blog.bioethics.net

Bioethics Needs More Than Number Crunchers, says Caplan

Even as one trained in said number or data or fact crunching--whether you want to call us social scientists or empirical bioethicists or what have you--I do not take issue with Caplan's essential view--bioethics needs more than just facts to do its job well--it needs those who can argue and educate as well, too. I'll call that the bioethics trifecta. Ideally, a bioethicist would be able to do all three--collect, analyze, and discuss and/or disseminate one's data in the literature, engage in a sound moral argument, and be able to educate the public about bioethical issues.

That doesn't seem like too much to ask. But hardly anyone is trained to do so. I think that was Zeke's point.

But in any case, Caplan's argument is below. Btw, it is passing through the digital world of 1s and 0s that comprises "the new bioethics" grapevine more quickly than anything I've ever seen. How ironic is that?

Summer Johnson, PhD

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Facts alone won't suffice for the field of bioethics
by Arthur Caplan

When you get old enough as a practitioner in any field young people seek your advice about what they should do if they want to do what you do. Given that my age seems to be increasing exponentially this has been happening to me with increasing frequency. Undergraduates, high school students, medical students, those pursuing degrees in law and nursing and even those interested in a mid-career change have been asking me what they need to do if they want to pursue a career in bioethics.

I have thought about their question quite a bit. I have come to realize that the answer is not the same for everyone who presents the questions. But, the core of the answer is pretty much the same; pursue masters level training in bioethics, acquire familiarity with key social science methods and tools, learn something about a particular sub-area of the health sciences or life sciences and, seek out every opportunity to fine tune your analytical and rhetorical skills by working with others on projects, research, consulting, or teaching activities. At its heart bioethics is an interdisciplinary activity and knowing how to work with others who do empirical, historical, legal and normative work is a must.

I had thought that advice to be sound until I heard Zeke Emanuel's plenary address to open the most recent annual meeting of the American Society of Bioethics and the Humanities. Zeke espoused a vision for future bioethicists that I think is narrow, misguided and wrong. Now I say that in the spirit that Zeke himself enjoys--vigorous debate about a matter that both of us consider of the gravest importance.

Zeke Emanuel, a physician with a degree in political science as well, is one of the best and brightest scholars in the field of bioethics. His writings are solid and exemplify how best to integrate empirical inquiry with normative analysis. And the 'shop' he has run at the NIH Clinical Center for many years prior to moving into the Office of Budget and Management to work on health reform has done an outstanding job training younger scholars in the ins and outs of bioethical inquiry. These facts are precisely why Zeke's recent plenary address to the American Society of Bioethics and the Humanities was so disappointing.

Zeke began his speech by joking that he knew much of what he had to say would annoy his audience. He then proceeded to argue that the future of bioethics and of bioethicists depended upon the field moving away from its high public profile in political, media and policy debate. What bioethics needs, he argued, is a beefing up of the shabby empirical foundation it now relies upon for its normative and policy claims.

The only way for bioethics to flourish, to paraphrase Zeke's key contention, is if bioethicists spend less time in public places, more time mastering quantitative methods and publishing empirically grounded research on topics such as informed consent and surrogate decision-making at the end-of-life in peer-reviewed journals. He also went on to add that he did not find any merit in masters programs or PhDs in bioethics since without a more robust empirical foundation there could be little value in such training.

A young, wanna-be bioethicist, Zeke contended, would be best served seeking training in behavioral economics, psychology, decision theory or perhaps, he grudgingly conceded, sociology. Those armed with these tools could be expected to create the rigorous empirical foundation that bioethics now sorely lacks. Moreover, Zeke predicted, those willing to enter bioethics by heading down his prescribed path can expect generous financial support in the form of a pot of gold provided by a National Institutes of Health poised and eager to provide funding for rigorous research.

