Bioethics: Analyzing Reasoning in Moral Controversy

In bioethics, moral controversies may have high stakes. Differences of fact or opinion are of a different nature than moral disagreements. There are factual disagreements where a truth may be discovered, making one side right and one side wrong. During the COVID-19 pandemic, some such factual questions were politicized, but that alone does not turn them into moral questions. That is, the question of whether masks prevent spread of COVID-19 is a factual question regardless of who believes it. The current role of factual disagreement has to do with reporting and beliefs not with the fact itself. There also are constant new discoveries and there is a time of uncertainty in the process of discovery of facts. While there may be turbulence during the learning process, facts, when ascertainable, answer controversies easily.

Simple opinions are easy too—they are the arena where people may just agree to disagree. We do not all need to have the same taste and preferences. But some opinions concern morals, and the need to address, understand, and possibly resolve them is helpful to society.

Moral Controversy

But moral controversies arguably feel more like facts than opinions to some people, although it is difficult or impossible to prove morals true objectively. To David Enoch, phenomenology could demonstrate the lived experience of holding the belief. (A post about moral objectivity and moral relativism is coming soon.) We should not approach moral disagreement in the same way as other disagreements about opinions. Agreeing to disagree may disenfranchise one side unfairly.

bioethics moral controversy protest
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For example, to me, a moral approach to climate change favors mitigation, adaptation, preparation, and sustainability. But the morals-based argument that those goals conflict with individual and corporate freedoms inherent in natural law (or negative rights), the US Constitution, or other rights-based frameworks, poses a problematic impediment. To dismiss the other side without an effort to understand its reasoning ignores the moral controversy. The subject of a moral controversy can be legislatively resolved. It can be winner-take-all or involve compromise. But moral resolution requires an effort to understand the other side’s reasoning.

I use the term “mid-level morals” to address those beliefs about right and wrong that are not fundamental to the inner workings of society. For example, at a certain non-foundational level the extent to which people expect dependability or respect authority varies significantly. (The UN has found common ground on many human rights that are fundamental like freedom from slavery and torture, or a right to liberty.) Within the US, people who view themselves as highly moral engage in things other people consider highly immoral because morals vary. Taking a seat on the subway when an elderly person is standing may violate one person’s moral code and be virtually unnoticed by another.

Sometimes, morally heated debates are unproductive in the policy process. A compromise that does not shame anyone for their views or revolve around moral self-praise but provides a solution is better than two competing sides hashing out the moral issue, both believing their side is moral fact. The Righteous Mind by Jonathan Haidt gives insight into different moral structures and competing views like how differently people define fairness.

Are We Having a Moral Disagreement?

Access to health care is a moral, practical, and financial issue. People engage in the healthcare debate with different types and degrees of interest. To many weighing in, their opinion may not reflect something deep enough to label moral, while to others the issue is so deeply moral, they view it as moral fact. Competing views by libertarians and communitarians highlight moral investment in different solutions. Many people view health care as a human right and health care for those in poverty especially as a moral commitment. But many healthcare policy disagreements may be just about nonmoral opinion, or concern facts like cost, and not rise to the level of moral controversy. Sorting out the moral from the logistical is an important step to understanding how to build consensus around policy. If it is mere opinion, it seems easy to resolve legislatively by elected officials or referendum. Toning down the moral aspect, e.g., eliminating rights talk from the healthcare debate, can be helpful to achieve a policy change. But the moral disagreement requires studying the other side’s reasoning with an eye to consensus. The moral disagreement may outlast the policy debate.

Many people in the US view freedom of religion as a moral absolute. Others saw a moral obligation to prevent spread of COVID-19 even if that required forbidding live in-person church services. Each may argue the position as if it were objective and as if it were a fact that their belief is right. Each learning the other side’s reasoning could contribute to resolving the moral conflict while courts hashed out the permissibility of restrictions, albeit in a disparate way.

As we observe political polarization in the US, we see that legislation does not answer the moral questions. It can change lives, and represent progress, but it does not always bring sides together or represent cohesion. Legislation is not always a sign of winning a moral debate.

moral controversy with doctor
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Some Disagreements are Moral to One Party and Mere Opinion or Fact to the Other

To me, disagreements in the healthcare setting are deeply moral and personal, in the mid-level moral realm. But some doctors probably feel they are not of a moral nature. If a doctor sees a disagreement as fact or opinion, but not moral, the disconnect is gaping. Autonomy is surely a moral issue and a cornerstone of bioethics. But other mid-level values like avoiding unnecessary medication, to me, reflect non-universal moral values, or moral norms that are community-based and cultural. Those who avoid excess medication or look for non-medical approaches like diet, exercise, and lifestyle, may reflect a moral norm among an elite, a friend group, a family, or a local culture. Facts enter care decisions as well, and the doctor must know and express treatment options. Dismissive doctors may not realize the depth of the meaning to the person seeking care. The murky territory of even identifying an issue as moral makes it difficult to reason on the same wavelength.

Examine Reasoning—Avoid “Because-I-Said-So”

Factual disagreements and differences of opinions on issues not recognized as moral become intertwined with issues that are deeply moral to some people. An approach requiring an effort to understand the other side would improve the difficulty we face in moral controversies in a country with a plurality of norms.

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Bioethics: Black Male Life Expectancy Drops to 68!

The current estimated life expectancy of a Black man in the US is now 68 years. That is seven years less than White and Hispanic male life expectancy. It is a gap that cannot be explained entirely by the medical causes of death in the CDC report. To solve the disparity, people must look to the circumstances that lead to a health and social profile of vulnerability to early death.

The CDC Report

The decrease in life expectancy in the US announced today of 1.5 years includes vastly different life expectancy changes for Black people and for Hispanic people, and Hispanic men in particular. The decreases are 3 years for the Hispanic population, to 78.8 years (3.7 years for Hispanic men); 2.9 years for the non-Hispanic Black population, to 71.8 years; 1.2 years for the non-Hispanic white population, to 77.6 years. See the CDC Table for expectancy at each age by race and ethnicity.

The report does not highlight the already low Black male life expectancy and most of the media is focused on the change, not the existing disparity. A gap that had been slowly closing suddenly increased significantly. The CDC classified known “health” causes to the non-Hispanic Black male decrease of 3.3 years. The overall decline in the Black population was attributed to “COVID-19 (59.3%), unintentional injuries (11.9%), homicide (7.7%), heart disease (5.9%), and diabetes (3.6%)”  offset by improvements in cancer and some other categories.

life expectancy, COVID-19, racial disparity
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How to Speed Up Solutions

Policy change must focus on the social determinants of health and economic opportunity. The frameworks for Justice of Access and Justice of Opportunity apply to the vast differences in opportunity available. Racial progress in diversity and inclusion is slow to address all the underpinnings of the life expectancy numbers.

