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
Showing posts with label Beneficence. Show all posts
Showing posts with label Beneficence. Show all posts

Tuesday, May 14, 2024

New California Court for the Mentally Ill Tests a State’s Liberal Values

Tim Arango
The New York Times
Originally posted 21 March 24

Here is an excerpt:

The new initiative, called CARE Court — for Community Assistance, Recovery and Empowerment — is a cornerstone of California’s latest campaign to address the intertwined crises of mental illness and homelessness on the streets of communities up and down the state.

Another piece of the effort is Proposition 1, a ballot measure championed by Gov. Gavin Newsom and narrowly approved by California voters this month. It authorizes $6.4 billion in bonds to pay for thousands of treatment beds and for more housing for the homeless — resources that could help pay for treatment plans put in place by CARE Court judges.

And Mr. Newsom, a Democrat in his second term, has not only promised more resources for treatment but has pledged to make it easier to compel treatment, arguing that civil liberties concerns have left far too many people without the care they need.

So when Ms. Collette went to court, she was surprised, and disappointed, to learn that the judge would not be able to mandate treatment for Tamra.

Instead, it is the treatment providers who would be under court order — to ensure that medication, therapy and housing are available in a system that has long struggled to reliably provide such services.

“I was hoping it would have a little more punch to it,” Ms. Collette said. “I thought it would have a little more power to order them into some kind of care.”

Here is a summary:

California's new CARE Court (Community Assistance, Recovery and Empowerment) is a court system designed to address the issues of mental illness and homelessness. It aims to provide court-ordered care plans for individuals struggling with severe mental illness who are unable to care for themselves. This initiative tests the state's liberal values by balancing individual liberty with the need for intervention to help those in crisis.

Monday, March 4, 2024

How to Deal with Counter-Examples to Common Morality Theory: A Surprising Result

Herissone-Kelly P.
Cambridge Quarterly of Healthcare Ethics.


Tom Beauchamp and James Childress are confident that their four principles—respect for autonomy, beneficence, non-maleficence, and justice—are globally applicable to the sorts of issues that arise in biomedical ethics, in part because those principles form part of the common morality (a set of general norms to which all morally committed persons subscribe). Inevitably, however, the question arises of how the principlist ought to respond when presented with apparent counter-examples to this thesis. I examine a number of strategies the principlist might adopt in order to retain common morality theory in the face of supposed counter-examples. I conclude that only a strategy that takes a non-realist view of the common morality’s principles is viable. Unfortunately, such a view is likely not to appeal to the principlist.

Herissone-Kelly examines various strategies principlism could employ to address counter-examples:

Refine the principles: This involves clarifying or reinterpreting the principles to better handle specific cases.
  • Prioritize principles: Establish a hierarchy among the principles to resolve conflicts.
  • Supplement the principles: Introduce additional considerations or context-specific factors.
  • Limit the scope: Acknowledge that the principles may not apply universally to all cultures or situations.
Herissone-Kelly argues that none of these strategies are fully satisfactory. Refining or prioritizing principles risks distorting their original meaning or introducing arbitrariness. Supplementing them can lead to an unwieldy and complex framework. Limiting their scope undermines the theory's claim to universality.

He concludes that the most viable approach is to adopt a non-realist view of the common morality's principles. This means understanding them not as objective moral facts but as flexible tools for ethical reflection and deliberation, open to interpretation and adaptation in different contexts. While this may seem to weaken the theory's authority, Herissone-Kelly argues that it allows for a more nuanced and practical application of ethical principles in a diverse world.

Wednesday, November 23, 2022

You Can't Win at Morality

Kurt Gray, Will Blakey, and Carlos Rebollar
Moral Understanding Substack
Originally posted 26 OCT 22

Here is an excerpt:

Moral Ideals

Most of us want to do good in the world, and follow a set of moral guidelines, or “ideals.” But the word “ideals” has dangerous roots. The etymology of the very word “ideal” implies perfection, which we authors believe is bad.

 In 1796, Immanuel Kant used the word “ideal” to describe a hypothetically perfect person, thing, or state. It may have been easy for Kant to fetishize the perfect moral person, but it’s not clear that he is the best role model for us modern people (or anyone else). Kant was a weird guy. He once likened sex to sucking dry a lemon (scholars think he died a virgin), he thought you had to tell the truth even if it meant the slaughter of an innocent family, and he thought it was a good idea to get a portrait taken that highlighted his giant bald forehead and left most of his face in darkness (see picture).

Despite Kant’s questionable judgment, an ideal-driven ethics is widely promoted. Christianity’s most popular role model is Jesus, and they say he was perfect. Tony Robbins, self-help guru, says that we should become the best version of ourselves. The reasoning goes, “if our ideals are unachievable, that’s the whole point! They’re supposed to make you shoot for the moon.” This is why Kant’s idealism is so seductive. We think it’ll make us never stop improving ourselves. When it comes to role models, we don’t search for pretty good people, we search for moral perfection and emulate it to the best of our abilities.

