Category: Health

When everyone is in danger from a disease, it seems irrational for a political party to politicize the threat. But this happened during COVID-19.  One reason is that while Americans seem extremely polarized; this is  more appearance than reality. While Americans do disagree strongly on some issues, there is considerable consensus about many issues. Because of this, political parties need to manufacture a conflict in which they can score points. Since a threat generates strong emotions, it can be ideal for politization as a party can tap into the emotions and manipulate them to its advantage. Taking a threat seriously can also be contrary to the interests of some and they will try to prevent this by politicizing the threat. If they succeed, they can recruit voters and get them to support policies that endanger these voters. Thus, a political party can have two excellent reasons to politicize a universal threat: to score political points and serve the interests of those who benefit from allowing the threat to remain unaddressed.

Politicization can be effective at engaging emotions and disengaging reasoning. There are many fallacies (such as group think) and cognitive biases (such as in group bias) that feed and are fed by ideology. If you are liberal, then you probably just thought of the Republican politicization of climate change. If you are a conservative, you might have been thinking about the sins of the Democrats. If so, then you can see how conflict can easily be created along party lines.

The COVID-19 virus presents a threat to everyone, but it was politicized. Initially the Trump administration downplayed the virus and accused the Democrats of using it to attack Trump and the idea that is a hoax aimed at hurting Trump persists. There were short-term advantages to politicizing the virus, such as keeping the markets calm through ignorance, to allow business to continue as usual and to hope that the virus would not arrive until after the 2020 election. Political points were also scored against the Democrats by accusing them of making up a virus threat to hurt Trump.

From the Republican perspective, the Democrats were the villains, doing terrible things to harm Trump and impede his efforts. On their view, it was the Democrats who were manufacturing the conflict; first by creating a virus hoax and then by interfering with Trump’s efforts to address the virus.  How one sees this matter will, obviously, tend to shake out along ideological lines, thus politicizing the issue of politicization.

While, as noted above, political points can be scored by politicizing an objective threat, this does have negative consequences. The most obvious is that time and resources are spent fighting manufactured political battles rather than uniting against a threat to everyone. Another consequence is that manufacturing a conflict requires that misinformation, thus misleading people and this can have enduring consequences. In the case of the virus, while Fox News and the White House did shift their position to match reality, the groundwork they laid still serves as a foundation for the enduring view that the virus is either a hoax or not very serious.

Some Republicans will want to blame the Democrats; a common narrative is that their impeachment efforts are partially to blame for the virus crisis. As would be expected, one’s ideological lens determines how one sees this matter: Trump and Fox News as the villains who politicized the virus or the Democrats as the villains who distracted Trump from the virus.

There are three solutions to the needless harm caused by this sort of politicization. The first is that politicians need to exercise judgment and restraint before engaging in politization of a crisis. The problem is that it is seen as a useful political tool. As such, getting politicians to use good judgment and exercise restraint is challenging. The second solution is that voters can support candidates who are more likely to exercise judgment and restraint. Third, voters also decide how they respond. If they resisted efforts to politicize a crisis that should be non-partisan, then the efforts of politicians would be far less likely to succeed.

One concern is the charge of politization can be used, ironically, to politicize an issue and silence legitimate criticism. For example, the facts show that Trump’s initial handling of the crisis was terrible and that he made untrue claims about the virus and the situation. As such, legitimate criticisms of these failures could be non-political. But if critics are Democrats or liberals, they could be accused of politicizing. To address this problem, critics should focus on the facts and steer clear of what might appear overtly political. This will be challenging, since the other party is unlikely to accept legitimate and fair criticism and will claim it is unfair politicization. As such, the manufactured polarization in the United States that has served the parties has done massive damage to America. As should be expected. Unless we address this, new crises will  repeat the harmful politicalization of the  COVID-19 crisis.

In the United States, health care is often seen as a private good. The benefit of a private good belongs primarily (or even exclusively) to the individual. But a private good could have some broader benefit as well. A private good is usually seen as being the responsibility of the beneficiary. Put roughly, you should pay for your private good, not the rest of us. There are many things that are clearly private goods.

For example, my running shoes are a private good because they benefit me, and I should be the one to buy them.  In terms of broader benefits, my health means that I do not miss work, and this benefits my employer and students. But this is not enough to make them a public good.  .

Obviously. a public good is supposed to benefit the public and is often seen as being the responsibility of society. Put roughly, it is a good for us and we should pay for it collectively. A public good need not benefit everyone directly. For example, public transport does not directly benefit someone who never uses it and only gets around by walking or biking.  There is considerable debate over what goods (if any) should be public. Public versus private health care is a matter of debate in the United States.

Apart from the United States, most wealthy countries have chosen public health care. The United States offers some public health care in the form of Medicare and Medicaid but people need to qualify for both and the Trump administration and Musk are doing what they can to cut into these programs.

Most working people rely on private health care. One reason is the rhetorical narrative that health care is a private goo or at least better as a private good. In terms of being a private good, the idea is that each of us is responsible for our own health care in that we must earn the money to pay for insurance and treatment. With the exceptions of Medicare and Medicaid, we are on our own. The idea is that my health is good for me, but not for you, hence I should bear the cost.

