A waiter at a restaurant tightly stuffs a large tea bag with loose tea and securely knots the bag, which is then placed in a pot of hot water. The tea bag is filled to maximum capacity, yet the tea is always way too weak. X is the amount of loose tea used and S is a strong pot of tea, the desired outcome.
The problem is scientific (no room to expand), but to recognize and resolve it takes common sense and logic. If someone asks how to make a pot of strong tea (how to reach the desired outcome), the answer may be “use more tea”. But the process (P) (an overstuffed tea bag) could negate the benefit of using the right amount of loose tea leaves. Importantly, S is not the only possible outcome of X. We cannot say conclusively, if X, then S. We can say if X, possibly S. And we know that if not X, then not S. That is, you do need tea leaves to make strong tea. But you need other things too. P has a causal relationship to S as well.
While that is obvious logic, when applied to more complex situations, simple logic and identifying possible causal relationships are crucial. Common sense speaks to sound judgment and relies on the tools and thinking skills to make practical decisions. The ability to come to a sensible solution is common sense. Variability in assumptions can change outcomes drastically. The tea example, which shows that the attempt to do the right thing, the generous thing, can be the downfall, relies on an incorrect assumption that more is better or will make a stronger pot of tea.
Common sense in evaluating ethical dilemmas relies on
- Challenging assumptions
- Keeping the big picture in mind and asking whether the steps do (or will) lead to the desired outcome
- Anticipating alternative outcomes
- Preparing for low probability outcomes as well as high probability ones
- Using valid inferences
- Identifying causal relationships
- Asking whether an outcome is likely, necessary, or possible
Example of an Easy Case: Conflicts of Interest in USDA Dietary Guidelines, MyPlate
In public health, lobbying influences dietary recommendations. I think the result is distrust in the nutrition data and in the guidelines. Lobbying can be as detailed as industry pressing for small print warnings or details and large print for broader food groups, and downplaying “important facts” leading the reader to initially think all items in a food group may be equally valuable. The USDA whittles away public trust when it sets forth dietary recommendations for schools and medical professionals based on industry influence. The original food pyramid and then MyPlate seemed to give people the go ahead to maintain a high carb diet or a diet centered around animal protein, while it is unlikely that the general population increased consumption of vegetables. The fine print does little to discourage any particular food although it does encourage meeting some subcategories like beans or nuts as part of one’s protein intake. The government assertion that 90 percent of Americans do not get enough dairy contradicts vast research on the healthy populations that do not eat dairy at all.
Whether the government should be in the business of recommendations depends first and foremost on the truth, the sanctity of the objectivity of the recommendations, and the population studies proving the dietary recommendations are sound. Lobbying can coexist with truthful data, but it reflects incentive to fudge the truth and present the most positive findings. Agribusinesses benefit financially from the recommendations.
And people’s diets vary. The MyPlate recommendations may be an improvement for many people, but for others, the recommendations would worsen the risks of outcomes like heart disease, obesity, or other diet-related illnesses. The MyPlate diet is too high in carbohydrate’s and too low in healthy fats, and distinguishes very little among choices within categories, using some fine print (or further website pages) to provide details. Those that would benefit from MyPlate would benefit more from a recommendation that is better supported by science and not influenced by industry.
If someone were to ask, “How can we devise dietary recommendations that would result in a healthier population?”, it is unlikely that the response would be that it is wise to consult those who make money selling the least healthy foods.
We know that public trust in government is decreasing. But I suspect that the relationship between financial conflicts of interest and public trust is overlooked by the bioethics community in particular where messaging gets significant attention compared to institutional trustworthiness.
There is ample evidence that lobbying hurts trust, but that done well with certain rules, it might affect public trust less. The OECD offers a guide to proper lobbying and public trust, focused on transparency and integrity. In the food and nutrition sphere, starting from the planning phase, I would chart the causes of ill health and the possible relationship between government and health. Government, to me, has an ethical duty to promote a healthy diet or to stay out of dietary advice. The least ethical proposition is to convince a public that a low-end or even a moderately healthy diet is beneficial. Messaging campaigns are often used to influence diet, but the messaging campaigns are disconnected from trustworthy behavior and the message is not quite correct.
Problems Not solved by recommendations
Dietary recommendations may be ignored because of food insecurity, very low wages and long hours eliminating time to cook, housing instability, industry marketing, and cultural influences.
Big picture questions include
- Who gets nutrition information from the government and relies on it as a primary source, incorporating the recommendations?
- Is government an appropriate source as it is quite apparent the US population is less healthy than the populations of other countries. Is the government obligated to study Blue Zones and the breadth of data?
- Should independent holistic nutrition counselors, doctors practicing functional medicine, or people who eat according to customs of those parts of the world with noteworthy health or longevity defer to government guidelines? (Of course not!)
- Would banning lobbying lead to a different “My Plate”?
- Would ending the USDA recommendations be better (obesity has more than doubled since the USDA began dietary recommendations)?
Conclusions Beyond Diet: Let’s Substitute COVID Vaccinations for MyPlate
Messaging was a tool to promote COVID vaccination. The rightful goodwill afforded to the scientists at companies like Pfizer and Moderna would take on more power if systemic problems were resolved. Most people agree that the vaccine development, production, and delivery saved lives, and negative messaging about the vaccine cost lives. Yet the logic that positive messaging is the only way to counteract negative messaging is problematic. Many people already had a negative attitude toward the pharmaceutical industry, government, and corporations and in the backdrop was a divisive culture and a distrust of both government and corporations. From The Tuskegee Study of Untreated Syphilis that targeted Black men from the 1932 to 1972 to Purdue Pharma’s fraud that cost hundreds of thousands of lives, to a distrust of what many see as overprescribing for mild to moderate physical and mental conditions, some (significant) distrust is rational. A messaging war ignores the value of trustworthiness across systems.
Financial conflicts of interest, the longstanding revolving door between industry and government agencies tasked with approving, and past pharmaceutical wrongdoing like Purdue Pharma’s OxyContin and Merck’s Vioxx influence public trust. Past ethics violations make the task of explaining that the vaccine is safe more difficult, something made much easier based on the ability to gather so much data so quickly due to the nature of the virus. The benefit of being vaccinated was evident quite early on, especially for those in risk groups by age or preexisting conditions. This Washington State updated data shows the risk of death and severe disease in the unvaccinated.
Messaging strategies may have improved vaccination rates along with other measures like requiring vaccination as a condition of participation. Under pressure, accepting the vaccine may not be a sign of trust at all. A different question may be how much does messaging (M) influence public trust (T)? And how would behaviors like limiting lobbying, closing the revolving door, limiting pharmaceutical advertising, adding more oversight of prescribing practices, and more adequately punishing wrongdoers like Purdue Pharma (collectively, W=trustworthiness) influence public trust? Leaning too much on messaging and too little on the foundational aspects of public trust is a bioethics blind spot. Identifying the prerequisites of trust would help. Trust in public health is a particular form of public trust. Without it, it is difficult to manage crises.