Before any prospective bioethicists answer Zeke's clarion call for rigor by dusting off their applications to departments of economics and the behavioral sciences let me try to point out why Zeke's vision about what bioethics should be is severely myopic as well as inadequate.

Zeke's call for bioethics to take a sharp empirical turn has power because it is embedded in his talk of the importance of data and rigor. Both are indeed important for bioethics for a variety of reasons. But, neither will get bioethics where it needs to be if it is to serve health care providers, patients, policy makers or the public.

Bioethics, in my view, has a duty to engage the public with bioethical questions. The topics that bioethics grapples with--how to manage dying, the use of reproductive technologies, what to do to maximize the supply of transplantable organs and tissues, how best to promote clinical and animal research, what information you should expect to receive as a patient about your diagnosis and treatment--are of keen importance and legitimate interest to everyone, rich and poor; young and old around the globe. Part, albeit part, but nonetheless a crucial part of the bioethicists role is to alert, engage and help to illuminate ethical problems and challenges both old and new in the health and life sciences. Note I do not say to solve them nor to be seen as an authoritative source to whom bioethical issues ought be assigned. Rather bioethics' role is both Socratic and prophetic--challenge, probe, question, warn, chastise, alert, and, as Zeke appreciates, irritate the powers that be when necessary.

In this role of moral diagnostician bioethicists must be responsible and strive for clarity in provoking public attention and debate. However, in this role data is often absent, in dispute or woefully poor. In addition questions loom large and pressing, passions run deep and fear and ignorance are omnipresent companions to doing bioethics with an eye toward helping the public understand issues and options. To engage in the public role that bioethics has and should enthusiastically continue to play in the media, policy, education, legislation and the law more tools are needed then empirical data no matter how rigorous or precise that data and the means used to generate it may be.

One must be able to present a cogent argument, know the areas of consensus that have been established about ethical issues over the history of medical ethics and bioethics, have a familiarity with health law, the infrastructure of policy and a grasp of political, cultural, literary, historical and social dimensions of what makes morality tick in various cultures. In the absence of these skills and knowledge data is completely and utterly blind, even useless. That is why it is precisely this skill set that the aspiring bioethicist should expect a masters program or a PhD program in bioethics to provide in order to gain the analytical and argumentative skills to competently and responsibly carry out the crucial public role bioethics has.

At the end of the day bioethics is a public activity which uses empirical inquiry and information as a tool. Admittedly empirical data are the most important of the tools in the bioethicists toolbox but still they are only one of the types of tools that are used.

Zeke's vision of bioethics completely confuses the instrument--compiling reliable empirical information relating to normative issues--with the job--informing the public about problems, options and suggesting possible avenues for their resolution.

Zeke's vision makes a bit more sense if one focuses on the role that bioethics plays within health care for professionals and institutions. There bioethicists often act as consultants or help formulate policy in ethically contentious areas working with providers and administrators and sometimes even payers. But even in this setting, while data is often essential it is never sufficient. Much of what occurs in doing an ethics consultation, for example, has as much to do with knowing how to mediate a dispute as it does a recitation of the facts of a case or having at hand well-supported information about the consequences of various courses of action. In many other situations the 'facts' are not known and won't be known--ever because the human interactions are too complex. Bioethics at the bedside is very much an ethical, social and personal activity and while data has a part to play it has about as much a part to play as it does in our everyday lives and decisions which is to say--sometimes it matters, often it does not.

Before the young bioethicist is told to follow Zeke's path of empirical positivism consider one other fact. We will not in our lifetime or that of our children ever achieve the kind of empirical certitude about much of anything of the sort that Zeke suggests will help future generations of bioethicists do their work. For every ethical problem for which sufficient data exists to point toward an answer a hundred blossom for which the data don't. For every ethical problem for which sufficient data have been assembled to make an answer rational, sensible, or even self-evident there are many where behavior, policy and practice do not and cannot be made to conform to that data. Sometimes data alone can point toward an answer. Almost always, however, it is a prior moral argument that points toward the use to which data will, could and ought be put whether that be in medical practice or in medical ethics. And more often then not moral and value arguments simply moot data and that situation cannot be rectified by appeals to more data.