As advocates for increasing moral understanding in the world, we are not arguing that people should stop striving to do good. But we do think that the quest for moral perfection can lead us astray. “The perfect is the enemy of the good” is a quote that’s useful in a lot of cases, but it’s especially useful when it comes to morality.

We argue that striving for moral perfection or “trying to win at morality,” has at least two main drawbacks: First, it can contribute to unhealthy thinking, and second, it can deter us from taking steps in the right direction. Instead, we propose that striving for more moral good (not the most) and practicing moral humility can help us do good in the world around us.

Anxiety is the Dizziness of Freedom… When Your Goal is Perfection

Achieving moral perfection is tricky because, as we saw with Janet, answers to the “most moral good” are uncertain. And this is a problem because uncertainty about big questions doesn’t feel good.

Take these big questions: Is God real? Are we living in a simulation? Why are we here and what is the meaning of life? For many, the uncertainty inherent in these questions is a background feature of life. But for others, including me (Will), it is too often an anxiety-provoking challenge. I struggle with “existential OCD,” a psychological disorder involving anxiety resulting from intrusive thoughts and discomfort about these big life questions. Not knowing why we’re all here or where we’re all going often stresses me out. But I’ve largely been able to combat this stress through therapy and renegotiating a better relationship with uncertainty.

Thursday, June 23, 2022

Thousands of Medical Professionals Urge Supreme Court To Uphold Roe: ‘Provide Patients With the Treatment They Need’

Phoebe Kolbert
Ms. Magazine
Originally posted 21 JUN 22

Any day now, the Supreme Court will issue its decision in Dobbs v. Jackson Women’s Health Organization, which many predict will overturn or severely gut Roe v. Wade. Since the start of the Dobbs v. Jackson hearings in December, medical professionals have warned of the drastic health impacts brought on by abortion bans. Now, over 2,500 healthcare professionals from all 50 states have signed a letter urging the Supreme Court to scrap their leaked Dobbs draft opinion and uphold Roe.  

Within 30 days of a decision to overturn Roe, at least 26 states will ban abortion. Clinics in remaining pro-abortion states are preparing for increased violence from anti-abortion extremists and an influx of out-of-state patients. The number of legal abortions performed nationwide is projected to fall by about 13 percent. Many abortion clinics in states with bans will be forced to close their doors, if they haven’t already. The loss of these clinics also comes with the loss of the other essential reproductive healthcare they provide, including STI screenings and treatment, birth control and cervical cancer screenings.

The letter, titled “Medical Professionals Urge Supreme Court to Uphold Roe v. Wade, Protect Abortion Access,” argues that decisions around pregnancy and abortion should be made by patients and their doctors, not the courts.

Here is how the letter begins:

Medical Professionals Urge Supreme Court to Uphold Roe v. Wade, Protect Abortion Access

As physicians and health care professionals, we are gravely concerned that the U.S. Supreme Court appears prepared to end the constitutional right to an abortion. We urge the Supreme Court to to scrap their draft opinion, uphold the constitutional right to an abortion, and ensure that abortions remain legal nationwide, as allowed for in Roe v. Wade. In this moment of crisis, we want to make crystal clear the consequences to our patients’ health if they can no longer access abortions.

Abortions are safe, common and a critical part of health care and reproductive medicine. Medical professionals and medical associations agree, including the American Medical Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American College of Nurse Midwives and many others.

Prohibiting access to safe and legal abortion has devastating implications for health care. Striking down Roe v. Wade would affect not just abortion access, but also maternal care as well as fertility treatments. Pregnancy changes a person’s physiology. These changes can potentially worsen existing diseases and medical conditions.

As physicians and medical professionals, we see the real-life consequences when an individual does not get the care that they know they need, including abortions. The woman who has suffered the violation and trauma of rape would be forced to carry a pregnancy.

Denying access to abortion from people who want one can adversely affect their health, safety and economic well-being, including delayed separation from a violent partner and increased likelihood of falling into poverty by four times. These outcomes can also have drastic impacts on their health.

Wednesday, June 22, 2022

South Carolina bill permits health care providers refuse non-emergency care based on beliefs

Brooke Migdon
The Hill
Originally posted 1 APR 22

Story at a glance
  • Legislators in South Carolina on Friday passed a bill which would allow healthcare providers to deny care based on their personal beliefs. It would also apply to insurance companies, which may be entitled to refuse to pay for care.
  • The bill would also protect those who decline to provide medical services from civil, criminal or administrative liability.
  • Some say the bill, known as the “Medical Ethics and Diversity Act,” would disproportionately affect the LGBTQ+ community, as well as women and people of color.
South Carolina lawmakers on Friday passed a bill allowing medical professionals and insurance companies to deny care based on personal belief. Some say the legislation, which now heads to the state Senate for consideration, would disproportionately impact LGBTQ+ people, women, and people of color.

Under the bill, titled the “Medical Ethics and Diversity Act,” South Carolina law would be altered to excuse medical practitioners, health care institutions and health care payers from providing care that violates their “conscience.” It would also shield those who decline to provide medical services to patients from civil, criminal or administrative liability.