There are also arguments that private health care is better than public health care. This can be countered by the fact that people go bankrupt due to medical expenses, people cannot afford and hence do not get basic care, and people  turn to GoFundMe to pay their medical bills. It is true that we have the best health care money can buy, if you have the money to buy it. I will set aside this debate to focus on the main issue: whether health care is best seen as public or private good. One way to approach this matter is to consider paradigm cases of public goods.

Consider, if you will, an alternative America in which defense, police, fire and the legal system are private goods analogous to how health care is a private good in the real America. In this alternative America, citizens need to purchase military, police and legal insurance or face high costs for purchasing military, police, fire and legal services. In the case of military and police coverage, a citizen would be provided with various degrees of military protection for their person and property. Without such coverage, a citizen would need to pay high costs to secure such services as defense against foreign enemies and police investigations into crimes committed against them. Those who could not pay might be able to qualify for some basic services through government programs such as Militaryaid and Policecare. Those unable to qualify for these programs and unable to afford the services would be on their own. They would need to rely on self-defense, a garden hose and vigilante justice to address threats and crimes against them. This would be fair and just—after all, having the military protect me does not benefit you, nor does having the police investigate theft of my truck benefit you. Only having the military protect you benefits you. Only having the police investigate the theft of your truck benefits you. So, by the logic of health care as a private good, police and military services are also private goods. The same would also apply to aspects of the legal system. Being able to defend my property or other rights in a legal system does not benefit you, it just benefits me.

There would be, of course, certain police, military and legal activities that would occur because they would be good for these institutions and the state. The police would certainly enforce laws that generated revenue for them and the state; but if the law served only your private good, then you would need to pay for its enforcement. Such institutions would be lean and efficient, operating in accord with strict market forces as God intended. Unless, of course, they grew bloated and inefficient.

In this world, the results would be like health care in the real world. People would be locked into jobs to keep their police, military, fire and legal benefits. People in need would turn to GoFundMe to pay to have their spouses’ murder   investigation or keeping Canadians off their land. Many people would be victimized, injured or killed because they lacked basic coverage. But defenders of the system would praise it for all it alleged virtues and mock other countries for their public police, military, fire and legal services.

Things like police, military, legal and fire services are seen as public goods because they meet a state’s minimal obligation of protecting its citizens. Such goods require large expenditures, thus requiring collective funding and this can be seen as justifying providing a collective good. The same can be applied to health care; just as the state should protect its citizens from ISIS, fire and crime, it should also protect its citizens from COVID-19 and cancer. After all, you are dead whether you are killed by an ISIS bomb, a criminal’s bullet or COVID-19.

Police, military and other such services are also seen as public goods because they do (mostly) benefit everyone—even though the specific applications benefit specific people. The same also applies to much of health care. For example, infectious illnesses spread and containing them is a public good. As another pragmatic example, sick and injured people contribute less to the economy, so treating them benefits the public by getting them back into serving their core functions in capitalism: working and spending. As such, health care should be seen as analogous to the public goods of the military, police, fire, and legal system. There are, of course, obvious exceptions in which medical procedures are entirely private goods (like face lifts) but these exceptions do not disprove the general principle.

When the COVID-19 virus invaded the United States, it found an ill-prepared and complacent foe. As such, the impact proved devastating. One clear lesson is that the aggressively for-profit health care system is a weak point in our national defense against disease. I will make my case with the obvious analogy between health care and military defense.

Imagine, if you will, that the United States military operated like our health care system. Our current health care system is analogous to relying on mercenaries, albeit with a professional code of ethics and some loyalty to the nation. During normal times, the health care system is almost entirely mercenary: it fights battles to make a profit. This is not to disparage medical professionals, but the profit model chosen by those who control health care. Because the goal is profit, the health care system is operated to minimize costs and maximize income. This means operating like a mercenary force: employing minimal personnel to do the job, maintaining only necessary resources for normal operations, focusing on the highest paying customers, and only taking on profitable contracts. This is a rational way to operate a mercenary unit. But is it a good way for a national military to run? That is, would it make sense for the United States to switch from a public military to a mercenary military?

Laying aside the usual problems of loyalty and dependability, relying on a mercenary (for-profit) military model would be a problem for the United States. One obvious problem is the United States needs a large force that ready to engage in prolonged conflicts that we do not always get to pick. After all, national security need not match up with what would be the most profitable military operations and requires keeping resources available, such as the reserves, that no purely for-profit military would sensibly maintain. If the United States relied on a mercenary military for its defense, it would face many challenges in times of crisis: rapidly ramping up to meet the challenge, making the operations profitable enough to motivate mercenary forces (such as paying them enough to protect everybody). These are, in fact, all the reasons why a country should have a public, national military rather than relying on mercenaries. After all, the United States needs a military that is ready to face whatever threat arises and not a force limited by the need to make a profit. It is thus no surprise that our mercenary healthcare system runs into analogous problems.

