Our Editor’s Pick for June 2016 is Brian Earp’s groundbreaking article, “Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on ‘FGM.’” Earp tackles the ethics of female genital cutting or “mutilation” (an ethically loaded term). This is a difficult topic that brings on board gender inequity, the integrity of the body, the value of cultural traditions, sexuality, colonialism, ethnocentrism, and other fraught axes of reflection.
This issue of KIEJ also features three commentaries on Earp’s article by Richard Schweder, Jamie Nelson, and Robert Darby that you may read here.
The Editor’s Pick for March 2016 is Franklin Miller and Marco Annoni’s paper, “Placebo Effects and the Ethics of Therapeutic Communication: A Pragmatic Approach.” This paper challenges one of the most fundamental metaethical pillars of traditional bioethics: the distinction between therapy and communication about therapy. Traditionally, we think that protecting autonomy requires communication about therapeutic possibilities before any therapy can begin; imposing therapy before obtaining informed consent may be beneficent, but it constitutes a paternalistic violation of autonomy. Miller and Annoni examine “therapeutic communication”: communication that enhances placebo effects in virtue of its manipulation of patient expectations. Placebo studies “demonstrate that the way in which health professionals communicate, disclose, frame, and contextualize information to patientsmay modulate symptoms across an array of highly prevalent conditions.” Thus “communication by clinicians has the power to turn diagnoses and prognoses into parts of the treatment.” Hence there is not always a neat distinction between communication and therapy, or between beneficence and autonomy considerations. This is a crucial challenge to the nearly universally presupposed division of ethical labor in medical care.
The editor’s pick for the September 2015 issue is “Enhancement and Obsolescence: Avoiding an ‘Enhanced Rat Race’” by Robert Sparrow. Sparrow identifies a social concern about making enhancements that increase productivity (including cognitive and physical enhancements) widely available: if these enhancements are not “upgradable” or are only upgradable at extravagant cost, we might end up with a situation in which every few years, a new crop of young adults renders their elders literally obsolete. His portrayal of the technological possibility of obsolescent people is powerful. This “enhanced rat race” would, Sparrow argues, intensify the competitive, class-divided, socially stratified, stressful character of capitalist culture at its worst. An important philosophical byproduct of his argument is that there are significant ethical distinctions between upgradable and permanent enhancements, as well as previously unnoticed ethical issues that arise if we make enhancements available to those with sufficient personal resources.
The editor’s pick for June is a timely pair of papers by Mark Navin and Heidi Malm that extend the contentious vaccination debates taking place in the United States to the domain of immigration justice.
First, in “HPV and the Ethics of CDC’s Vaccination Requirements for Immigrants,” Navin offers a defense of immunization mandates for migrants. He begins by critiquing the Centers for Disease Control’s (CDC) short-lived, pre-2009 policy that was used to exclude female immigrants who were not vaccinated for human papillomavirus (HPV). He then evaluates CDC’s new criteria, arguing that they replace the murky ethical commitments of the old policy with explicit moral reasons that can be justified from within competing perspectives on immigration justice. Thus on his view the policy shift constitutes a clear instance of moral progress that preserves the rights of both migrants and nation states. But even in light of this progress, Navin believes the new criteria may have been misapplied. He concludes by suggesting how they could still license exclusion based HPV vaccination status—a startling conclusion, given that the criteria were designed to avoid this very result.
In response, Heidi Malm argues against Navin’s narrower claim that an HPV vaccine mandate is justifiable. In “Immigration Justice and the Grounds for Mandatory Vaccinations,” Malm agrees that the new CDC criteria are vastly superior to the old, but she doubts how well they apply to the case of HPV. After providing a history of the stigma created by the health and immunization requirements for immigration into the US, Malm argues that uninfected, unvaccinated persons do not pose the right kind of threat to ‘herd immunity’ or public health to warrant exclusion.
This quarter’s editor’s pick is “Risks, Benefits, Complications and Harms: Neglected Factors in the Current Debate on Non-therapeutic Circumcision,” by Robert Darby. Darby offers a vivid critique of our current justifications for routine male circumcision. His critique focuses less on the practice itself than on how we have discussed the ethics of circumcision. He argues that our analyses of the ‘risks and benefits’ of the procedure have focused on narrowly medical concerns, and made invisible the layered symbolic, personal, and psychological significance of the foreskin and the attendant harms that may result from removing it without consent. He covers some of the fascinating social history of our attitudes towards circumcision, and develops an extended and effective analogy with mastectomy: while our current practices recognize and incorporate the potentially powerful personal significance of the female breast to identity and gender, our circumcision practices have no such sensitivity. This paper can be difficult to read, as it can be a challenge to confront a clear-headed critique of a procedure that many readers underwent or had performed on their sons with little reflection.