The attached flipbook is just the very basics on social determinants.

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Bioethics & Competition: Antitrust as a Determinant of Health

Antitrust is one of the biggest current issues in bioethics. Yet, beyond hospital and pharmaceutical industry mergers, it is overlooked by the field. Healthy competition in the corporate or business landscape would impact health. A lack of antitrust enforcement negatively affects health, access to healthcare goods and services, and access to those other goods and services that determine health, like healthy food, education, internet service, good jobs, and small business loans. Antitrust laws encourage competition within industries and provide rules that require fair play, and they bar monopolistic behaviors.

For basic background, the Sherman Antitrust Act makes it unlawful for people or companies to unreasonably restrain trade or conspire to monopolize. It covers price fixing, rigged bidding, and dividing a market. The Clayton Act (as amended by the Robinson-Patman Act of 1936) and the Hart-Scott-Rodino Antitrust Improvements Act 1976) forbids price discrimination, interlocked directorships (when the same person controls several competing companies), some exclusive sales arrangements, and other anticompetitive practices, and requires notice of mergers. The FTC Act also covers unfair and deceptive trading practices.

The Biden Administration Executive Order on Promoting Competition in the American Economy issued July 9 will increase regulatory focus on antitrust, pull other government agencies into enforcement, and have agencies review regulations across industries. Regulators will revisit guidelines for vertical and horizontal mergers. By mentioning industries (agriculture, banking, consumer finance, healthcare, internet service providers, technology platforms, transportation) and calling for regulatory agencies to take steps (amend, remove, or add regulations) to improve competition, the order directs more government attention to antitrust.

Biosciences and Seeds

Across industries, antitrust affects health. Now with a Bayer Monsanto merger and a Dow DuPont merger, four companies control  the control about 75 percent of the seed market and some say three companies control 60 percent.  Family farms have difficulty procuring “seeds, equipment, feed, and fertilizer”.  The corporate systems are less sustainable than family farms. They encourage monocrops and lead to less choice of affordable healthy food. Food Politics explores policy, business practices and food supply.

The international political structure and power of a handful of food companies changed the global food supply system. Market control by the “global north” dictates international and national policies leading to low wage growers, a complex system of exports, and the elimination of the voice of the public as consumers, environmental activists, or health activists. Obesity in the US is inextricably tied to food production and consumption and the incentives, and the deflated and inflated prices at various points in the system.

Internet Services, Social Opportunity and Education

In “Profiles of Monopoly”, internet service is depicted as primarily monopolistic in the US. The large corporations have failed to provide access to many in need and their practices make small providers face barriers to entry and an inability to garner any real market share collectively. Internet is necessary for education (even more so during the pandemic) and for the ability of older adults or people who are rural or homebound to establish and maintain important social connections. Internet connection also broadens job possibilities as working virtually relies on connecting.

Bioethics antitrust banking unbanked piggy bank
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Banking and the “Unbanked”

An inability to even participate in modern banking unleashes havoc on people with low incomes. In “How the Other Half Banks”, Mehrsa Baradaran explores the experiences of being left out of the largely merged system of big banks. Banks originally served a social or public purpose. 14.1 million adults in the US have no bank account. Black and Hispanic households are five times as likely to be “unbanked”. Many low-income customers resort to pay-day banking, check cashing services, and antiquated money wiring companies. People without ATM cards or check writing capabilities experience financial stress and pay more fees to accomplish simple financial transactions. Fees are usually highest for those with the lowest balances. Those living paycheck to paycheck are subjected to proportionally more fees while they are vulnerable to becoming unable to afford housing and food.

An inability to develop a credit rating makes it impossible to secure loans from institutions with the best rates. A failure to participate in the banking system effects health by narrowing prospects for those left out. People unable to access higher education or small business loans encounter difficulty in achieving those social goods like savings and jobs that determine health. Many Americans do not have any opportunity to earn interest or hold assets likely to appreciate.

The repeal of Glass Steagall, which separated retail and investment services, undermined the rules protecting how much of a banks deposits could be exposed to risk. The financial crisis or much of its damage to low- and middle-income people may have been prevented in a structure where local small banks served low- and middle-income individuals.

retail antitrust and bioethics
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Technology, Data, Retail, and Robotics

In the tech sector, data-generating patents allow monopolies over certain health information. Those monopolies unreasonably empower corporations over consumers of healthcare goods. Technology also is replacing personal labor, reducing the number of jobs available. Amazon uses technology and robotics to maintain its dominance in its monopoly and monopsony (buying monopoly). Without Amazon’s market dominance, smaller competitors might rely on labor more, hire more people, and create competition for employees, driving up wages and perks. In places where Amazon starts a warehouse, other warehouses tend to go out of business. In “Amazon’s Stranglehold: How the Company’s Tightening Grip Is Stifling Competition, Eroding Jobs, and Threatening Communities,” the Institute for Local Self-Reliance criticizes the business practices, citing vacant storefront, decreased competition and choice, poor working conditions, and contracts that take advantage of or pressure suppliers. The report also notes the vertical expansion into manufacturing competing goods crowding out other manufacturers.

bioethics hospital beds and antitrust in hospital mergers
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Large Hospital Systems

US healthcare costs are inflated, partly due to industry monopolization. Hospital mergers, sometimes seen as a symptom of the inability of multiple hospitals to compete, undermine competition that would spark higher quality at better prices. “A recent and widely discussed study by Yale economist Zack Cooper and others has found that if you stay in a hospital that faces no competition, your bill will be $1,900 higher on average than if you stay in a hospital facing four or more competitors.” Large hospital systems exert corporate control and make choices to close unprofitable hospitals regardless of community need. NCH Health Systems lobbied against a rural new hospital in Immokalee, Florida that would compete with them. One story of why it took so long for El Paso to finance and open its Children’s hospital argues that Tenet Health opposed the project out of a fear of competition. Rural areas and cities with few financial resources tend to suffer the most, as their populations travel further for care and pay more.

Hospitals also increasingly own physician practices. Now a majority of doctors do not own their practice. Once a hospital system or chain increases its market share or completely controls a region, it uses its power to negotiate with insurers. The negotiations are not just about price. They also cover referrals that keep people seeking care in the realm of the corporation.

Hospitals cite economies of scale and cost savings associated with size, but there is not much evidence and the savings are not passed on to consumers of healthcare. “Horizontal consolidation among hospitals almost universally results in higher prices and worse (or unchanged) patient outcomes, despite the fact that costs to hospitals do not significantly increase as a result of the consolidation.” Care coordination and electronic health records in large hospital systems may evidence economies of scale. And coordinating more physicians’ offices or radiology groups within the hospital corporation can also have some economic savings, or “economies of scope”. But there so far is not a way to prevent large hospital systems from wielding power that drives up prices and burdens consumers of healthcare.