Being focused on profits, the health care system operates with minimum resources and personnel. Maintaining a reserve of medical professionals and the resources needed for a crisis would cut deeply into profits. The government, it should be noted, does keep some medical resources in reserve, but this is obviously the public sector in operation. Because of this razor thin operation that maximizes profits, the health care system is like a mercenary unit: ill-prepared when the battle turns into a full-scale war requiring large reserves and resources. The health care system normally deals with the problem of resources by allocating them based on profit; like a smart mercenary commander who accepts the lucrative contract to fight easier opponents. In the case of health care, the wealthy get the best health care money can buy, while the poor get whatever is left over. But in the case of a national crisis, the response must be large scale: it is an invasion and not just the usual battles. People face the same problem, be it in a battle fought by mercenaries or health care provided by mercenaries: they need to be able to pay in order to get protection.

One principled reason we have a national public military rather than using mercenary forces is that we accept that the military should protect all citizens and not just those who can afford to hire their own mercenary forces. The same principle should apply to health care: having a mercenary medical system means that a citizen’s survival depends on what they can pay, and this is not acceptable. If we believe that the state should protect all citizens equally from ISIS and North Korea, then we should accept that the state should protect all citizens equally from COVID-19 and H1N1.

It could be sensibly argued that the military model fits in the case of pandemics and while health care should be modified to address the threat of pandemics, the for-profit model should remain for everyday medical matters. So, for example, everyone should have access to testing and treatment for COVID-19, but we should still be on our own when it comes to the flu, hepatitis or automobile accidents.

One reply is to argue that the state has obligations in the everyday medical care of the citizens. To use another analogy, if handling pandemics is like fighting a war, lesser threats are analogous to small-scale conflicts or police operations. We do not, for example, expect Americans to pay to get police services to address crimes against them, just because the crime is against them and not a pandemic of crime.

This is not to say that the state must pay for everything. No doubt someone is thinking about the state  paying for breast implants or face lifts. But expecting the state to pay for these would be like expecting the state to pay the bill because a citizen wanted to see a military parade on their street. As such, only the medically necessary should be covered. Just as we limit the obligations of the national military and local police, the obligations of health care can also be limited. This can lead to debates about what is necessary, but these disputes can be addressed in good faith.

It could be objected that people bring on their own health problems by bad choices and this should not be the responsibility of the state. But the same argument would apply to the police and military. For example, if the police thought that you did not take enough precautions to protect your car, they could refuse to do anything about it being stolen. Or, as another example, if you get attacked and injured, they could refuse to help you because you failed to take enough karate.

If we continue to rely on mercenary health care as part of our national defense, we can expect things to play out in a manner analogous to relying on mercenary forces for our national defense: no matter how brave or dedicated the individual soldiers are, a mercenary system is simply not up to facing the challenge.

One the face of it, it is reasonable to think a mass shooter must have “something wrong” with them. Well-adjusted, moral people do not engage in mass murder. But are mass shooters mentally ill? The nature of mental illness is a medical matter, not a matter for common sense pop psychology or philosophers to resolve. But critical thinking can be applied to the claim that mass shootings are caused by mental illness.

Using the strict medical definition, mentally ill people do not make up the majority of mass shooters and about 3% of violent criminals are mentally ill. Research consistently shows that the mentally ill are more likely to be victims of violence rather than perpetrators. Violence on the part of the mentally ill tends to be self-directed rather than directed at others.

Self-injury is a matter of concern, but mass shootings and gun violence are not primarily a mental health issue. While the mentally ill commit some gun violence, focusing on mental illness as the primary means to reduce gun violence would be an error, except to address cases of self-harm.

It could be objected that the definition of mental illness used above is too narrow and that engaging in a mass shooting is evidence of mental illness because a sane person would not do such a thing. While this has some appeal, expanding the scope of mental illness to automatically include those who engage in mass shootings would be problematic.

One obvious concern is that soldiers and police could thus be classified as mentally ill simply by being involved in shootings on par with a mass shooting. It could be countered that soldiers and the police (usually) use violence legally and rationally while mass shooters and people engaging in other gun violence do not. While it is true that mass shootings and gun violence are illegal, mass shooters do often act from grievances and ideology, just as soldiers and police are sent to kill over grievances and in accord with an ideology. As such, killing people for these reasons does not make someone mentally ill, unless we want to classify combat veterans and some police officers as automatically mentally ill. As far as the legal aspect is concerned, breaking the law hardly seems to show someone is mentally ill, otherwise all criminals would be insane and thus would always succeed in the insanity defense.

A second concern is that assuming mass shooters are mentally ill would eliminate the role of evil. If people do mass shooting things because of mental illness, then they are not evil in a morally meaningful sense. While this could be true, such an approach to evil would need to be applied consistently and not just to mass shootings. So, for example, when terrorists crash planes into buildings or blow up a wedding, they are suffering from mental illness and are not evil. One could attempt to work out accounts of ethics and mental illness that put the blame for gun violence on mental illness while putting the blame for terrorism on evil, but this would be challenging. After all, if a white supremacist kills people because he is mentally ill, then the same would apply to a member of ISIS. Interesting enough, while Republicans and the NRA rush to blame mass shootings on mental illness, they do not do the same for terrorism or other crime and it is interesting to compare the rhetoric used by the same pundit or politicians to describe these situations. This is not to say that a case cannot be made for eliminating the concept of evil in favor of the concept of mental illness, but this must be done in a principled manner and applied consistently.