Zeke ended his remarks that day by acknowledging he was not really trying to end the public role or policy dimension of bioethics. Rather he was just trying to reorient the field's priorities. I would suggest Zeke be heeded but only half-heartedly.

More data is needed in bioethics. More scholars with empirical quantitative skills are needed. That said, if the goal of bioethics is not simply to produce every-increasing amounts of NIH funded empirical data but rather to make a difference for the better in the lives of patients, their health care providers, scientists, and the general public then what we need and will continue to need are bioethicists who know their history, understand the power of cases, stories and analogical reasoning, can mount cogent, coherent arguments based on the best information at hand, who are comfortable talking with a state legislator, an NIH institute director, a TV talking-head, an athletic coach, a small town family doctor and a minister. Aspiring bioethicists would be well served to develop that full skill set and to seek out bioethics programs that can teach them to meet all of those needs.

Should Hwang Do Time in the Big House?

For the disgrace and shame he placed upon stem cell research in South Korea and for many stem cell research more generally, he should do some time in the slammer. Or at least that's my view.

But Nature.com tells us that Woo Suk Hwang's verdict is imminently on the horizon and that he may do jail time for violating that country's bioethics law.

So while we wait on the edge of our seats for the gavel to drop in Seoul's Central District Court Criminal Division, send in your comments. Should Hwang, arguably stem cell research's most notorious not-yet-convicted crooks, go to jail?

Summer Johnson, PhD

Is Nanotechnology the Key to Happiness?

Nanotechnology has been called a great many things--the great leveler, the panacea to all that ails the world, the technology that will allow us to solve all of our problems from world hunger to pollution.

But this month, at nanotechnow.com, Tihamer Toth-Fejel makes the rather provocative claim that the "exponential nanomanufacturing capabilities of Productive Nanosystems will simply enable us" to fulfill human needs and desires (of all kinds" better. That's a pretty sweeping statement, if you ask me. And I'm pretty sure that I don't buy it. In fact, I'm pretty sure that if that were true it would come at such a radical cost or at least change to the world as we know it that we wouldn't recognize our world, or ourselves, in this "Productive Nanosystem Planet" Toth-Fejel describes.

But you don't have to take my word for it. You can read his argument yourself and decide whether you think nanotechnology is the key to fulfilling all human desires, wealth and happiness. I just wouldn't bet the bank (or mine), or my future's happiness, on it.

Summer Johnson, PhD

Yes, Today. Snowe, Tomorrow?

According to the WSJ Health Blog, Senator Olympia Snowe of Washington State is making no promises as to whether she will continue to back the Senate Finance bill for health care reform.

Why does this matter? For any one who has been even following this train wreck / folly of the last few months to get health care reform passed by the United States Congress knows that where Madame Snowe goes the rest of the the Senate has tended to follow because for this Republican to back a largely liberal bill means something....just ask Fox News.

But she offers little real comfort or assurance that she will stick with her position for good, which means that the ups and downs of this debate of will or won't health care reform be passed is likely to continue a little bit longer.

So we'll all keep biting our nails and hoping...it could still be a bumpy ride to the finish line.

Summer Johnson, PhD

Yes, Today. Snowe, Tomorrow?

According to the WSJ Health Blog, Senator Olympia Snowe of Washington State is making no promises as to whether she will continue to back the Senate Finance bill for health care reform.

Why does this matter? For any one who has been even following this train wreck / folly of the last few months to get health care reform passed by the United States Congress knows that where Madame Snowe goes the rest of the the Senate has tended to follow because for this Republican to back a largely liberal bill means something....just ask Fox News.

But she offers little real comfort or assurance that she will stick with her position for good, which means that the ups and downs of this debate of will or won't health care reform be passed is likely to continue a little bit longer.