This linked pair of papers follows up on and develops problems raised in our September 2014 (24:3) special issue on obesity and the regulation of bodies. Bonotti and Loi each focus on British food labeling laws, arguing that—despite the common idea that being ‘informed’ is a precondition for autonomy—sometimes the right to avoid certain information can be an important component of flourishing autonomous agency. Labeling foods as ‘healthy’ or ‘unhealthy’ can inappropriately control how we interpret our food choices and how we experience certain foods, and it can take foods out of their proper context. In turn this can unduly interrupt important values and sources of pleasure. At the same time, having nutrition information available in an easily accessible and usable form can also be an important contributor to agency and health.
Matteo Bonotti, PhD, is Lecturer in Political Theory in the School of Politics, International Studies and Philosophy at Queen’s University Belfast. He received his MSc in International and European Politics and his PhD in Politics from the University of Edinburgh. His research interests lie in contemporary political theory, with a special focus on issues concerning ethical pluralism and diversity in their various manifestations (e.g. religious, linguistic, dietary) and how the state should respond to them.
Michele Loi, PhD, has a postdoctoral research grant funded by FCT (Portuguese Foundation for Science and Technology) at the University of Minho in Braga, Portugal. He received his PhD in political theory from Libera Università Internazionale degli Studi Sociali (LUISS) in Rome. His main contributions to political philosophy and bioethics relate to the debate on human enhancement and the ethical relevance of genetics and epigenetics.
In this paper, Hey and Kimmelman address the special ethical challenges researchers face during the early stages of a research program, in the face of radical uncertainty. In such early–phase trials, our normal techniques for balancing risks with potential benefits are not especially helpful, given our lack of knowledge of the impact of our interventions. Hey and Kimmelman defend a “risk-escalation” strategy, which calls for researchers to build up to the point where they are offering maximal benefit slowly, as uncertainty diminishes. They argue that this approach is more likely to sustain long-term drug development, avoid harm, and further the social goals of medicine.
Spencer Phillips Hey, PhD, is a postdoctoral fellow in Biomedical Ethics at McGill University and a member of the Studies in Translation, Ethics, and Medicine (STREAM) research group. He received his PhD in philosophy from the Rotman Institute of Philosophy at the University of Western Ontario.
Jonathan Kimmelman, PhD, is Associate Professor in Biomedical Ethics, Experimental Medicine, and Social Studies of Medicine at McGill University, and directs the Studies in Translation, Ethics, and Medicine (STREAM) research group.
In this issue’s lead article, DeGrazia brings the currently emotional debates over gun control policy within the purview of bioethics. Violence and policies concerning violent weapons are crucial health issues, and yet bioethicists have done little to bring their tools and insights to this domain. DeGrazia’s paper thus breaks new ground. He defends a moderate gun control policy, and argues that from the point of view of public health, it is morally inexcusable not to tighten gun regulations in the United States, regardless of which moral framework we employ.
David DeGrazia, PhD, is Senior Research Fellow in the Department of Bioethics at the National Institutes of Health and Professor of Philosophy at The George Washington University. His books include Taking Animals Seriously, Human Identity and Bioethics, and Creation Ethics: Reproduction, Genetics, and Quality of Life. DeGrazia’s research has been supported by fellowships from NEH, ACLS, and NIH. His published articles have appeared in such journals as Hastings Center Report, Philosophical Forum, Philosophy and Public Affairs, and Ethics.
In this paper, Biddle extends the discussion of the structural and contextual forces that can make biomedical research ethically problematic by shifting our attention to systemic distortions at the level of epistemic practices. He argues that, given that scientific practices and inferences always proceed under conditions of uncertainty, private interests ineliminably shape scientific methodology; furthermore, in an age in which for-profit companies play an enormous role in funding and directing pharmaceutical research, this shaping raises special ethical risks.
Biddle develops a concrete policy proposal for how to address these epistemic and ethical distortions. He outlines in detail an “adversarial” system of FDA review, in which we give up the pretense of interest-free science and instead build dissent and debate into our institutional organization, thereby enabling “organized skepticism” about the claims of pharmaceutical research. Biddle insists that focusing on the institutional environment of research (as opposed to individual researchers’ greed or dishonesty, for instance) is the best way to understand the ethically significant epistemic pitfalls of this research and the best way to compensate for them.
Justin B. Biddle, PhD, is Assistant Professor in the School of Public Policy at the Georgia Institute of Technology. His primary research interests are in philosophy of science and bioethics, especially concerning the role of values in science and the epistemic significance of the social organization of research. His recent work has focused on the epistemic and ethical implications of current intellectual property and licensing policies in biomedical research and in agricultural biotechnology.