Dozens of state residents in February testified against the bill, calling it vague and overbroad. They also shared concerns that the legislation would disproportionately impact marginalized communities.

In a statement on Friday, Human Rights Campaign Legal Director Sarah Warbelow said she finds it “disturbing” that politicians in South Carolina are prioritizing individual providers’ beliefs over the wellbeing of patients.

“This legislation is dangerously silent in regards to the needs of patients and fails to consider the impact that expanding refusals can have on their health,” she said. “Religious freedom is a fundamental American value that is entirely compatible with providing quality, non-discriminatory healthcare. It is not a license to deprive others of their rights simply because of personal beliefs.”

Warbelow said the bill sends a message to patients with non-medical views inconsistent with that of their doctors that they are “not equal members of society entitled to dignity and respect.”

Editor's Note: Those politicians who pass laws based on culture wars are clearly violating the principle-based ethics on which all medical ethics rely.  If they pass harmful laws that conflict with health care ethics, then they are not fit to serve.

Saturday, March 12, 2022

The Moral Injury of COVID: How Will Nurses Survive?

Diane M. Goodman
Originally posted 11 FEB 22

Here are some excerpts:

According to recent statistics, 1 in 5 nurses have retired from active duty since the pandemic began. Far from feeling like heroes, nurses now feel exhausted, demoralized, underappreciated, and severely overworked. They are broken in ways that cannot be repaired.

Recently, an intensive care unit nurse abandoned his shift in the middle of the night and walked off into the unknown only to be found deceased 2 days later. What happened to this caregiver? Was his distress so severe he could not communicate pain? One can only wonder.

Nurses across the country are suffering from moral injury.


This is what nurses feel prepared to do, but it violates their moral code.

Nurses may be unfamiliar with the process of rationing care, but the pandemic has changed that perspective. Nurses are now dealing with a form of rationing that leaves them miserable, in tears, and in persistent distress.

Providing care for 10 patients as opposed to a maximum of five forces nurses to make appalling decisions. Which patient needs my attention now? Will another patient die while I am in this room? How can I choose without suffering lasting trauma from my decisions?

Nurses have repeatedly been placed in impossible situations throughout the pandemic.

Remember the early days of PPE shortages? Nurses went without appropriate attire to protect their peers, at times with fatal results. 


The profession prides itself on delivering the highest quality care it can. But when was the last time nurses felt that they were meeting this standard? How can they? They are working in a system where their own needs are minimized to meet the demands of an ongoing COVID patient population.

Moral injury, which can lead to moral trauma if unresolved, is different from burnout. 

Moral injury affects our sense of right and wrong. Moral injury is different because it represents a situation of witnessing care or offering care that conflicts with our internal compass. It is witnessing patients die without loved ones, repeatedly, or instituting a crisis standard of care that feels endless, although no earthquake, tornado, or bus accident has occurred. It is a feeling of running behind without the possibility of ever getting a break.

Moral injury is lasting distress that leads to feelings such as guilt, anger, and shame. There are true psychological implications for this type of angst. 

Saturday, February 26, 2022

Experts Are Ringing Alarms About Elon Musk’s Brain Implants

Noah Kirsch
Daily Beast
Posted 25 Jan 2021

Here is an excerpt:

“These are very niche products—if we’re really only talking about developing them for paralyzed individuals—the market is small, the devices are expensive,” said Dr. L. Syd Johnson, an associate professor in the Center for Bioethics and Humanities at SUNY Upstate Medical University.

“If the ultimate goal is to use the acquired brain data for other devices, or use these devices for other things—say, to drive cars, to drive Teslas—then there might be a much, much bigger market,” she said. “But then all those human research subjects—people with genuine needs—are being exploited and used in risky research for someone else’s commercial gain.”

In interviews with The Daily Beast, a number of scientists and academics expressed cautious hope that Neuralink will responsibly deliver a new therapy for patients, though each also outlined significant moral quandaries that Musk and company have yet to fully address.

Say, for instance, a clinical trial participant changes their mind and wants out of the study, or develops undesirable complications. “What I’ve seen in the field is we’re really good at implanting [the devices],” said Dr. Laura Cabrera, who researches neuroethics at Penn State. “But if something goes wrong, we really don't have the technology to explant them” and remove them safely without inflicting damage to the brain.

There are also concerns about “the rigor of the scrutiny” from the board that will oversee Neuralink’s trials, said Dr. Kreitmair, noting that some institutional review boards “have a track record of being maybe a little mired in conflicts of interest.” She hoped that the high-profile nature of Neuralink’s work will ensure that they have “a lot of their T’s crossed.”

The academics detailed additional unanswered questions: What happens if Neuralink goes bankrupt after patients already have devices in their brains? Who gets to control users’ brain activity data? What happens to that data if the company is sold, particularly to a foreign entity? How long will the implantable devices last, and will Neuralink cover upgrades for the study participants whether or not the trials succeed?