So we'll all keep biting our nails and hoping...it could still be a bumpy ride to the finish line.

Summer Johnson, PhD

In New York, You Get the Shot Or Walk the Plank

As Art Caplan's most recent MSNBC column explains, New York is taking a hard line on health care workers getting their flu vaccinations this year. It's quite simple: get the shot or lose your job. Health care workers rallied in Albany, NY yesterday protesting that their rights were being violated by being forced to take the vaccine, but some ask: what about the rights of the hundreds of patients that they contact each day whom they could potentially infect by NOT taking the vaccine?

Ultimately, Caplan argues its a matter of professional ethics: put patients first, man up and get the shot. Even if it doesn't guarantee protection against every strain of flu, what do these healthcare workers have to lose--and they certainly have something to gain--the potential protection of their patients from giving them the flu.

To read more of Caplan's argument, click here, or read the argument below.

Summer Johnson, PhD

Health workers must get flu shot or quit
by Arthur Caplan, PhD
Enough already with the whining, moaning, demonstrating and protesting by health care workers. Doctors, nurses, respiratory therapists, nurses' aides, and anyone else who has regular contact with patients ought to be required to get a flu shot or find another line of work.

The California Nurses Association and the National Nurses Organizing Committee have issued statements that individuals should be able to refuse the vaccine. The New York State Public Employees Federation said that "vaccination for influenza is not as effective in the control of disease as vaccination for diseases such as polio, measles and mumps." Other health groups wanted to know why those who preferred to shun the shot could not simply wear masks.

Last week hundreds of people showed up in Albany, N.Y., at a rally to protest New York State's plan to require all state workers to get both an annual flu shot and a swine flu vaccine. Most at the rally said their rights were being infringed.'

Excuse me? What rights might those be? The right to infect your patient and kill them? The right to create havoc in the health care workforce if swine flu hits hard? The right to ignore all the evidence of safety and efficacy of vaccines thus continuing to promulgate an irrational fear on the part of the public of the best protection babies, pregnant women, the elderly and the frail have against the flu? Those rights?

Many hospitals in Illinois, Washington, Missouri, Georgia and Maryland are putting in place flu shot mandates. My own institution, the University of Pennsylvania Health System and its affiliated, top-ranked Children's Hospital are leading the way in getting mandates moving. Why? The answer is simple: The vaccine will save lives.

Only half get vaccine
The annual rate of health care workers getting flu shots has been hovering around 50 percent at most institutions for years. The evidence for the toll this low vaccination rate takes on patients and staff has been mounting year after year.

If you can get close to 100 percent vaccination rates you can cut patient death rates from flu by 40 percent. Sick days among doctors and nurses drop by about the same amount. Eleven babies died of swine flu during the last week of September alone, according to the Centers for Disease Control and Prevention. With a potentially potent form of swine flu on the horizon, those kind of grim statistics have made hospital infection disease experts sound the alarm to implement mandates to boost vaccination rates.

Nothing works as well as vaccines to prevent getting the flu and transmitting it others. Masks may help, but still 20 percent of those who wear them get sick. There is no evidence that vitamins, special diets, fresh air or any other alternative ideas does anything to make flu viruses less nasty. And all we really have to fight swine flu are ventilators, some drugs that may or may not work and the new vaccine.

The medical establishment has been recommending that kids get flu shots forever. The state of New Jersey just put into practice a law requiring flu shots for young schoolchildren in day care and preschool. The U.S. Armed Forces has no time for anyone who will not get a flu shot. If you want to legally immigrate to this country you have to roll up your sleeve. Why should health care workers be treated any differently?

I understand that there are a few people who have medical reasons not to get a flu shot. Those people are and should be exempt. But that is not the issue driving opposition to mandates. When there is push back it is based on the notion that the individual's rights are being trampled in the name of the common good.