Considering the above discussion, the mental illness explanation for mass shootings (and gun violence) is not adequate. While seriously addressing mental illness would be laudable, it would not eliminate mass shootings and would have an insignificant impact on most violence (other than self-inflicted violence). This is not to say that mental illness should not be addressed, it absolutely should. But claiming mental illness explains gun violence is an error and a distraction from addressing the causes of gun violence.

According to the FDA, it “is responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices; and by ensuring the safety of our nation’s food supply, cosmetics, and products that emit radiation.” Given this mission, the FDA should put the interest of public health ahead of other concerns, such as the profits of a pharmaceutical company. While many at the FDA are dedicated to this mission, federal agencies are routinely captured by industry. So, it is not surprising that the FDA has benefited companies at the expense of public health. Charles Seife wrote an article that appeared in the February 2018 issue of Scientific American. While there are legal issues here, my concern is with ethics

On the face of it, the moral problem is easy to solve. As the FDA is tasked with protecting public health, its moral duty is to do that. Putting public health at risk to benefit a company or individual would be wrong. Part of the problem, as noted by Seife, is that the FDA is secretive, which makes it difficult for the public to know about the FDA and the products it approves. Another part of the problem, also noted by Seife, is that the FDA seems willing to allow research misconduct to remain unreported. Under the current administration, it seems likely that things will only get worse.

While it is tempting to see evidence of misdeed when drugs are recalled or given new warnings, it must be noted that this should be expected even when products are properly evaluated. This is because of how inductive reasoning used in product trials works. While inductive logic is essential, it has a fundamental problem that is called, shockingly enough, the problem of induction. Since an inductive argument’s conclusion always “leaps” beyond its premises, the conclusion of such an argument can always be false, even when all the premises are true. Since the controlled experiments of the trials are inductive, they can be properly conducted  and still yield a false conclusion. These trials are then generalized to the entire population, which is another inductive argument and another chance for things to go wrong.

For example, even a large sample will not contain every genetic or physiological variation relevant to drug interactions. As such, a drug that was safe in the trials might have unexpected results out in the wild. So, one should not rush to judgment if an approved drug needs a warning label revision or has unexpected effects on some people. That said, the concern about how the FDA operates remains, as Seife’s research indicates.  As such, the FDA seems to have acted wrongly by putting corporate interests ahead of public health. It remains to be seen what the future will bring, but even under traditional administrations, the FDA has engaged in bad behavior. If even this modest oversight is stripped away, things will become much worse.

An obvious solution is to make the FDA’s process and data available to the public. Under this solution, the public would have access to everything that occurs within the FDA as well as all the information provided to the FDA by the companies whose products are being evaluated. While this would solve the problems noted above, there are reasonable concerns about such complete transparency.

Allowing full public access to the FDA’s information would also allow the same access to competing pharmaceutical companies (and others with a financial interest in the data). Such transparency would allow access to a company’s trade secrets, commercial and financial information.  This could cause “substantial competitive injury” and would be like playing poker while being forced to let everyone see your cards. Because of the potential harm, such full transparency would seem to be wrong.

It could be countered that all companies would be on equal footing, and no one would have an advantage. Going back to the poker analogy, if everyone must show their cards, no one has an advantage. The obvious problem is that foreign companies that do not undergo FDA approval would have access to the data and this could give them an edge against companies that sought FDA approval.

Another counter is to argue on utilitarian grounds: even if transparency harmed companies, the advantage to public health would outweigh this. But this could be countered by arguing the reverse. As these concerns are reasonable, complete transparency is morally problematic under the current economic system. As such, what would seem to be needed is an approach that protects the public while also protecting the legitimate interests of companies.

As Seife noted in his article, the information the FDA has kept from the public includes data about harmful side-effects and concerns about the efficacy of products. This information has been redacted or withheld based on the harm that would be done to the company if the truth were known. While it is true that releasing such information could harm a company’s profit, this is not a morally acceptable reason. After all, the mission of the FDA is to protect public health; protecting private profit at the expense of public health is a violation of this mission.

While a company or individual does have a right to keep certain information private, this right does not extend to concealing danger to others. To use an analogy, while I do have the right to keep my medical records private, I do not have the right to keep it a secret if I were infected with Ebola. To use another analogy, while a company would have a right to keep its manufacturing process for snacks secret, it has no right to keep secret the fact that the main ingredient is rats. The public does not have a right to know their trade secrets; but they do have a right to know if the snacks contain rats. Likewise, while the public does not have a right to know the legitimate trade secrets of a drug company, they do have the right to know the side-effects and efficacy of the drugs they take. As such, the FDA can fulfil its proper mission of protecting public health while also protecting legitimate trade secrets. Companies that want to profit on concealing data from the public with FDA collusion might be dismayed by this, but they have no moral right to expect this—especially when they can still make massive profits by making safe and efficacious drugs.