Dr. Johnson, of SUNY Upstate, questioned whether the startup’s scientific capabilities justify its hype. “If Neuralink is claiming that they’ll be able to use their device therapeutically to help disabled persons, they’re overpromising because they’re a long way from being able to do that.”

Neuralink did not respond to a request for comment as of publication time.

Friday, February 25, 2022

Public Deliberation about Gene Editing in the Wild

M. K. Gusmano, E. Kaebnick, et al. (2021).
Hastings Center Report
10.1002/hast.1318, 51, S2, (S34-S41).


Genetic editing technologies have long been used to modify domesticated nonhuman animals and plants. Recently, attention and funding have also been directed toward projects for modifying nonhuman organisms in the shared environment—that is, in the “wild.” Interest in gene editing nonhuman organisms for wild release is motivated by a variety of goals, and such releases hold the possibility of significant, potentially transformative benefit. The technologies also pose risks and are often surrounded by a high uncertainty. Given the stakes, scientists and advisory bodies have called for public engagement in the science, ethics, and governance of gene editing research in nonhuman organisms. Most calls for public engagement lack details about how to design a broad public deliberation, including questions about participation, how to structure the conversations, how to report on the content, and how to link the deliberations to policy. We summarize the key design elements that can improve broad public deliberations about gene editing in the wild.

Here is the gist of the paper:

We draw on interdisciplinary scholarship in bioethics, political science, and public administration to move forward on this knot of conceptual, normative, and practical problems. When is broad public deliberation about gene editing in the wild necessary? And when it is required, how should it be done? These questions lead to a suite of further questions about, for example, the rationale and goals of deliberation, the features of these technologies that make public deliberation appropriate or inappropriate, the criteria by which “stakeholders” and “relevant publics” for these uses might be identified, how different approaches to public deliberation map onto the challenges posed by the technologies, how the topic to be deliberated upon should be framed, and how the outcomes of public deliberation can be meaningfully connected to policy-making.

Wednesday, February 23, 2022

I See Color

Khama Ennis
On The Flip Side
Original date: February 13, 2020

9 minutes worth watching: Patient biases versus professional obligations

Sunday, October 24, 2021

Evaluating Tradeoffs between Autonomy and Wellbeing in Supported Decision Making

Veit, W., Earp, B.D., Browning, H., Savulescu, J.
American Journal of Bioethics 

A core challenge for contemporary bioethics is how to address the tension between respecting an individual’s autonomy and promoting their wellbeing when these ideals seem to come into conflict (Notini  et  al.  2020).  This  tension  is  often  reflected  in  discussions  of  the  ethical  status  of guardianship and other surrogate decision-making regimes for individuals with different kinds or degrees of cognitive ability and (hence) decision-making capacity (Earp and Grunt-Mejer 2021), specifically when these capacities are regarded as diminished or impaired along certain dimensions (or with respect to certain domains). The notion or practice of guardianship, wherein a guardian is legally appointed to make decisions on behalf of someone with different/diminished capacities, has been particularly controversial. For example, many people see guardianship as unjust, taking too  much  decisional  authority  away  from  the  person  under  the  guardian’s  care  (often  due  to prejudiced attitudes, as when people with certain disabilities are wrongly assumed to lack decision-making capacity); and as too rigid, for example, in making a blanket judgment about someone’s (lack of) capacity, thereby preventing them from making decisions even in areas where they have the requisite abilities (Glen 2015).

It is  against  this  backdrop that  Peterson,  Karlawish, and  Largent (2021) offer  a  useful philosophical framework for the notion of ‘supported decision-making’ as a compelling alternative for  individuals  with  ‘dynamic  impairments’  (i.e.,  non-static  or  domain-variant  perceived mpairments  in  decision-making  capacity).  In  a  similar spirit,  we  have  previously  argued  that bioethics would benefit from a more case-sensitive rather than a ‘one-size-fits-all’ approach when it comes to issues of cognitive diversity (Veit et al. 2020; Chapman and Veit 2020). We therefore agree with most of the authors’ defence of supported decision-making, as this approach allows for case- and context-sensitivity. We also agree with the authors that the categorical condemnation of guardianships  or  similar  arrangements  is  not  justified,  as  this  precludes  such  sensitivity.  For instance, as the authors note, if a patient is in a permanent unaware/unresponsive state – i.e., with no  current  or  foreseeable  decision-making  capacity  or  ability  to  exercise  autonomy  –  then  a guardianship-like regime may be the most appropriate means of promoting this person’s interests. A similar point can be made in relation to debates about intended human enhancement of embryos and children.  Although some critics  claim that  such interventions  violate the autonomy  of the enhanced person, proponents may argue that respect for autonomy and consent do not apply in certain cases, for example, when dealing with embryos (see Veit 2018); alternatively, they may argue that interventions to enhance the (future) autonomy of a currently pre-autonomous (or partially autonomous) being can be justified on an enhancement framework without falling prey to such objections (see Earp 2019, Maslen et al. 2014). 

