmful, this is a paternalistic value judgement. Where a ventilator has some chance of saving a person's life, it is largely up to that person to decide whether it is a harm or a benefit to take that chance.

Instead, this statement is obscuring the necessary resource allocation decision. It is sanitising rationing by pretending that intensive care doctors are only doing what is best for every patient. That is simply false.

The info is here.

Saturday, March 28, 2020

Hospitals consider universal do-not-resuscitate orders for coronavirus patients

Ariana Eunjung Cha
The Washington Post
Originally posted 25 March 20

Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation few have encountered in their lifetimes — how to weigh the “save at all costs” approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.

The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient “codes,” and their heart or breathing stops.

Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.

Richard Wunderink, one of Northwestern’s intensive-care medical directors, said hospital administrators would have to ask Illinois Gov. J.B. Pritzker for help in clarifying state law and whether it permits the policy shift.

“It’s a major concern for everyone,” he said. “This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances.”

Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country’s major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

The info is here.

Friday, March 27, 2020

Coronavirus and ethics: 'Act so that most people survive'

Georg Marckmann
Originally posted 24 March 20

Here is an excerpt:

Triage, a word used in military medicine, means classification. What groups do you classify the patients into?

There are several categories. Critically-ill patients are treated immediately, the treatment of seriously-ill patients is delayed, and patients who are slightly ill are treated later. Patients with no chance of survival receive purely palliative care.

The crucial element of situations involving a large number of sick people that we can no longer care for adequately is that we have to switch from a patient-centered approach to a group- or population-oriented approach. In a patient-centered approach, we try to adjust treatment as best we can to ensure the well-being of the individual patient and accommodate their wishes.

In a group-centered approach, we try to ensure that the incidence of illness and death within a population group is as low as possible. This places a strain on those making these decisions, because they're not used to it.

As a basic rule, we try to act in such a way that the largest number of people survive, because that is in the public interest.

The info is here.

Human Trafficking Survivor Settles Lawsuit Against Motel Where She Was Held Captive

Todd Bookman
Originally posted 20 Feb 20

Here is an excerpt:

Legal experts and anti-trafficking groups say her 2015 case was the first filed against a hotel or motel for its role in a trafficking crime.

"It is not that any hotel is liable just because trafficking occurred on their premises," explains Cindy Vreeland, a partner at the firm WilmerHale, which handled Ricchio's case pro bono. "The question is whether the company that's been sued knew or should have known about the trafficking."

After a number of appeals and delays, the case finally settled in December 2019 with Ricchio receiving an undisclosed monetary award. Owners of the Shangri-La Motel didn't respond to a request for comment.

"I never thought it would be, like, an eight-year process," Ricchio says. "Anything in the court system seems to take forever."

That slow process isn't deterring other survivors of trafficking from bringing their own suits.

According to the Human Trafficking Institute, there were at least 25 new cases filed nationwide against hotels and motels last year under the TVPA.

Some of the named defendants include major chains such as Hilton, Marriott and Red Roof Inn.

"You can't just let anything happen on your property, turn a blind eye and say, 'Too bad, so sad, I didn't do it, so I'm not responsible,' " says Paul Pennock with the firm Weitz & Luxenberg.

The info is here.

Thursday, March 26, 2020

Respirators, our rights, right and wrong: Medical ethics in an age of coronavirus

Dan Sulmasy
Being human in helping others.nydailynews.com
Originally posted 22 March 20

The coronavirus pandemic is upon us. This novel virus has disrupted lives, killed people, and wreaked havoc with our economy. COVID-19 has also raised novel ethical questions and generated ethical duties for the public, health professionals and the government. Just as our health system has been caught off guard, so have our ethics.

The general principles that guide care for individual patients are the duty to help the sick and respect their autonomy. The general principles that guide public health ethics are concern for the common good and justice. In the current crisis, these principles all come into play. We are in this together. Even if the personal risk for an individual is not great, the risk to the common good is immense. But the measures taken to mitigate the effects of the virus must be just and fair.

The duties for the general public are not arbitrary. They might seem mundane, but they are important and ought to be considered truly ethical duties. Obey the rules: We owe this to each other. Wash your hands. Keep six feet away from strangers. Don’t shake hands with, kiss or hug strangers or acquaintances. Disinfect surfaces where the coronavirus might linger. Self-quarantine if you become sick. Call or email your doctor through an encrypted system or telemedicine connection.