Considering the actions of the current administration, it is terrifying to consider how much worse things could become. Information about side-effects and ineffective drugs have been concealed in the past, but Trump and Musk are dedicated to dismantling the federal government, including the FDA. In the best of times, it did not protect us very well and it is reasonable to think it will become much worse. While it is always wise to be cautious about drugs and procedures, it would be prudent to be extremely cautious about forthcoming FDA approvals.

While the United States has the best health care money can buy, many Americans cannot afford it. Many Americans are underinsured or not insured and even the insured might face denial of coverage. Americans, as their response to the execution of a health care CEO, are aware of this. Most politicians, with the exception of people like Bernie Sanders, have put their faith in the fact that people forget quickly and have done nothing to address this problem.

A lack of insurance puts the health of the uninsured at risk and health care institutions suffer financially. Medical bankruptcy also occurs at an alarming rate.  Because of these problems, there have been proposals to extend Medicare to all Americans.

On the positive side, this would provide everyone with health insurance. This would benefit those without insurance and would also help the finances of healthcare institutions. As the system already exists, it would mostly be a matter of scale. This would come with serious challenges, but they are obviously not insurmountable. While there are clear advantages to expanding Medicare, a rational assessment requires looking beyond the positive aspects and, as much as possible, without the filters of ideology.

An obvious concern is the cost of such an expansion. Those who already pay for insurance would not suffer any financial impact from the switch, unless the cost of Medicare was significantly higher than what they are paying now.  As the cost could have negative impacts on the economy and individuals, it needs to be assessed rationally.

A second concern is the impact on the health insurance industry. While some might be tempted to think that only the CEOs would suffer, the insurance industry is made up of a range of people who depend on their jobs to survive. Switching to Medicare for all would eliminate the private health insurance industry and put people out of work directly and indirectly. Somewhat ironically, those on the right who oppose Medicare expansion usually see firing workers as a positive thing while those on the left express concern for workers. One possibility is that former insurance workers could be retrained and hired to work for Medicare, assuming that it is not swept away in the current zeal to destroy government agencies and programs that protect and benefit non-billionaires.

 It is also worth considering other economic aspects. While it should not be assumed that this cost will be too high relative to the benefits, this cost needs to be considered. Again, while it is appealing to think that eliminating private insurance would only harm evil CEOs, the effects on others should be considered. But given the tremendous harm Americans suffer from the current system; its replacement would certainly do more good than harm.

A third concern is fraud. While fraud does occur with private health insurance, Medicare is sometimes a cash cow for fraudsters. In 2014 about 10% of Medicare’s total budget was lost to fraud. Expanding Medicare to everyone would turn the cash cow into a cash herd. Fraud could and should be addressed even if Medicare is not expanded, but the cost of fraud must be included in the calculations used to assess the merits of expanding Medicare. While the right advances the narrative that it is poor people who defraud the government, the evidence is that it is the wealthy. This does make intuitive sense: if the poor were as good at committing fraud as the right claims, they would no longer be poor. But even with the inevitable fraud, an expansion of Medicare would be superior to the existing system, which siphons money from Americans into the accounts of CEOs.

A fourth concern is usually advanced by conservatives, namely that the elimination of the for-profit motivation will ruin the quality of health care with socialism. One reply is to note that health care will remain for-profit: Medicare for all does not nationalize health care institutions, just the insurance industry. And the motivation provided by the for-profit approach is to profit more, and that typically involves worse rather than better medical care.

That said, it could be argued that with one entity paying all the bills costs will increase and quality will decrease—but what is needed is evidence for these claims. If they are true, then this would be a problem that could be addressed. The rest of the world

In July of 2002 the New England Journal of Medicine published a study on arthroscopic surgery.

The experimental group members underwent surgery while the control group received placebo surgeries.  Somewhat surprisingly, those receiving the placebo reported feeling better and performed better at walking and stair climbing than those in the experimental group. After reading this study, I wrote “Lies…the Best Medicine?” and it appeared in my What Don’t You Know? While working through my massive backlog of magazines, I came across an update on placebo surgeries in Scientific America in which Claudia Wallis argued in favor of fake operations. Reminded of my ancient essay, I am revisiting thoughts on the ethics of placebo surgeries.

As in my old essay, I think that there is a good argument against placebo surgery. Treating a patient with a placebo requires deception. If the effect requires the patient to believe they have received surgery, then the patient must be convinced of an untruth. If the medical personnel are honest and tell the patient the the surgery was fake, then they would, presumably, not benefit from it. If it is wrong to lie, then this deceit would be wrong. What would make it even worse is that medical personnel should be honest with patients.  Thus, even if placebo surgery is effective or even more effective than real surgery, then it should not be used.