Saturday, October 9, 2021

Nudgeability: Mapping Conditions of Susceptibility to Nudge Influence

de Ridder, D., Kroese, F., & van Gestel, L. (2021). 
Perspectives on psychological science 
Advance online publication. 


Nudges are behavioral interventions to subtly steer citizens' choices toward "desirable" options. An important topic of debate concerns the legitimacy of nudging as a policy instrument, and there is a focus on issues relating to nudge transparency, the role of preexisting preferences people may have, and the premise that nudges primarily affect people when they are in "irrational" modes of thinking. Empirical insights into how these factors affect the extent to which people are susceptible to nudge influence (i.e., "nudgeable") are lacking in the debate. This article introduces the new concept of nudgeability and makes a first attempt to synthesize the evidence on when people are responsive to nudges. We find that nudge effects do not hinge on transparency or modes of thinking but that personal preferences moderate effects such that people cannot be nudged into something they do not want. We conclude that, in view of these findings, concerns about nudging legitimacy should be softened and that future research should attend to these and other conditions of nudgeability.

From the General Discussion

Finally, returning to the debates on nudging legitimacy that we addressed at the beginning of this article, it seems that concerns should be softened insofar as nudges do impose choice without respecting basic ethical requirements for good public policy. More than a decade ago, philosopher Luc Bovens (2009) formulated the following four principles for nudging to be legitimate: A nudge should allow people to act in line with their overall preferences; a nudge should not induce a change in preferences that would not hold under nonnudge conditions; a nudge should not lead to “infantilization,” such that people are no longer capable of making autonomous decisions; and a nudge should be transparent so that people have control over being in a nudge situation. With the findings from our review in mind, it seems that these legitimacy requirements are fulfilled. Nudges do allow people to act in line with their overall preferences, nudges allow for making autonomous decisions insofar as nudge effects do not depend on being in a System 1 mode of thinking, and making the nudge transparent does not compromise nudge effects.

Saturday, October 2, 2021

We’ve Never Protected the Vulnerable

Aaron Carroll
The Atlantic
Originally posted 5 Sept 21

Here is an excerpt:

The Americans With Disabilities Act provides for some accommodations for people with disabilities or diseases in certain situations, but those are extremely limited. They also apply only to the afflicted. My friend’s wife, a teacher, couldn’t tell her school that she needed special treatment because someone was vulnerable in her life. The school implemented no precautions to reduce her chance of being exposed to illness and getting sick, in order to keep her husband safe at home. Neither could his kids demand changes at their schools. Asking schools to alter their behavior to protect relatives of students may seem like a big ask, but I couldn’t even persuade all of our close friends to get vaccinated against the flu to protect him.

COVID-19 has exposed these gaps in our public solidarity, not caused them. The way we handle influenza is the best example, as the infectious disease that usually causes the highest number of deaths each year. Even though the young and the old are at real risk from flu, along with the immunocompromised, we’ve almost never engaged in any special protections for these groups. I’ve begged people for years to get immunized to protect others, and most don’t listen. Other countries mask more during respiratory-virus seasons; almost no one even thinks of masking here. Few distance from others, even though that’s a more palatable option for most Americans. To the contrary, many people consider it a mark of pride to “tough it out” and come to work while sick, potentially exposing others.

Our current situation with COVID-19 is especially difficult because so many Americans believe they’ve already given more than enough. Any further adjustments to their life, even if they seem small, feel like too much to bear. It’s natural that Americans want to get back to normal, and I’m not arguing that we should lock down until no risk remains. I’m asking that we think about others more in specific settings. We don’t all have to wear a mask all the time, but we could get used to always carrying one. That way, if we are around people who might live with others at high risk, we could mask around them and stand a little farther away. We could cancel our evening plans or miss a concert if we’re sick. Is it really that hard to get a flu shot every year?

Friday, October 1, 2021

The prisoner’s dilemma: The role of medical professionals in executions

Elisabeth Armstrong
Journal of Medical Ethics
Originally posted 7 Sept 21

Here is an excerpt:

Clinician Participation in Executions is Either Wrong or Misguided

Clinicians might participate in executions out of an inappropriate commitment to capital punishment; this position of leveraging medical education and credentials to punish or harm has no grounding in ethical conversation. It is entirely inappropriate to undermine trust in the medical profession in service of one’s political or philosophical beliefs – those ought to be relegated to the voting booths.

However, some practitioners might be present at an execution out of a well-intentioned, but misguided commitment to preventing suffering. Their reasoning is along the lines, “If states are proceeding with an execution, shouldn’t a clinician be present to ensure there is no undue harm or suffering?” Writing on lethal injections, Dr. Sandeep Jahaur writes in the New York Times, “Barring physicians from executions will only increase the risk that prisoners will unduly suffer,” in violation of the Hippocratic Oath and the 8th Amendment of the US Constitution. He points out that no ethics board would allow the testing of execution drugs on human participants, therefore, in the absence of a “controlled investigation” it is important that a doctor is present to assist when things go awry.