In New York City, the many mergers that created three large hospital systems also led to closures of smaller hospitals, defining who has access to care nearby, essentially leaving outer some neighborhoods with fewer full-service hospitals. The business models also seem to favor specialties over primary care.

Moving Toward Enforcement Should Benefit Consumers and Health

One article points to libertarian judges and a judicial movement toward freedom to enter contracts and increasing respect for corporate rights as a cause for the lax enforcement. The executive order may represent a movement away from the extreme view of corporate rights. Enforcement will protect small businesses, consumers, and workers. A politically neutral idea (historically many Republican and Democratic politicians favor competition) as reviewed under a multiple streams framework, antitrust is ripe for enforcement.

Antitrust enforcement may not seem like the answer to the health woes of the country. But it is a key determinant with a role in obesity, access to health care, internet service, earnings potential, and a rebirth of competitive small businesses with hiring potential. As such, antitrust enforcement should be explored as a social or political determinant of health.

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Happy with Less: A Feminist Take on the Personal Growth Self-Help Industry

Through a feminist lens, the self-help industry is sometimes ethically problematic, as noted by various scholars. In particular, the personal growth self-help industry presents a bioethics issue surrounding mental and physical health, equality, justice, employment discrimination, and child care. It challenges the balance between pursuing more and being content with what one has. Some self-help ignores the determinants of health, mental health, and economic upward mobility. This post calls for critical theory and feminism to analyze the role of personal growth self-help in lowering expectations and outcomes.

Critiques of Self-Help

Many self-help critiques focus on the individual aspect, arguing that self-help undermines the collective, especially women. Self-help perpetuates the use of psychology over public policy to create change. The individual aspect over the collective is not the only problem. Personal growth self-help undermines the individuals who would challenge the status quo more if they were not being taught that they must change. It divides and conquers by redirecting women’s attention toward analyzing themselves. But personal growth self-help hurts not only the collective voice of women, it sacrifices the uniqueness and individuality in favor of a robotic sameness. The industry is designed to make people “better”. Many women in the self-help landscape might each achieve a change in someone else were they not directed to change themselves.

For example, challenging a discriminatory boss who promoted a man with less experience has more individual and societal value than self-blame, self-analysis, and ultimately acceptance of one’s lesser position. The worst outcome of self-help is the personal complacency it yields. Change the male boss not the woman. Some women drop the fight for what they want altogether while they focus on themselves. Self-help has the power to make some women who want to reenter the workforce feel “happy” with child-rearing or settle for direct sales or inferior paying positions instead of a positions reflecting their skills and education. When seriously abused, self-help makes people question their emotional responses.

People should not exclusively blame others or society for an inability to achieve some defined success. Individuals should be held to high standards. I am in favor of nutrition, health, lifestyle, and exercise data, or improving organizational skills, and making objective changes, even to outlook, work ethic, or attitude. Some of those changes may be bodily and others emotional. But personal growth self-help legitimizes settling for less.

The Blurring of Professions in Self-Help

“You’re Not Broke You’re Pre-Rich” is a self-help book. So is “The Secret.” Through different mechanisms, both strategies imply that ignorance as to the tools to become rich is the reason you are not rich. One offers unrealistic financial advice. The other suggests a positive outlook draws money to you.

Positive psychology introduced the concept that thinking positive thoughts influences outcome and emotion. Positive psychology diverts focus to positive thoughts and behaviors. In “The Gendered Nature of Self-Help”, Sarah Riley, Adrienne Evans, and Emma Anderson assert most “psychological frameworks in the self-help literature” “share a similar vision of a flawed individual whose route to a better life rests on developing greater self-mastery over their thoughts and/or behaviours.” Riley, et al. say “in giving up the “fight against”, such perspectives within self-help minimise structural inequalities and refute collective resistance against such inequality.” The Secret is in the vein of positive psychology at the intersection of religion. It suggests that thinking positively alone will draw financial and relationship success.

“Remember that your thoughts are the primary cause of everything.”― Rhonda Byrne, The Secret

While I assert that is simply not true, it can be a religious or spiritual statement. But the Secret blends assertions about behavioral sciences, employment, and financial success, with non-factual beliefs.  

Happierhuman.com, “backed by science”, a psychology-based self-help website, depicts women in many of its articles about happiness, mindfulness, and other emotions. While the research is scientific, the type of research may be detrimental to those individuals who would explore making change outside themselves. The website has pros and cons and probably helps some people.

But, mindset is not everything. By muddying the waters between religion, psychology, and advice, self-help conflates personal control unrealistically and uses professionals and pseudo-professionals to validate its ideas. Ideas surrounding destiny do not belong in medical, psychological, or science-based books. New careers like life coaching or other counseling broadened who interprets and delivers empirical research to consumers. (In that vein, I delivered nutrition data.) Personal growth combines topics adding a spiritual or religious element to the science and social sciences where it does not belong. In evaluating the recommendation of self-help books by psychologists, David J. Tobin and Jessica L. Bordonaro citing Rosen, G.M. said “the proliferation of untested do-it-yourself books reflected commercial considerations rather than professional standards.” 

Does Self-Help Work?

While there is not enough empirical data about the value of personal growth self-help, one article suggests pros and cons. In “Do Self-Help Books Help?” Ad Bergsma found self-help books get a message to a larger audience. Yet certain self-help books like those that have people imagine weight loss to achieve it, are ineffective. (As a nutrition counselor, I distinguish psychological self-help from nutrition science or even from advice on incorporating fresh foods into one’s lifestyle.) The empirical data, albeit incomplete, also might miss the big picture problem. The data possibly suggesting that those engaging in psychological self-help cope better or achieve personal growth might also prove my assertion: self-help makes people complacent and happy with less.

Bergsma also cites studies of self-help book users finding most are women, psychology-oriented, and believe in self-control. In one study, many had “greater life satisfaction”. It is likely that self-help books, retreats, webinars, etc. do help some people in many satisfying ways, as demonstrated by numerous testimonials and back covers. Many people engage in expensive self-improvement retreats or webinars. Yet personal financial success depends on almost infinite factors including personal attributes, society, public policy, social norms, and life circumstances. The biggest factor affecting wealth is wealth at birth.

Self-help bioethics and yoga.
Photo by Jared Rice on Unsplash Self-help and self-care often require a big budget.

The Backdrop for Highly Educated Women

For many women, money-making and career satisfaction can be difficult to achieve, especially if any years were spent raising children. Many people outside the traditional workforce (9 to 5 jobs outside the home) have blogs, small sales businesses, or extensively volunteer even in professional level leadership positions. Yet their skills are rarely seen as good enough to those hiring in the traditional employment arena based on both education and field. Among households with two highly educated parents, many women defer to men whose jobs require long hours. That is, among the highest paying jobs excessive hours became a requirement. Almost 30 percent of women do not work in the traditional job market and raise children. Among those with higher educations, many have trouble reentering the job force despite valuable skills.