One counter to this argument is that even when patients know they are receiving a placebo, it can still be effective. Medical personnel could be honest with patients about a placebo surgery and, perhaps, still maintain the effectiveness of the non-treatment. This would allow the use of placebo surgery while avoiding the moral problem. However, this does not solve the problem for cases in which patients must not know whether they are receiving surgery or the placebo. Placebo surgery is often used to test the effectiveness of surgeries in a rigorous manner. If the surgery is no better (or even worse) than a placebo, then there would be no medical reason to use the surgery over a placebo or no surgery at all.

It can be argued that deception in such situations is acceptable. One approach is to use examples of acceptable, beneficial deception. Obvious examples include the benign deceits about Santa Claus, the Easter Bunny and the Tooth Fairy. As another illustration, there are lies people tell to avoid causing others suffering. If this sort of benign deceit is acceptable, then so is the use of deceit to produce the placebo effect or to conduct a study for the greater good.

A second approach is to focus on the purpose of the medical profession. While philosophers and scientists are supposed to seek the truth, the end of medicine is to relieve pain and prevent or cure illnesses. If deception, in the form of a placebo, can achieve the end of medicine, then it is one more tool, like a scalpel or drug. In fact, it could be argued that effective placebos are even better than drugs or surgery. Surgery always involves some risk, and most drugs have side effects. Placebos would, presumably, involve little or no risk. That said, it is worth considering that there could also be mental side-effects with placebos.

Since placebo treatment is usually not free, it could be objected that it is still wrong: patients are charged, and nothing has been done for them. If medical personnel were using placebos to cover up illnesses and injuries while pocketing profits from fake treatment, then that would be unethical. However, if the treatment is honest and works then it would be as legitimate as any other form of treatment. So, if a patient needs to see a doctor to get the placebo effect working properly and it works as well or better than the “real” treatment, then it is as reasonable to bill for the placebo treatment as it is a real treatment—although the price should be adjusted accordingly. If the placebo effect could be created without involving medical personnel, then charging patients for it would be unethical.

In the case of studies in which the subjects are not paying, then there would be no special moral concern for the use of the placebo. Its use would, in fact, be required for a proper experiment. This does raise the usual moral concerns about conducting experiments, but that is a subject worthy of consideration on its own.

A few years ago, at my annual checkup, my systolic blood pressure was 145. My doctor was concerned and asked me to monitor my blood pressure. I already owned an automatic blood pressure checker and started taking regular readings, finding that my blood pressure was consistently good (110-130) at home. This inspired an investigation.

I found that one cause was the stress of driving: I’m hyper-vigilant when I drive and my blood pressure spikes. My first reading at the doctor’s office will be high because of this; my second reading is always normal. I also found out that my habit of hydrating also caused the spike. I always visited the water fountain when I arrive, at least until I learned that this also spiked my blood pressure. Thus, I solved my “high” blood pressure problem. But this interest in blood pressure led me to “do my own research” and I recalled that the definition of high blood pressure had changed over the years. The ideal now is 120 systolic (though there was a push for 115). Looking into the change, it turns out that the pharmaceutical companies that sell blood pressure medication were instrumental. This influence extends worldwide, with the WHO panel on this having industry connections. Pharmaceutical companies have engaged in concerted efforts to “educate” and influence doctors. This connection has not gone unnoticed, leading some to question whether the new guidelines are legitimate or a money maker for the pharmaceutical companies. While I will not assume a conspiracy, it is rational to be concerned.

The scientific evidence shows that high blood pressure is unhealthy, but there is still the question of what is too high. There are also practical concerns about properly measuring blood pressure: instruments are often inaccurate; blood pressure varies greatly depending on circumstances and so on. Since I am not a medical expert, I will focus on critical thinking and not directly address the medical issues.

One obvious concern with the seemingly biased research is whether it is accurate. That this is a legitimate worry is illustrated by the infamous case of how the sugar industry paid scientists to blame fat, thus distorting health information. The pharmaceutical companies’ role in the opioid crisis shows these companies have no moral qualms about causing harm to make profits. As such, it is reasonable to be suspicious about the guidelines for blood pressure.

One interesting way to motivate suspicion in this matter across the political spectrum is to make use of climate change. Climate change deniers often assert that there is a conspiracy among climate scientists to deceive the public about climate change. Or, at the very least, the scientists are in error because they are being misled by ideology. Those who believe in climate change claim that the fossil fuel industry has been engaged in a disinformation campaign motivated by a desire for profit.

While the two sides differ about who is engaged in disinformation, they both agree that disinformation is a strategy. As such, it would make sense to them that there could be disinformation about blood pressure. The emotional appeal would be to climate change deniers based on their distrust of science while those who believe in climate change would tend to accept that an industry is engaged in disinformation to the detriment of people.

That said, the fact that research is biased, and disinformation has been spread does not entail that the research must be wrong. The blood pressure guidelines could be medically sound; it might just be coincidence that they were influenced by corporations and that the new guides increase their profits.