Dr. Jahaur adds that if doctors (or other clinicians) do not assist, people with less experience are often called upon to insert catheters, assess and insert the IVs, mix and administer the drugs, monitor a patient’s vital signs, then confirm death; and of course, step in if anything goes wrong. Dr. Atul Gawande agrees that it is unlikely that a lethal injection could be performed without a physician without the occasional tragic mistake. As recently as October of 2014, the lack of involvement from clinicians resulted in the administration of an incorrect drug to an inmate – resulting in forty-three minutes of writhing and groaning before he died.

The Case for Ending Practitioner Participation

There is no denying that these cases of suffering are disturbing and compelling. Ultimately, however, the bioethical case for participation is grossly outweighed by the case against it: medical involvement on any level intrinsically violates the ethical principles of autonomy, beneficence, non-maleficence, and justice – compromising the foundations of the medical system. (Underline added.)

Wednesday, August 25, 2021

As a doctor in a COVID unit, I’m running out of compassion for the unvaccinated. Get the shot

Anita Sircar
The Los Angeles Times
Originally published 17 Aug 21

Here is an excerpt:

The burden of this pandemic now rests on the shoulders of the unvaccinated. On those who are eligible to get vaccinated but choose not to, a decision they defend by declaring, “Vaccination is a deeply personal choice.” But perhaps never in history has anyone’s personal choice affected the world as a whole as it does right now. When hundreds and thousands of people continue to die — when the most vulnerable members of society, our children, cannot be vaccinated — the luxury of choice ceases to exist.

If you believe the pandemic is almost over and I can ride it out, without getting vaccinated, you could not be more wrong. This virus will find you.


If you believe if I get infected I’ll just go to the hospital and get treated, there is no guarantee we can save your life, nor even a promise we’ll have a bed for you.

If you believe I’m pregnant and I don’t want the vaccine to affect me, my baby or my future fertility, it matters little if you’re not alive to see your newborn.

If you believe I won’t get my children vaccinated because I don’t know what the long-term effects will be, it matters little if they don’t live long enough for you to find out.

If you believe I’ll just let everyone else get vaccinated around me so I don’t have to, there are 93 million eligible, unvaccinated people in the “herd” who think the same way you do and are getting in the way of ending this pandemic.

If you believe vaccinated people are getting infected anyway, so what’s the point?, the vaccine was built to prevent hospitalizations and deaths from severe illness. Instead of fatal pneumonia, those with breakthrough infections have a short, bad cold, so the vaccine has already proved itself. The vaccinated are not dying of COVID-19.

SARS-CoV-2, the virus that causes COVID-19, has mutated countless times during this pandemic, adapting to survive. Stacked up against a human race that has resisted change every step of the way — including wearing masks, social distancing, quarantining and now refusing lifesaving vaccines — it is easy to see who will win this war if human behavior fails to change quickly.

Sunday, August 22, 2021

America’s long history of anti-science has dangerously undermined the COVID vaccine

Peter Hotez
The Dallas Morning News
Originally published 15 Aug 21

Here is an excerpt:

America’s full-throated enthusiasm for vaccines lasted until the early 2000s. The 1998 Lancet publication of a paper from Andrew Wakefield and his colleagues, which wrongly asserted that the measles virus in the MMR vaccine replicated in the colons of children to cause pervasive developmental disorder (autism), ushered in a new era of distrust for vaccine.

It also resulted in distrust for the U.S. Health and Human Services agencies promoting vaccinations. The early response from the Centers for Disease Control and Prevention was to dismiss growing American discontent for vaccines as a fringe element, until eventually in the 2010s anti-vaccine sentiment spread across the internet.

The anti-vaccine movement eventually adopted medical freedom and used it to gain strength and accelerate in size, internet presence and external funding. Rising out of the American West, anti-vaccine proponents insisted that only parents could make vaccine choices and they were prepared to resist government requirements for school entry or attendance.

In California, the notion of vaccine choice gained strength in the 2010s, leading to widespread philosophical exemptions to childhood MMR vaccines and other immunizations. Vaccine exemptions reached critical mass, ultimately culminating in a 2014–2015 measles epidemic in Orange County.

The outbreak prompted state government intervention through the introduction of California Senate Bill 277 that eliminated these exemptions and prevented further epidemics, but it also triggered aggressive opposition. Anti-vaccine health freedom groups harassed members of the Legislature and labeled prominent scientists as pharma shills. They touted pseudoscience, claiming that vaccines were toxic, or that natural immunity acquired from the illness was superior and more durable than vaccine-induced immunity.

Health freedom then expanded through newly established anti-vaccine political action committees in Texas and Oklahoma in the Southwest, Oregon in the Pacific Northwest, and Michigan and Ohio in the Midwest, while additional anti-vaccine organizations formed in almost every state.

These groups lobbied state legislatures to promote or protect vaccine exemptions, while working to cloak or obscure classroom or schoolwide disclosures of vaccine exemptions. They also introduced menacing consent forms to portray vaccines as harmful or toxic.