The smartest people I know have been or are mothers not in the traditional (or any) workforce. I know that is probably because of the privilege of living in New York City among a highly educated populace. Yet something is amiss when they can’t find jobs commensurate with their experience and skills. Organizations like the On Ramp Fellowship program have helped and the now obsolete Pace Law School New Directions for Attorneys program helped me.

With difficulty finding careers that appreciate one’s level of education, life experience, and expertise, some women resort to improving themselves, a path that often leads to learning to be happy even if they earn less than they deserve, have fewer job opportunities than their male counterparts despite qualifications, and are unduly penalized for taking years off to raise children. A lack of childcare, a structure in which the highest paying jobs require extra time commitment, and an unwillingness in most industries to value nontraditional work hurt women.

Many women have achieved a return to a great career that challenges them and uses their skills. Others are extremely content with or without the self-help industry. It is the source of the contentment among that subset using the self-help industry that is at issue.

How Do We Problematize Self-Help?

The personal development market is a 38-billion-dollar industry. Yet free speech is a cornerstone and protects a marketplace for all points of view and many benefit from self-help. The industries are consumer-based. The consumers represent all income levels.

The problematizing must include the context that allowed self-help to develop its current trajectory and the negative, anti-feminist effects of self-help. Why do some people see themselves as in need of personal growth?

The categorical distinction between spiritual hopefulness and psychology is blurred and in need of repair. The positive psychology movement fuels the personal growth part of the self-help industry.

Is happiness an important or worthy goal?

When the problem is the individual versus the collective, the typical critique, then the need for individual responsibility may be underestimated. Self-help may deprive individuals of a valuable tendency to challenge the status quo. (It might however empower some to do so.)

More Data and a Framework of Oppression

In the self-help realm, theories of oppression could be helpful. Self-help may improve someone’s life but that improvement must be weighed against the opportunity cost of other potential improvements, both individual and across society.

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Partial Bibliography

Riley S, Evans A, Anderson E, Robson M. The gendered nature of self-help. Feminism & Psychology. 2019;29(1):3-18. doi:10.1177/0959353519826162

David J. Tobin Jessica L. Bordonaro. Self-help books: An area of ethical responsibility for professional counselors. Gannon University.   https://www.shsu.edu/piic/spring2008/tobin.html

Schilling KM, Fuehrer A. The Politics of Women’s Self-Help Books. Feminism & Psychology. 1993;3(3):418-422. doi:10.1177/0959353593033021 (older article)

Rosen, G. M. (1987). Self-help treatment books and the commercialization of psychotherapy. American Psychologist, 42(1), 46–51. https://doi.org/10.1037/0003-066X.42.1.46

Why Is it so Difficult to Challenge the Bioethics Status Quo?

My effort to add critical thinking to bioethics, a choppy path at best, sparked me to question some fundamentals about academic publishing. From long ago on the Urban Law Journal at Fordham Law School to my current position at Voices in Bioethics, Columbia University’s journal, I have encountered and managed viewpoint discrimination.

In training peer reviewers, I created a workshop to explain the purpose of peer review, especially in the context of philosophy and the humanities. We have nine qualities we evaluate objectively in a process that eliminates viewpoint discrimination, ensures that reliable sources are used in context, evaluates arguments for originality, soundness, and clarity, and in our case, ensures that articles adhere to our specific writing and style guidelines. The guidelines avoid unsubstantiated conspiracy theories, but we do publish articles that project viewpoints with which I disagree. Our system has an added layer to provide a new peer reviewer if one challenged only the point of view rather than the quality or scholarly aspect of the work. We also make every effort to help first-time authors have their voices heard, ensuring more viewpoints are added to the public discourse.

Bioethics as Doctor-centric?

A lot of bioethics pieces by those in academics or medicine project ideas that are rampantly expressed and remain “inside the box”. In my extensive research on pediatric refusals, it was rare to find articles challenging the paternalistic status quo compared the vast number of articles that begin by assuming the doctor is right and look at ways to get parents to “comply” albeit while “empowering them”. The growing use of empirical research in bioethics seems to further detract from the thought pieces. I hope that bioethics articles will increasingly challenge common assumptions and principles. Those most affected by ethics committees, laws, and practices are generally not part of the elite who write the journal articles.

Bioethics may prefer followers to leaders. There can be an expectation that four principles are enough, that doctors are usually right, and that bioethics committees are a valid and positive development. In a pediatric bioethics class, I found my challenges dismissed or condemned because rather than applying principles differently, they challenged principles, considerations, assumptions, and analytical frameworks. The parenting experience did not fit the medicalized narrative. And my legal and professional background spark me to apply critical theory and challenge the status quo when it leads to unjust results. Competition among ideas can exist within required frameworks or can challenge people to think beyond or outside of those frameworks to find a better approach.

Bioethics Issues

I also challenge processes for identifying bioethical issues. New issues with bold approaches are less likely to be published in traditional journals compared to papers offering tweaks on other arguments already in the bioethics discourse. In the typical trajectory, attention to bodily or individual decisions (will preimplantation genetic diagnosis further a moral good?) and benefits of new scientific discoveries (will facial recognition in health care be a positive development?) quickly shifts to access and justice (if the tech comes to fruition, how will those seen as marginalized access the new discovery?). We spend time discussing access to something that does not exist yet while people do not have access to healthcare basics. Some articles address access to clinical trials on behalf of those whom I sense would have not much interest or benefit. There are endless issues and not enough platforms willing to project the viewpoints less heard.

Some nonissues like therapeutic misconception tend to become an assumed bioethics problem, with devoted solutions. Scholarly journals should be increasingly open to challenges to the assumed problems and identifying more pressing issues.

Challenging the Status Quo

Writing a post (now posted on this website) challenging the status quo about mental health care, I received an uncomfortable ad hominem criticism with highly intrusive personal questions suggesting that I should explain what special personal knowledge or experience I had. The recommendation that I share more personal information to strengthen my position left me uneasy. It has never dawned on me to compel authors to provide personal testimony in public policy or clinical ethics articles. I encounter many impersonal professional policy posts on the blogs I read. Was it a sign of viewpoint discrimination or simply advice to make a juicier post? Constructive feedback is helpful to anyone wanting to convey their argument. I wonder (and am truly uncertain) if I had written the very same post but favored the medicalized approach whether I would have faced similar scrutiny from the editor.

Peer Review Processes Can Control Whose Voices Are Heard

Beyond blog posts, the concept and methods of peer review and whose voices are amplified in the public sphere of academic publishing are ripe for challenge. At Voices in Bioethics we take measures to be open to well-researched viewpoints with which we disagree. I have quite a few examples. Yet many journals do not have policies like ours to prevent viewpoint discrimination. There is also a competing important need to ensure accurate and complete factual representations, coherent logical arguments, and to eliminate invalid arguments as some could even be harmful and dangerous.