The problem is that there is a lack of unbiased research to confirm or discredit the biased research. As such, confidence in the guidelines should be relatively low. That said, the evidence does show that we should strive to keep our blood pressure low. The evidence also shows that the non-drug ways to do this (exercise, rest, good diet, stress management) are good for you even if you don’t have high blood pressure. So, I agree that people should use those methods to be healthy and that high blood pressure is probably bad. However, medication is another matter.

When it comes to medication, the first question (which has been addressed) is whether there is an actual problem. As noted above, high blood pressure does seem to be bad. But it is not entirely clear what is too high. The second question is does the medication work? On the face of it, FDA approved blood pressure medications do seem to work—in that they lower blood pressure. This leads to the third question: if they work, do the benefits outweigh the side effects?

The oldest (and least profitable) blood pressure medication, diuretics,  seem to work with minimal side effects. The new (and more profitable) ones seem to have problematic side effects including increased risk of stroke, increased risk of heart attack, and increased rates of suicide and depression.  As such, the rational approach to these medications (as always) would be to weigh the possible harm against the possible benefits. While there are certainly some objective factors in play here, there are also subjective factors, such as how people feel about risk and side effects. Part of the problem in weighing the harms and benefits takes the discussion back to the question of what constitutes unhealthy high blood pressure. Since the research on this is biased, judging whether the drugs the pharmaceutical companies are selling are worth the side effects (and cost) is problematic. Without trustworthy information on the danger, one cannot make a good judgment about accepting risks to offset that alleged danger.

While my focus is on blood pressure, the same sort of problem arises generally for medicines and surgeries: without independent, trustworthy research we cannot make good health decisions. Unfortunately, there is a problem with independent research. There has been a systematic defunding of public institutions that engage in research, and this creates two major impacts.

The first is that important medical research is often not conducted due to lack of funds. The second is that industry often funds research, which biases it. One plausible, but not perfect, solution is to increase the funding of public institutions so that they can increase independent and objective research into health issues. This, of course, will tend to be opposed by industry and the Trump administration. While this would reduce their research expenses, it would give them far less control over the research, which would be a problem for their profits.

A more radical approach would be to impose additional regulations on the pharmaceutical industry such as requiring establishing the validity of medical claims via independent, publicly funded research before drugs could be marketed. The challenge would be to balance the need for objective, trustworthy research against medical innovation and the legitimate business interests of the for-profit industry.

While some might balk at such regulations and make appeals to the free market, it must be pointed out that the key to the pharmaceutical business is the patent system. This is a form of government regulation that prevents competition that corporations usually like. These patents are backed up by the public institutions of law enforcement and the courts. As such, cries about the free market should not be heeded, unless the regulation is truly unfair and too restrictive. On a personal note, it does worry me that I am unsure whether my blood pressure might be a problem, or whether the pharmaceutical companies are lying so they can extort money through a campaign of deceit. In a civilized nation that cares for its citizens, that should not be a real worry. And yet it is. And it seems likely that matters will only get worse.

 

 

As J.S. Mill and others have argued, freedom of expression is a fundamental liberty and the people working at crisis pregnancy centers have that right. But crisis pregnancy centers purport to offer an alternative to abortion—though they seem to routinely engage in deception rather than honest persuasion. This raises moral questions about freedom of expression.

To get the obvious out of the way, those who work for crisis pregnancy centers have the moral right to express their views on abortion. They also have the moral right to try to persuade others to accept their views. A key part of the freedom of expression is the freedom to engage with others who are willing to listen. So, the freedom of expression of these centers is not in dispute.

One concern, which was addressed in my previous essay, is the ethics of deceit. While people do have the right to express their views, freedom of expression is not a license to lie. But it must be noted that there is an important distinction between making an untrue claim and lying.  While there are many forms of lying, the common form requires that a person believes they are making an untrue claim and that they have the intention to deceive. So, if the those at the centers believe the untruths they tell women, then they are not lying. However, this does not get them off the moral hook completely as there is also an ethics of epistemology (the theory of knowledge). Just as there is a moral obligation, as per Thomas Aquinas, to consider one’s actions before acting, there is also an obligation to confirm one’s beliefs before trying to get others to accept them. The seriousness of this obligation, as with actions, is in proportion to the seriousness of the likely consequences of the belief. Being epistemically irresponsible about knowing birth control’s efficacy or the medical effect of abortion is morally unacceptable. As with any liberty, there are also associated responsibilities. Due diligence and honesty in the claims one makes are part of these responsibilities. That is, freedom of expression is not freedom from truth and proper research (which is more than just Googling while under the influence of confirmation bias).

A second concern is values. While people do not have a right to their own facts, they do have the right to their own values (and the responsibility of the consequences of those values). While some embrace the self-defeating notion that relativity of values requires tolerance (it self-defeats because claiming tolerance as an objective value contradicts relativism), it would beg the question to assume that values are objective (or subjective). Even if values are objective, there is still the problem of sorting out which values are right. Because of this, it is more difficult to show that someone has the wrong values. There do seem to be some clear exceptions: those who advocate for rape and genocide have indisputably gotten things wrong. However, moral philosophy has vast tracts of disputed territory and rational moral disagreement helps warrant the freedom of expression. Since we do not always know what is right, it would often be both foolish and wrong to silence people with differing views.