The Texans for Vaccine Choice PAC formed in 2015, helping to accelerate personal belief immunization exemptions to a point where today approximately 72,000 Texas schoolchildren miss vaccines required for school entry and attendance.

Sunday, July 25, 2021

Should we be concerned that the decisions of AIs are inscrutable?

John Zerilli
Originally published 14 June 21

Here is an excerpt:

However, there’s a danger of carrying reliabilist thinking too far. Compare a simple digital calculator with an instrument designed to assess the risk that someone convicted of a crime will fall back into criminal behaviour (‘recidivism risk’ tools are being used all over the United States right now to help officials determine bail, sentencing and parole outcomes). The calculator’s outputs are so dependable that an explanation of them seems superfluous – even for the first-time homebuyer whose mortgage repayments are determined by it. One might take issue with other aspects of the process – the fairness of the loan terms, the intrusiveness of the credit rating agency – but you wouldn’t ordinarily question the engineering of the calculator itself.

That’s utterly unlike the recidivism risk tool. When it labels a prisoner as ‘high risk’, neither the prisoner nor the parole board can be truly satisfied until they have some grasp of the factors that led to it, and the relative weights of each factor. Why? Because the assessment is such that any answer will necessarily be imprecise. It involves the calculation of probabilities on the basis of limited and potentially poor-quality information whose very selection is value-laden.

But what if systems such as the recidivism tool were in fact more like the calculator? For argument’s sake, imagine a recidivism risk-assessment tool that was basically infallible, a kind of Casio-cum-Oracle-of-Delphi. Would we still expect it to ‘show its working’?

This requires us to think more deeply about what it means for an automated decision system to be ‘reliable’. It’s natural to think that such a system would make the ‘right’ recommendations, most of the time. But what if there were no such thing as a right recommendation? What if all we could hope for were only a right way of arriving at a recommendation – a right way of approaching a given set of circumstances? This is a familiar situation in law, politics and ethics. Here, competing values and ethical frameworks often produce very different conclusions about the proper course of action. There are rarely unambiguously correct outcomes; instead, there are only right ways of justifying them. This makes talk of ‘reliability’ suspect. For many of the most morally consequential and controversial applications of ML, to know that an automated system works properly just is to know and be satisfied with its reasons for deciding.

Friday, June 25, 2021

Rugged American Individualism is a Myth, and It’s Killing Us

Katherine Wasson
Hastings Center
Originally published 4 June 21

The starkest picture of rugged American individualism is one we learned in school. A family moves West to settle the land and struggles with the elements.  Yet, even in these depictions, settlers needed help to raise a barn or harvest crops. They drew on the help of others and reciprocated in return. In the 21st century few Americans live in any way close to this largely self-sustaining lifestyle. Yet, the myth of rugged individualism is strong and persistent.

The reality for all of us is that none survive or flourish without the help of others. Whether it is within a family, peer group, school, religious institution, or wider community, all of us have been helped by others. Someone somewhere encouraged us, gave us a break or an opportunity, however small.  Some have experienced random acts of kindness from strangers. The myth of rugged individualism, which often means “pulling yourself up by your own bootstraps,” is outdated, was never completely accurate, and is harming us.

Holding tightly to this myth leads to the misperception that an individual can do (or not do) whatever they want in society and no person or, perhaps especially, government entity can tell them otherwise. People say, “As long as my choice doesn’t harm anyone else, I should be able to do what I want.” How they know their action does not harm anyone else is unclear and there are examples from the pandemic where personal choice does harm others. In bioethics we recognize this view as an expression of individual autonomy; the freedom to govern oneself.  Yet, such blinkered views of individual autonomy are misguided and inaccurate. Everyone’s autonomy is limited in society to avoid harm to the self or others. We enforce seatbelt and drunk driving laws to these ends. Moreover, that we rely on others to function in society has been made very clear during the pandemic. We need others to provide food and education, collect our garbage, and conduct the scientific research that informs our knowledge of the virus. These contributions support the common good.

We have seen rugged individualism on full display during the coronavirus pandemic. It can lead to a disregard for the worth and value of others. While many people observed public health restrictions and guidelines, others, including some elected officials, refused to wear masks and are now refusing vaccination. Those who cling to their individualism seem to view such restrictions as unnecessary or unacceptable, an infringement on their individual rights and freedoms. They are not willing to sacrifice a degree of their freedom to protect themselves or others. The result has been 33,264,650 cases and 594,568 deaths in the United States and counting. 

Thursday, June 24, 2021

Updated Physician-Aid-in-Dying Law Sparks Controversy in Canada

Richard Karel
Psychiatric News
Originally posted 27 May 21

Here is an excerpt:

Addressing the changes for people who may be weighing MAID for severe mental illness, the government stated the following:

“If you have a mental illness as your only medical condition, you are not eligible to seek medical assistance in dying. … This temporary exclusion allows the Government of Canada more time to consider how MAID can safely be provided to those whose only medical condition is mental illness.