Bioethics should welcome the opinions of the many people wanting a say in largescale societal health matters (the kind of society we want to have) or simply a say in what goes into their own bodies. That welcome should not be contingent on going along with the status quo. Well-researched, scientifically accurate, important arguments by those outside of medicine, tech, and science are the most worthwhile check on industry. Those articles must come from patients, parents, ethicists, social workers, lawyers, consumers, and others with key insights. Otherwise, critical theory will take a backseat to convenient principles and self-regulation.

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Medicating Mood & Stress: Clinical Bioethics and Public Health Ethics Conflict

In COVID-19, public health ethics and clinical ethics converged. The effort to reconcile competing ethical priorities should go further, especially in the case of refusals of antidepressants and antianxiety medications for children and adolescents. Generally, in the example of how clinical and public health bioethics clash, the doctor treats the patient but does so ignoring big picture data on overuse of pharmaceuticals. When people seeking care bring up largescale public health or consumer data, should the physician who does not subscribe to beliefs in disease creep and asserts the person needs the medicine consider the public health data on widespread use of medication? What is the clinical role of societal data?

Many doctors rely on pharmaceuticals for symptoms that once were simply feelings and emotions. Yet they do so with ample clinical data, clinical trials, and with expertise. Those patients wishing to refuse may feel unable to persuade the doctor to acknowledge the data on widespread overuse in the clinical setting.

Public health ethics call for kids playing outside.
Photo by Robert Collins on Unsplash

The medical data demonstrates some level of efficacy (medicine may be especially crucial in a mental health emergency or a severe or chronic case). But the data, especially on mild to moderate mental health issues, to me, suggests overuse. What is overuse? Overuse could be an amount of use beyond that needed for medical treatment, that is an amount subjectively declared too much based on what is defined as “needed”. (Here overuse does not mean personal use of a prescribed medicine with symptoms of overuse.) Overuse implies a set of norms (e.g., a cultural or personal non-medicalization preference that creates an obligation to save medicine for a last resort) and a set of assumptions (e.g., that some amount of use based on raw data or sales of pharmaceuticals is unnecessary). Those asserting the numbers reflect appropriate use similarly rely on norms, a near-absolute professional obligation to use medicine as a first- or second-line option, assumptions about the benefits and goals, and a willingness to tolerate side effects. I suspect that many prescribing clinicians are unlikely to consider their own prescribing habits contributing to “overuse” but other scientists, public health professionals, epidemiologists, and health data social scientists note the circumstance of overuse.

The public health infrastructure and socioeconomic or political conditions may make it easier to access medication than to achieve those social or public goods that determine mental health. That is, demand (or arguably need) increased due to poor policy. Pharmaceutical advertising may also impact the demand for medicines, contributing to use. While certainly the failure to address those goods that support mental health contributes, Marcia Angell’s assertion that the epidemic in mental health is partially due to broadening diagnostic criteria and aggressively treating mild and moderate conditions is likely accurate. The nonmedical factors increasing use would be best addressed by policy and situational changes.

While rightly, the person seeking or refusing care, making decisions according to their values, is the focus of the appointment with the physician, the ethical issue of whether the largescale data should impact the prescribing habits should be addressed. By the numbers, public health information, epidemiology, or consumer data validates a public health concern that pharmaceuticals are overused. The clinical care, overdiagnosis, and prescribing habits do not align with an arguably robust public interest in reducing the use of antidepressants and antianxiety medications. The availability of such medicines to those who want them, also a societal issue, is secondary to the issue of the difficulty people avoiding the medicines face. Going against doctor’s recommendations is not easy.

Public health ethics call for outdoor activities and groups interaction.
Photo by Artem Kniaz on Unsplash

**NOTE: the following paragraph mentions suicide rates. If experiencing a need for help, contact https://suicidepreventionlifeline.org / 800-273-8255.

Antidepressant use is way up yet not tied to a decrease in suicide rates or to a decrease in disability claims due to depression. Antidepressants “do not always have a beneficial effect on the risk of suicidal behavior.” The continued debate over their effectiveness varies geographically. In the US, they are well accepted in the medical community, so much so that opting out of them for a teenager is difficult and even can be medical neglect. Yet Marcia Angell questioned the overuse of many drugs for anxiety, depression, and an array of mental illnesses years ago, citing disease creep. The expanded definitions of mental illness (arguably 46 percent of Americans encounter one in their lifetime), new phobias, and a blurring of the lines and definitions evidence disease creep. Not long ago, nervousness was an everyday feeling. Now, psychology aims to define feelings as different from emotion—feelings “are what arise as the brain interprets emotions”.

I assert that neurological advances and a better understanding of the physical and biological mechanisms of emotion have created a movement to treat unwanted emotions or emotions that may get in the way of accomplishing a task. The new developments may have influenced prescribing habits for mild or moderate symptoms, alleviating the need to address mental health prevention through broad policy. To a degree, psychiatry is a short-term band-aid; but when seen as curative or the best approach, medicine could be hampering the development of policies that promote access to the social determinants of mental health.

There is an inherent financial conflict of interest that contributes to the long average lengths of pharmaceutical use (or even of therapy). Lisa Cosgrove, et al. argue “It is not surprising that proponents of the movement—who are mainly psychiatrists and psychologists—strongly advocate for scaling up diagnosis and pharmacological and psychotherapy interventions. Certainly, many youth in the U.S. and internationally are underserved and in need of treatment. However, the fact that the pharmaceutical industry and the mental health professions are obvious beneficiaries of scaling up efforts warrants more serious attention.”

Public health ethics call for approaches to loneliness.
Photo by Anthony Tran on Unsplash loneliness

It may be worth stepping back and allowing more societal input into why we view some emotions as “bad”, whether resilience is lost when people choose pharmaceuticals over coping mechanisms, and whether the approval of drugs to treat mild to moderate cases of depression and anxiety in adolescents or children should be withdrawn. From 2000-2016 there was a steady increase in the suicide rate in the US. From 1999 to 2014, antidepressant use soared, a trend that is continuing. I anecdotally observe pushback among friends who are mothers: many do not want to label a little nervousness “anxiety” or seek medical treatment for emotions, moods, and feelings. Yet pediatricians seem to see it differently and prefer to engage in emotion as a medical endeavor early on even when the experiences are mild.

Research on older adults demonstrates increased resilience. While age and experience likely contribute, I wonder whether being raised without access to drugs for emotions allowed some people to outgrow their anxieties, mild depression, or even irrational fears without intervention. The same generation certainly may have been hurt by policies surrounding the more seriously mentally ill, who were often institutionalized. Like many adults, I attribute my resilience to experiences building resilience growing up. I wonder whether societal conditions like helicopter parenting and pharmaceutical approaches to anxiety could lead to a less resilient generation of adults in time.