While the various sides on the abortion issue tend to believe they have the objective truth; the issue is morally complicated and an area of reasonable moral dispute. Those who think they have the right answer still have an excellent reason to accept this, if only on pragmatic grounds. Even if they are winning now, they might be losing tomorrow and need the freedom to make their case. If they are losing now, they would want the freedom to make their case. So, the center folks have the right to present their values as do those who disagree with them.

The final concern I will address is the matter of compelled listening. While there have been some legal cases involving compelled speech, there is also the moral question of compelled attention. The easy and obvious view is that people have no general right to expect others to listen to them, although there are contexts where there can be such an expectation. People also do not, with some notable exceptions, have the right to harass people under the guise of free expression. To use an analogy, you have a right to swing a knife around as much as you wish as long as you are not slashing at other people. Likewise, you can express yourself however you wish, provided that the expression is not aimed at harassing, coercing or harming others. I admit there is a problem with sorting out what counts as harassment, coercion and harm. This must be addressed by considering specific types of cases and by developing general guidelines. For example, college students don’t have grounds to claim that a speaker they dislike is automatically harming them because they dislike what they hear. As another example, a student who is shouting a speaker they dislike is both violating the speaker’s right to free expression and endeavoring to compel others to listen to them over the speaker, and are in the process of trying to violate two rights.

Returning to the centers, they do have every right to try to persuade, but the tactics that are coercive, deceptive or harassing are not protected by moral freedom of expression. While they do have the right to express their views, they do not have the right to trick, harass or coerce others into listening to or accepting their views. Naturally, the general principles at work here apply generally, especially to the freedoms of people I disagree with.

 

 

While I think abortion is morally tolerable and should be legal, I recognize that there are competing moral views that can be held in good faith. Proponents and opponents of abortion have the right to argue for their views and influence others. So, I have no moral objection against the idea of a pregnancy crisis center that provides accurate information about alternatives to abortion and assistance to women who elect to not have an abortion. Unfortunately, pregnancy crisis centers often seem to engage in willful deceit.

Some years ago, John Oliver did a show on the deceptive practices of these centers. While Oliver is a comedian, his claims were backed up with evidence: these centers often trick women. One common technique is masquerading as an abortion clinic or health care provider by locating close to such places and using similar names. They also tend to use the trapping of professional medicine to create the illusion they are a clinic despite not being licensed to provide medical care. Another tactic is to make untrue claims about abortion, such as the claim that abortion increases the risk of cancer and infertility.

While centers are usually allowed to give ultrasounds, they seem to routinely mislead women about the results. While there is a shortage of funding for women’s health, many states provide public money to these centers. This should worry people who profess to favor small government and to oppose public money being used for ideological causes. After all, one of the arguments advanced against public funding of Planned Parenthood is that public money might be used for something some people find morally or religiously unacceptable. The same logic should apply to these centers.

On the face of it, deceit seems morally wrong and centers that engage in it are acting immorally. This is especially ironic given these centers tend to be affiliated with religious organizations and the bible is clear about lying. That said, one can argue in favor of the approach of these centers.

It can be argued that such deceit is justified on moral grounds because the end justifies the means. The obvious moral theory to use here is utilitarianism: the action that creates the most good and the least harmful is the right action. In the case of the centers, they could accept that deceit is generally not a good thing, but that the harm of deceiving the women and girls is exceeded by the good of misleading them so that they do not have an abortion. To use an analogy, lying to a murderer to keep them from murdering would be morally right on utilitarian grounds.

Even if one accepts the utilitarian approach, there is still the question of whether the centers are doing their moral calculation right: is the good they claim to do outweighing the harms to the women and girls they deceive? Obviously, pro-choice people would disagree. There is also my usual line: why lie if the truth will suffice? In the case at hand, if abortion is truly as evil as the center folk believe, then telling women the truth should suffice to convince them. If they must lie to people, then one would suspect that they must not have faith in their own reasons and arguments. They could, of course, reply by doubling down on the utilitarian approach and contend that people are not swayed by good reasons nor are they drawn to the right thing without being led there by deceit.

Accepting utilitarianism does create its own problem: if the ends justify the means in terms of deceiving to prevent abortion, then the same principle also applies to abortion. As such, abortion would be subject to the same utilitarian calculation and could turn out to be acceptable on these grounds. In any case, its wrongness would be conditional upon the harms and benefits.

The centers could reply that they are not utilitarians; they just hold that the end justifies the means when it comes to lying about abortion. They could hold that abortion is inherently worse than lying and it is acceptable to do lesser evils to prevent greater evils. While this is a consistent position it is morally problematic as there are non-deceitful ways to reduce abortions, such as providing cheap and effective birth control, funding quality sex-education, improving support services for women and girls who have babies, and so on. After all, it is hard to justify doing evil to stop evil when there are viable non-evil alternatives. If someone gladly embraces deceit to advance their cause when morally better alternatives exist, one must question their ethics.