Unless you are experiencing life-threatening distress, don’t rush to the emergency room where you could infect people having heart attacks or complications of cancer. Don’t hoard food, disinfectant wipes, or toilet paper. Don’t spread false and alarming rumors on social media.

Italian nurse with coronavirus dies by suicide over fear of infecting others

Daniela TrezziYaron Steinbuch
Originally published 25 March 20

A 34-year-old Italian nurse working on the front lines of the coronavirus pandemic took her own life after testing positive for the illness and was terrified that she had infected others, according to a report.

Daniela Trezzi had been suffering “heavy stress” amid fears she was spreading the deadly bug while treating patients at the San Gerardo Hospital in Monza in the hard-hit region of Lombardy, the Daily Mail reported.

She was working in the intensive care unit while under quarantine after being diagnosed with COVID-19, according to the UK news site.

The National Federation of Nurses of Italy expressed its “pain and dismay” over Trezzi’s death, which came as the country’s mounting death toll surged with 743 additional fatalities Tuesday.

“Each of us has chosen this profession for good and, unfortunately, also for bad: we are nurses,” the federation said.

The info is here.

Wednesday, March 25, 2020

COVID-19 and the Impossibility of Morality

John Danaher
philosophical disquisitions
Originally published 16 March 20

The stories coming out of Italy over the past two weeks have been chilling. With their healthcare system overwhelmed by COVID-19 cases, Italian doctors are facing tragic triage decisions on a daily basis. In severe cases of COVID-19 patients need ventilators to survive. But there are only so many ventilators to go around. What if you don’t have enough? Who should you save? The 80 year old with COPD and other medical complications or the slightly healthier 50 year old without them? The 45 year old mother of two or the 55 year old single man? The 29 year old healthcare worker or the 38 year old diabetes patient?

Questions like these might sound like thought experiments cooked up in a first year ethics class, but they are not. Indeed, decision-making of this sort is not uncommon in crisis situations. For example, infamous tales are told about what happened at the Memorial Medical Center in New Orleans during Hurricane Katrina in 2005. With rising flood waters, no electricity and several critically ill patients who could not be evacuated, medical workers at Memorial had to make some tough decisions: abandon patients and leave them die in agony or administer euthanizing drugs to end their suffering more quickly? The suspicion is that many chose the latter course of action.

And medical decisions are just the tip of the iceberg. As we are all now being asked to isolate ourselves for the common good, many of us will find ourselves confronting similar, albeit less high stakes decisions. Which is more important: my duty to care for my elderly parents or my duty to protect them (and others) from potential transmission of disease? My duty to work to ensure that other people have the essential services they need or my duty to myself and my family to protect them from illness? We may not like to ask these questions, but we cannot avoid them.

But what are the answers? What should people do in cases like this? I don't know that I have much in the way of specific guidance to offer, but I do have a point that I think is worth making. It's at times like this that the essentially tragic nature of much moral decision-making reveals itself. This tragedy lurks in the background most of the time, but it is brought into sharp relief at times like this. Once we are aware of this ineluctable tragedy we might be inclined to change some of our common moral practices. We might be less inclined to blame others for the choices they make; and we might be more conscious of the pain of moral regret.

The info is here.

What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

K. Drabiak and J. Wolfson
AMA J Ethics. 2020;22(3):E221-231.
doi: 10.1001/amajethics.2020.221.


Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics.

Fraud in Health Care

Growth in corporatization and profitization in medicine, insurance company payment rules, and government regulation have fed natural proclivities, even among physicians, to optimize profits and reimbursements (Florida Department of Health, oral communication, September 2019). According to the most recent Health Care Fraud and Abuse Control Program Annual Report, in one case a management company “pressured and incentivized” dentists to meet specific production goals through a system that disciplined “unproductive” dentists and awarded cash bonuses tied to the revenue from procedures—including many allegedly medically unnecessary services—they performed. This has come at a price: escalating costs, fraud and abuse, medically unnecessary services, adverse effects on patient safety, and physician burnout.

Breaking the cycle of bad behaviors that are induced in part by financial incentives speaks to core ethical issues in the practice of medicine that can be addressed through a combination of organizational and cultural enhancements and more transparent practice-based compliance and risk management systems that rely on front-end data analytics designed to identify, flag, and focus investigations on fraud and abuse at the practice site. Here, we discuss types of health care fraud and their impact on health care costs and patient safety, how this behavior is incentivized and justified within current and evolving medical practice settings, and a 2-pronged strategy for mitigating this behavior.

The info is here.