We need a holistic examination of whether we as a country (or a world as the problem is somewhat global but more severe in the US) benefit from or are hurt by more drugs in the mental health arena. Everyone acknowledges the medicine might help. But having everyone live within tight emotional parameters could be harmful, a notion that supports acceptance of neurodiversity in other arenas like autism. And people deserve physician support for the many nonmedicalized ways to accomplish the same goals.

Public health ethics call for fresh, healthy foods.
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Exercise and healthy eating habits contribute to overall mental health, something I recommended as a nutrition counselor. Nutrition is often overlooked by doctors facing mild and moderate cases of depression and anxiety. The Ultramind Solution has many medical non-pharmaceutical options. Lifestyle changes also have power to decrease anxiety and depression. The use of social media may hurt self-esteem and exacerbates all different societal pressures to live up to varying aspirations whether fitness, body image, popularity, or even college choice. The pressure to be the smartest, fastest, and prettiest contributes to anxiety. Those contributions are not in the medical realm. In the case of refusals of pharmaceuticals for mental health, reconciling the public health bioethics with the clinical bioethics would lead to a more cohesive approach and foster public trust and trust in the doctor-patient relationship. The public should not rely on pharmaceuticals at the expense of promoting solutions to societal problems that hurt mental health.

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Bioethics and Obesity: Toward a Syndemic, Broad Policy Approach

Bioethics must recognize a syndemics approach to ethical solutions to the obesity epidemic in the US. The line between public health and personal health is artificial. Economic, political, and social structures influence the body in the doctor’s office. Public health approaches obesity various ways—usually by recommendations of exercise and lifestyles that are unattainable. Public programs to encourage eating vegetables and exercising exist at all levels, community to federal. Yet an anticipated 50 percent of the population will have obesity by 2030. Attacking the problem at the individual or behavioral level is unlikely to solve it but remains the prevailing theme.

Some aim to address obesity at the “systems level”, recognizing that obesity does not reflect a linear cause-and-effect relationship. Yet the WHO key factors to protect against obesity focus on personal habits. Scholarly articles recommending important steps like nutrition labeling mix personal behavior into policy. That is, the recommended policies often target individual behavior calling for change rather than corporate or government policy that would open the opportunity to change. I am a huge proponent of labeling, but the obesity epidemic tends to reflect pricing, not labeling. Another example is the New York City ban on sodas over a certain size or the concept of a soda tax. Both aim to control individual purchasing habits. Yet they do not control why soda is cheap to make – agriculture subsidies.

Huge economic structures, federal policies, the global food trade, and food politics influence obesity. Completely eliminating personal responsibility is not the answer. But the most ethical approach to the obesity that results from diet and lifestyle must identify the non-personal and non-genetic causes of obesity and eliminate them. The bioethics community fails people experiencing obesity by applying a myopic set of principles validating actions that encourage those experiencing obesity to change habits. Even in calling for approaches that shore up food sources, remedy food deserts, increase farmer’s markets, and place vegetables in bodegas, the bioethics community seems to focus more on government and nonprofit programs than on political market distortions like subsidies, or on the lobbying that allows corporate interests to impact health. The other bioethics obsession (and my passion admittedly) is freedom, yet that also keeps the bioethics at the bodily level and distracts from the issue of how much corporate freedom exists and how to balance that when it infringes individual’s ability to be free from something.

Bioethics obesity and corn syrup transported by train
Corn syrup transported by train. Photo by Robin Jonathan Deutsch on Unsplash

At the federal level, competing priorities have downstream effects. Corporate lobbying influences federal decisions and dollars. The Farm Bill includes SNAP and policies that favor some crops over others (“staples”), leading to growing foods that tend to then be processed. The subsidies for commodity crops act as an insurance program for those unhealthy crops. A farmer, or Big Ag, has incentive to grow corn and soy knowing that if they face a crop failure (weather, pest, or environmental) or a market failure (e.g., lower commodity prices when there is too much supply), the government will pay the difference. The corn contributes to corn syrup, a contributing cause of obesity, and the policies keep soda cheap. The Farm Bureau, an insurance and lobbying group, represents farmers, but its lobbying efforts reflect its relationships with Big Food rather than small family farms. The Farm Bill directed incentives to transition to organics, but fruits, nuts, and vegetables remain “specialty crops” and are not eligible for subsidies.

Food corporations took on major lobbying efforts ahead of the 2020-2025 Dietary Guidelines. HHS and the USDA oversee and rewrite the guidelines every five years incorporating nutrition science and epidemiology, yet the lobbying muddies the waters. I personally find it comical that Secretary of Agriculture Sonny Perdue and a Big Pharma exec (Alex Azar, Secretary of HHS) have the power to comment on what anyone eats, yet their letter introducing the new guidelines asks Congress to make policy that makes it easier for individuals to “make food and beverage choices that are rich in nutrition.” Historically, Perdue projected stances that would make it more difficult for people to afford healthy foods and he wanted to impose a work requirement for SNAP.

Bioethics obesity map U.S.
https://www.cdc.gov/obesity/data/prevalence-maps.html

I am skeptical of any role of government in what we eat. Public health and the US Congress operate under the assumption that the government should convey to the people some outline for eating. If they continue to do so, it would only be appropriate to have their policies make those eating choices easier. Better education, wages, and opportunities correlate to better food choices. As seen in the map above, our poorest states have the highest percentage of people with obesity. Addressing poverty would be better than telling those in poverty to eat more vegetables.

A framework to analyze the ethical problem must look to the downstream effects of a broad swath of policy initiatives. The Farm Bill, school lunch programs, and food-related policies are not the entirety of the problem. Exploring families and their experiences would show the lived experience of putting food on the table: Where are they shopping? How much does their food cost? Are they cooking? How much is fresh versus processed or packaged? Public policy makes unhealthy food cheap. Low wages make people rely on cheap food.

In the middle, many people are not educated about health and nutrition. I do not recommend they solely rely on the federal government among the many sources of information although the federal government, NIH, CDC, etc. do have largescale epidemiology and PubMed puts much of it in one place. I would use caution knowing the federal government’s conflict of interest due to its openness to the food lobby. The scrambling of industry to influence the guidelines and then to create processed foods that conform to the macro-nutrient dietary outline undermines the guidelines. Eating is cultural and personal, and perhaps best kept that way.

A framework to address the ethical issues surrounding obesity should avoid discussions of bariatric surgery for kids or the size of a soda, and look at poverty, wages, and subsidies with an eye to the lived experience of those with obesity.