Look, there are legitimate issues that ought to be debated whenever someone says you must do something to benefit others ranging from taxation to restrictions on driving under the influence. But health care workers' own code of ethics dictates that they put the interests of others -- their patients -- first.

Getting a flu shot is the least those who claim to be bound by professional ethics ought to do. It's time to man-up and protect those at risk in our hospitals and nursing homes, along with each other, and make getting a flu shot a part of the responsibility of being a healer.

"Academic Doping" is Just Plain Dumb (as Something to Fear)

The first media story I read about Dr. Vincent Cakic's Journal of Medical Ethics paper about the ethical concerns about academic doping I was able to shrug off as just one more enhancement story.

But after reading the 5th or 6th this week about Dr. Cakic's mind-boggling take on "academic doping", the most ridiculous argument made yet this year in an ethics paper had gained so much traction (in the media, at least) that it was time someone said that there is nothing new in his pill bottle.

I began to wonder if this is what neuroethics had degenerated to when I came across a summary of Dr. Cakic's argument in the Times Higher Education supplement, which quoted the author as saying, "As laughable as it may seem, it is possible that (urine testing of students) could very well come to fruition in the future."

Laughable? It's downright, dumb. First, what kinds of substances should we be testing students for when more than 4.4 million children in the US are diagnosed with ADHD and more than 50% taking some kind of drug like Ritalin, Concerta, Focalin or Provigil? Dr. Cakic are you ready to take urine samples of more than 2 million children? Get out your dipsticks and a whole lot of

Where do we draw the line between the children who "need" to be taking these medications and those who are taking perhaps slightly too large a dose or maybe really aren't quite ADD-enough to justify the medications they take and are simply enhancing their brains?

In other words, how will we know when we are dealing with a student who needs Provigil or Ritalin and one who is simply engaging in "cosmetic neurology", as Cakic calls it? Moreover, who are we (I'm using the royal "we" here) to tell college aged students or older high schoolers that they can't be in control of the functioning of their brain when we allow them to be in control of the functioning of their reproductive systems and other "cosmetic" aspects of their lives?

Is Cakic really advocating that schools should become like police states and prior to large standardized testing periods everyone has to go pee into a cup to ensure that everyone is neurologically au naturale? And what about the rest of the school year? Should students be subjected to random drug checks to ensure that their grades aren't jacked up by some pharmacological support?

The analogy that Dr. Cakic draws between doping in sport and "academic doping" is a false one. Olympians claim to be the very best in their sport through training and practice--and agree to a particular set of standards of what it means to be an Olympian who trains to achieve greatness of the human form sans enhancement. (However, even those boundaries of what is "natural" versus what is allowed through "enhancements" such as supplements and the like is being pushed further and further of late.)

Our children, however, do not claim to be "academic olympians". But thank goodness for people like Leon Kass and Dr. Cakic for offering another naive intuitionist account to guide us all for figuring out the difference between the morality of Princeton Review and the sin of Ritalin.

Summer Johnson, PhD

The AJOB Family of Journals Grows by Two!

Today, now available at editorial.bioethics.net, are The American Journal of Bioethics' new sibling journals, AJOB Neuroscience and AJOB Primary Research.

These latest additions to the AJOB family will begin publishing in 2010 and each have 4 issues per year of exciting new content written by the top scholars in the field.

AJOB Neuroscience, now its own freestanding journal, will be edited by Paul Root Wolpe and its associate editor, John Banja, focusing on a wide range issues in the brain sciences.

AJOB Primary Research will be edited by Alexander A. Kon and will publish original empirical research using a wide range of qualitative and quantitative research methods, public policy research, and other social science research.

Authors interested in submitting to any of the AJOB family of journals can now go directly to the new AJOB portal found at editorial.bioethics.net find all three AJOB journals and read more.

Be sure to stop by and see the editors of all the AJOB journals at ASBH this year to learn more about these exciting new publications, including changes to AJOB's format and its being published for a full 12 issues a year!