“To support this work, the government will initiate an expert review to consider protocols, guidance, and safeguards for those with a mental illness seeking MAID and will make recommendations within a year (by March 17, 2022).

“After March 17, 2023, people with a mental illness as their sole underlying medical condition will have access to MAID if they are eligible and the practitioners fulfill the safeguards that are put in place for this group of people. …”

While many physicians and others have long been sympathetic to allowing medical professionals to help those with terminal illness die peacefully, the fear has been that medically assisted death could become a substitute for adequate—and more costly—medical care. Those concerns are growing with the expansion of MAID in Canada.

Monday, April 19, 2021

The Military Is Funding Ethicists to Keep Its Brain Enhancement Experiments in Check

Sara Scoles
Originally posted 1 April 21

Here is an excerpt:

The Department of Defense has already invested in a number of projects to which the Minerva research has relevance. The Army Research Laboratory, for example, has funded researchers who captured and transmitted a participant’s thoughts about a character’s movement in a video game, using magnetic stimulation to beam those neural instructions to another person’s brain and cause movement. And it has supported research using deep learning algorithms and EEG readings to predict a person’s “drowsy and alert” states.

Evans points to one project funded by Defense Advanced Research Projects Agency (DARPA): Scientists tested a BCI that allowed a woman with quadriplegia to drive a wheelchair with her mind. Then, “they disconnected the BCI from the wheelchair and connected to a flight simulator,” Evans says, and she brainfully flew a digital F-35. “DARPA has expressed pride that their work can benefit civilians,” says Moreno. “That helps with Congress and with the public so it isn’t just about ‘supersoldiers,’” says Moreno.

Still, this was a civilian participant, in a Defense-funded study, with “fairly explicitly military consequences,” says Evans. And the big question is whether the experiment’s purpose justifies the risks. “There’s no obvious therapeutic reason for learning to fly a fighter jet with a BCI,” he says. “Presumably warfighters have a job that involves, among other things, fighter jets, so there might be a strategic reason to do this experiment. Civilians rarely do.”

It’s worth noting that warfighters are, says Moreno, required to take on more risks than the civilians they are protecting, and in experiments, military members may similarly be asked to shoulder more risk than a regular-person participant.

DARPA has also worked on implants that monitor mood and boost the brain back to “normal” if something looks off, created prosthetic limbs animated by thought, and made devices that improve memory. While those programs had therapeutic aims, the applications and follow-on capabilities extend into the enhancement realm — altering mood, building superstrong bionic arms, generating above par memory.

Tuesday, April 13, 2021

Can Clinical Empathy Survive? Distress, Burnout, and Malignant Duty in the Age of Covid‐19

A. Anzaldua & J. Halpern
Hastings Report
Jan-Feb 2021 22-27.


The Covid‐19 crisis has accelerated a trend toward burnout in health care workers, making starkly clear that burnout is especially likely when providing health care is not only stressful and sad but emotionally alienating; in such situations, there is no mental space for clinicians to experience authentic clinical empathy. Engaged curiosity toward each patient is a source of meaning and connection for health care providers, and it protects against sympathetic distress and burnout. In a prolonged crisis like Covid‐19, clinicians provide care out of a sense of duty, especially the duty of nonabandonment. We argue that when duty alone is relied on too heavily, with fear and frustration continually suppressed, the risk of burnout is dramatically increased. Even before Covid‐19, clinicians often worked under dehumanizing and unjust conditions, and rates of burnout were 50 percent for physicians and 33 percent for nurses. The Covid‐19 intensification of burnout can serve as a wake‐up call that the structure of health care needs to be improved if we are to prevent the loss of a whole generation of empathic clinicians.


The Dynamics of Clinical Empathy

Clinical empathy, a specific form of empathy that has therapeutic impact in the medical setting and is professionally sustainable, was first conceptualized by one of us, Jodi Halpern, as emotionally engaged curiosity. Her work challenged the expectation that physicians should limit themselves to detached cognitive empathy, showing how affective resonance, when redirected into curiosity about the patient, is essential for therapeutic impact. Halpern's interactive model of affective and cognitive empathy has been supported by empirical research, including findings regarding improved diagnosis, treatment adherence, and coping as well as studies of specific diseases (for example, about improved diabetes outcomes), though more research is needed to precisely identify the specific ways that affective resonance and cognitive curiosity contribute to meeting specific clinical needs. This model is also supported by neuroscientific findings showing how affective attunement improves cognitive empathy.

Models of compassion in medical care add valuable practices of mindfulness but do not emphasize an individualized appreciation of each patient's predicament. We thus work with Halpern's model, which emphasizes using emotional resonance to inform imagining the world from each patient's perspective. Halpern defines the cognitive aim of imagining each patient's perspective as “curiosity” because the practice of clinical empathy as engaged curiosity is founded on the recognition that each patient brings their own distinct world, with a unique set of values and needs that the physician cannot presume to know. This is a subtle but vital point.