Feature Photo by 𝓐𝓵𝓲𝓪 𝓦. on Unsplash

Bioethics, Robots, and The Future of Work

Self-driving cars, warehouse robots, EZ-pass, do-it-yourself check-outs, and ATMs threaten the future of work. Work and its many components including pay, atmosphere, feeling of inclusion, and empowerment are social determinants of health. Potential job loss is a valid consideration in ethical arguments to restrict the development or uses of new technologies, yet there is not a foundational approach to the issues. Because regulations are slow to catch up with technology, corporate actors with conflicts of interest are the arbiters, weighing the pros and cons of their own technological inventions. Some have proposed an IRB-like solution to monitor and approve new tech, but that solution seems unlikely and distant. Regulations are responsive (and usually late) when they could be formulated in advance of anticipated job loss.

Photo by David Levêque on Unsplash

Many people see progress as an intrinsic good, even if it leads to “technological unemployment”. To others, traditions like a 9 to 5 job are a good, and life is centered around the workplace, making adjustments or job loss not just financially challenging but socially demoralizing as well. Historically, the industrial revolution and paradigm shifts sparked by singular inventions threatened jobs. According to estimates, there could be a 50 percent net decrease in employment due to robotics within 20 years. Progress and work each have intrinsic and instrumental value. Luckily, there is no simple bioethics formula to characterize and weigh harms. The interdisciplinary nature of bioethics, defined as moral philosophy of health-related sciences like medicine, health, biologics, pharmaceuticals, and broader STEM fields, calls for the tech, public health, policy and legal, economics, and psychology fields to collaborate with philosophers. Philosophy must drive the framework and ensure a fair approach and a valid analysis, incorporating logical reasoning and critical theory. A simple weighing of harms won’t do.

The Ethical Difference in Comparative Cases: The Moral Goodness of the Job Lost

Case A: Loss of a Polluting Job and Growth of an Environmentally Friendly Industry

In industries like coal mining that pollute or bear some intrinsic bad, I would consider job loss an ancillary bad when greener innovations threaten the industry. Or consider loss of a safer job in a polluting industry like fossil fuels where the person was not taking health risks on the job. Many people may not weigh the harm of that type of job loss as heavily, or could argue it is a good, that cleaner energy has some acceptable roadkill. The more robotics, the fewer “green” jobs. The environmentally favorable unemployment arguably is for the greater good in the long term, but whether its harms can be mitigated by corporate, community, and government actions is unclear.

Climate change mitigation and maintaining employment are sometimes competing goals. Those losing jobs that pollute are not often the same people who then gain a green job. When bioethics looks for weighing processes, underlying values influence analysis. One may argue that all job loss is bad, while another may argue that all jobs that pollute are bad. Simplistic harm reduction would support the person whose job is lost. Utilitarianism tends to assume the ability to weigh goods but does not provide guidance on how to weigh even a small loss of something incredibly meaningful subjectively to the person losing it. The loss of a terrible job in a terrible industry may create a downward spiral in a human life.

Bioethics principles fail here—beneficence to society favors green jobs; beneficence to the person employed in the polluting job turns into harm reduction (or holds society back in its efforts to decrease pollution.)

Case B: Pollution Ancillary to Commutes

Human costs are compared to the benefits or the good generated by automation, robotics, and new technologies. The utilitarian who believes all jobs that pollute are bad may justify job losses too easily. Under that practice, if all automation and robotics cut out some long commutes that pollute, the environmental effect may outweigh its effects on those fired, even if the industry being automated was not a contributor to pollution, and, even if the automation does not serve any good other than to the corporation using it. (Commuting to be a bank teller uses gas. ATM saves that teller’s gas.) Dismissing the harms of the job loss in an industry that pollutes could lead to a slippery slope in which all new tech can justify job loss, regardless of its purpose or use. The earth might be better if everyone stayed home.  

In the ATM situation, the ATM is not really “doing good.” Nor is a warehouse robot. But in the new green job (for example wind energy with few employees replacing a coal mine), the industry is doing good. The benefits of new technologies open many issues: Who benefits from them? Does a single entity or all of society share in the benefits?

Case C: The Robot Makes an Industry Safer

Robotics in solar energy will decrease the need for workers, especially those in dangerous jobs. A robot doing good (both by saving a person from a dangerous job and by creating renewable energy) a person who was doing good, but doing so was dangerous, lost a job “Robotic assistance has already begun to replace a number of high-risk jobs, such as assembly line and manufacturing jobs, and medical lab technicians.”

In cases of robots bearing the danger, the issue of the industry remains. If a robotic device does the job that pollutes instead of a person, the person’s safety is a significant benefit: no exposure to coal dust, but also no paycheck. Devoting resources to create robotics which further “dirty” industries like coal may be permissible under a “harm reduction” bioethics approach; a robot would not be susceptible to lung damage. But devoting tech to dirty nonrenewable energy when innovation should go toward sustainable energy sources is undesirable. Government rewards for engaging in the “right” tech help and regulations to discourage the wrong tech help. The market itself is not the perfect driver of ethical tech decisions. Markets thrive on access to the cheapest even as consumer preferences change toward greener products.

Job Loss, Work, and Purpose

The “crisis in meaning” for the terminated employee is problematic regardless of what job was lost to technology. The push and pull between corporate and government responsibility for lost jobs covers something technical rather than emotional. As such, the government compensating through welfare programs like a universal basic income or food and housing assistance would not satisfy any emotional deficit from unemployment. Regulations could require corporate taxation or payments directly to former employees to keep the burden on the corporation, also failing to address the less tangible value of work like emotions, purpose, and community.

Work is integral to wellness for many people. In the US, a strong work ethic is valued, but if there is not enough paid work to be done by people, the norms or value structure would need to change. A societal effort to realign unemployment with acceptable adjectives, not laziness or failure is unlikely. Yet a musical chairs approach would further the negative stereotypes while a concerted effort to address the future of work could alter or modernize the moral value we place on work.

To me, the importance of work is so embedded culturally that encouraging innovation that involves more people, job sharing, and better wages would be a better approach. Underemployment would be less problematic if people had enough money and participated in other meaningful activities. Shannon Vallor asserts that adaptation, or flexibility is a virtue necessary to deliberate a “prudent course of technosocial action” (p. 148). Her delineation of flexibility as a virtue is important, but, to me, many people are personally less flexible, dislike change, and will not embrace such a virtue. I would argue that society is not ready to devalue work or to improve a conditioned perspective on people “of leisure”. Even in the right geopolitical landscape with the right entities sharing the responsibilities, and even with safety nets, Americans equate work and purpose. It seems unrealistic to redefine what makes life purposeful.

An analysis of the future of work should start with purpose—what it is to lead a purposeful life—and should include ways to develop new industries with high paying jobs of the future. Robotics should not replace main street social interactions. What kind of society do we want to live in? And, with how much personal interaction? Who should approve which technologies for which use? Should some tech be reined in, and other tech encouraged? The larger impact on society implies many stakeholders, most of whom so far have had no voice in tech ethics.