For any additional questions, please contact the editors at any time! We look forward to hearing from you and receiving your submissions soon.

Summer Johnson, PhD
Executive Editor, the AJOB family of journals

Stay Up-to-Date about H1N1 at pandemic.bioethics.net

WIth the launch this week of the national vaccination program for swine flu, debate is raging over whether children should be vaccinated, who should be first in line to receive the vaccine, and whether the program in general will be effective.

Is America ready for a nationwide flu vaccine drive?

Should parents be worried about vaccinating their children? Is it safe?

Has the H1N1 virus been overblown?

To read about a wide range of perspectives on these questions and many more, go to pandemic.bioethics.net for daily updates, commentary, and opinion from more than 250 readers in bioethics, health policy, the media and more.

Visit us today (and everyday) to learn more!

Summer Johnson, PhD

Nonsense. It's Good For You.

Who knew that "The Ministry of Silly Walks" and other such absurdities could actually strengthen our brains? Yes, it's true. Nonsense is good for your noggin.

But it isn't just the absurd, but the out of place, the "something that is off" sensor that is tripped in your brain, including a whole range of things from the inane (simple changing of patterns) to the insane (seeing a jackalope, perhaps?) that jars the brain from its normal routine into an entirely new way of thinking, says new research discussed today in the NYT.

So why does this matter? It suggests a number of things about the way in which our world ought to be structured if we want our brains to continue riding along the normal neurological highway, producing the same kind of thinking and solutions (or lack thereof to problems). But if in fact we want to jolt our brains into entirely new ways of thinking for the purposes of creative thinking, writing or other endeavors, that is, according to this research, more possible than we believed before. It is, in fact, the notion that putting one's self into a situation where they may encounter the absurd or unusual or simply non-patterned ways of thinking may in fact lead to new ways of seeing the world that is in fact rather revolutionary.

Creativity may follow disorientation. New ideas may follow chaos. Perhaps this should mean that Monty Python should be required viewing for all budding artists, writers, or anyone stuck in a rut?

Summer Johnson, PhD

Slapping Docs' Hands for Not Washing Them

That's the recommendation from the master of medical checklists Peter Pronovost of Johns Hopkins University and Robert Wachter of University of California at San Francisco, says the WSJ Health Blog.

Lack of accountability is the reason why a whole range of medical errors exist contend the pair, according to a NEJM article, including unnecessary infections.

With the H1N1 flu season on the brink, taking the precautions are even more necessary--so penalizing those who don't wash up has become even more important than usual.

The kinds of punishments proposed by Pronovost and Wachter include laying off health practitioners for up to a week for failing to wash their hands. While this may seem rather draconian under normal circumstances, in the time of a pandemic, letting these professionals know that hospitals mean business about hygiene may not be a bad idea.
However, laying off doctors in a pandemic when it may be a time for "all hands on deck" may not be the most sensible approach. Perhaps fines to these physicians and nurses would be a better approach.

Clearly something must be done to show them that hand washing is serious business; the question is how to enforce the rules and how best to ensure patients will not be put in danger by healthcare practitioners who may be lax about basic hygiene.

Summer Johnson, PhD

Right to Reform says Caplan

Published last week in the Journal of Clinical Investigation, Art Caplan discusses the "right to reform". What does this quite simple sounding phrase mean?

Well, those three words say a lot more than one might guess at first glance. In Caplan's argument, he claims that health reform both is all wrapped up and mired down in it quite a lot of ethics talk, values language, and moral commitments which both makes health reform so essential and, quite frankly, so difficult.

But that's why getting bogged down in the details and letting health reform "simply die under the weight of nitpicking, fear-mongering, sloganeering, and the invocation of details as obstructions to change" would be such a travesty.

As I read Caplan's argument, not only is there a right to health reform, but it is right to reform because all citizens deserve access to basic health care.

And I simply couldn't agree more.

Summer Johnson, PhD