Featured Photo by Alex Kotliarskyi on Unsplash

Big Data: Reconciling Privacy, Antitrust, and Data-Generating Patents

Data-Generating Patents require a broad ethical approach that incorporates business ethics. Ethics should that adhere to the spirit behind antitrust law and competition to protect consumers. Intellectual property rights are expanding. Data-generating patents can preclude competitors from obtaining, collecting, or generating the same type of data. It also deprives people of control over their data and privacy. Trade secret law protects the data generated by the technology. The patents provide a windfall of market share in the data market which is not the market of the technology or biomedical device patented. (e.g., if a patented search engine of social media outlet collects data from millions of people, trade secret law protects the actual data longer than a patent would; Myriad Genetics patented the BRCA testing data resulting from its technology giving them exclusive access to the breast cancer genetic data.)

Big Data & Trade Secret Protection

In Association for Molecular Pathology v. Myriad Genetics, Inc., the Supreme Court held that natural sequences of DNA (gDNA) were unpatentable but that cDNA is synthetic and therefore patentable. Brenda Simon and Ted Sichelman note that even after losing the patents on most of the products and the impending expiration of others, Myriad continues to use trade secret law to protect its database of patient information. Trade secret law does not have an end date so the ability to create a monopoly, barrier of entry to competing businesses, or to use big data as an advantage in marketing and producing other products is great. The market control can inhibit innovation and access to data for the public good or public health, hurting consumers and the public.

Privacy in the Data Windfall

Privacy poses an additional problem. Data-generating patents and many products that generate data put data exclusively in the hands of the products’ creator. The general public may not be aware of the data’s collection and use. The data is also often separate and distinct from the product. That is, someone may use an Apple watch without realizing what biometric and other personal data including time and place data Apple will then own or control. The audio information collected could track a conversation, its time and place. That audio includes people near the watch, not only the wearer of the watch. Apple’s patents refer to “additional sensor data”, data clusters, and personal characterization data. The data could provide helpful information to the user, but also could provide information to other actors (e.g., traffic data to the government) or to classify users by habits like staying up late. Tracking routine activities gives companies a marketing advantage in products completely unlike the products that led to the data collection.

Photo by Markus Spiske on Unsplash

Data Fairness

Monopoly behavior, privacy breaches, and the marketing advantages are just the surface of the ethical issues. In Barcode Me, I explore the concept of paying individuals for the data collected. Additional issues include bias and how goods and services are marketed based on stereotyping, preference assumptions based on behaviors, and how the marketing itself can feed many divides. For example, companies will aim ads for inexpensive, packaged foods at people eating inexpensive, packaged foods. They will aim ads for healthy organic foods and corresponding lifestyle products at people eating organic foods. Companies expand the snapshot using stereotypes and the ads further behavioral divides. When an expensive product generates data, large data sets may leave low-income consumers out altogether. Data skewed toward the wealthy leads to broad conclusions that may affect public health, public policy, corporate behavior, and health care. Furthering the divide in a consumer way can lead to further political and economic polarization and affect health disparities.

Tech Ethics & Antitrust

The deeper ethical issues of how we want tech companies or discoveries regulated speak to who should benefit from technology and how. Overregulation would deprive the population of the benefits of big data, yet a failure to protect consumers leaves them vulnerable to monopoly behaviors, high prices, stereotyping, and a lack of control over their own data. A multiangled approach could look to using current antitrust laws and to modernizing antitrust laws to solve some of the issues and require products to create better ways for consumers to limit data collection.

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Why the Biggest Health News of the Week is the ProPublica Tax Report

The ProPublica report on the taxes paid by the ultrawealthy is an important backdrop in a syndemic framework for evaluating health. A strong tax base contributes directly to health in several ways. Public parks, social services, education, community health centers, strong infrastructure, and Medicaid rely on tax dollars. Medical research is often funded by NIH seed money. Tax dollars have ramifications for the fight against racism, covering federal judges, federal support of states improving housing, policing, and education.

The basket of goods known to determine health relies on certain collective, public goods, which require a strong tax base. Grit and determination may help people take advantage of those goods or compensate for a lack of them, but the social determinants of health generally require access to education, food, positive workplace conditions, and living wages.

When the tax structure favors the ultrawealthy, the result is continuing the corporate welfare state. Failure to pay a living wage is a pervasive problem in the United States. Minimum wage workers have trouble paying rent and cannot afford a two-bedroom apartment in any US county. The Out of Reach report tracks the gap between income and housing.

In the New York mayoral debate on Wednesday, the affordable housing discussion was purely supply side, and reflected only ideas about development. A demand-side approach would be much better, yet no candidate used the housing question to examine why people cannot afford housing here. To say the housing does not exist hardly gets to the root of the problem. Workers are generally saddled with low wages and taxpayers fill the gap through financing social services, SNAP, and housing and healthcare subsidies.

As the low taxes are legal and embedded in the tax code, the  “true tax rate” of 3.4 percent is sort of a “what-if” analysis as growth in wealth is not taxed as income, nor is it taxed at all unless an asset is sold. Abigail Disney explains how it is to be wealthy, and how protecting that wealth can cloud out other priorities. She also cites the concept that “government cannot be trusted with money.” The idea that the government is not the right entity to have, redistribute, or spend too much money as it does so either inefficiently or dishonestly with political motivations, while antiquated, is a predominant Republican viewpoint that perpetuates low taxes as a primary policy platform. The one feature that I see uniting old school Republicans and Trump voters is the use of distrust for government as an excuse for very low taxes on the ultrawealthy. Certainly, the wealthy vary in their wealth protection strategies and in their political views, and many wealthy people do not support candidates promoting low taxes for the ultrawealthy.

Some tax history reveals a change in the degree of willingness to tax income in the Reagan and post-Reagan era. Now, cries of socialism depict all taxes and all social programs as “socialism” in contrast to the historically higher tax rates associated with capitalism in the United States, a capitalist country.

From 1944 through 1951, the highest marginal tax rate for individuals was 91 percent, then 92 percent for 1952 and 1953, and back to 91 percent in 1954 until 1963. (I cannot imagine a Congress haggling over 91 or 92 percent now.) In 1964 tax year, it was lowered to 77 percent, and then to 70 percent for tax years 1965 through 1981. Even for the early Reagan years, it was 50 percent. After the experimentation at the 28 percent level in 1988, 1989, and 1990, it has remained under 40 percent. See IRS historical taxes, Table 23

Currently, the highest marginal tax rate is 37 percent. The social determinants of health probably require more from the ultrawealthy to create a sustainable tax base that fosters opportunity. If taxes were to be kept low, eliminating corporate welfare by requiring large corporations to pay higher wages would alleviate some of the burden shouldered by the taxpayers—Should my taxes go to SNAP or housing assistance for an Amazon or Walmart employee? This US Government Accountability Office report shows that they do.