The Patient Protection and Affordable Care Act turns to a nontraditional mechanism to improve public health: employer -provided financial incentives for healthy behaviors. Critics raise questions about incentive programs' effectiveness, employer involvement, and potential discrimination. We support incentive program development despite these concerns. The ACA sets the stage for a broad-based research and implementation agenda through which we can learn to structure incentive programs to not only promote public health but also address prevalent concerns.

Individuals can often take steps to preserve or improve their own health. They can eat appropriate quantities of healthy foods, exercise, and refrain from smoking. They can obtain preventive care and adhere to their physicians’ advice about how best to manage their health. But they often fail to take these steps.A widespread failure to adopt healthy behaviors can significantly erode public health while increasing health care costs. Obesity, for example, increases the risk of heart disease, stroke, liver disease, and certain (...) cancers. By one estimate, it is responsible for almost 10 percent of medical spending in the United States, or about $147 billion per year. Smoking increases the risk of heart disease, stroke, lung disease, and cancer; it accounts for nearly 20 percent of deaths each year in the United States and about $96 billion in health care expenditures. (shrink)

The HealthyFood program offers members up to 25% cash back monthly on healthy food purchases. In this randomized controlled trial, we tested the efficacy of financial incentives combined with text messages in increasing healthy food purchases among HF members. Members receiving the lowest cash back level were randomized to one of six arms: Arm 1 : 10% cash back, no weekly text, standard monthly text; Arm 2: 10% cash back, generic weekly text, standard monthly text; Arm 3: 10% cash back, (...) personalized weekly text, standard monthly text; Arm 4: 25% cash back, personalized weekly text, standard monthly text; Arm 5: 10 + 15%NET cash back, personalized weekly text, standard monthly text; and, Arm 6: 10 + 15%NET cash back, personalized weekly text, unbundled monthly text. In the 10 + 15%NET cash back, the cash back amount was the baseline 10% plus 15% of the net difference between healthy and unhealthy spending. The generic text included information on HF and healthy eating, while the personalized text had individualized feedback on purchases. The standard monthly text contained the cash back amount. The unbundled monthly text included the amount lost due to unhealthy purchases. The primary outcome was the average monthly percent healthy food spending. Secondary outcomes were the percent unhealthy food spending, and the percent healthy and unhealthy food items. Of the members contacted, 20 opted out, and 2841 met all inclusion criteria. There were no between-arm differences in the examined outcomes. The largest mean difference in percent healthy spending was between Arm 1 and Arm 2, and the largest mean difference in percent unhealthy spending was also between Arm 1 and Arm 2, but no differences were statistically significant after correction for multiple comparisons. None of the tested financial incentive structures or text strategies differentially affected food purchasing. Notably, more than doubling the cash back amount and introducing a financial disincentive for unhealthy purchases did not affect purchasing. These findings speak to the difficulty of changing shopping habits and to the need for innovative strategies to shift complex health behaviors. NCT02486588 Increasing Engagement with a Healthy Food Benefit. The trial was prospectively registered on July 1, 2015. (shrink)

Most donated organs in the United States come from brain dead donors, while a small percentage come from patients who die in “controlled,” or expected, circumstances, typically after the family or surrogate makes a decision to withdraw life support. The number of organs available for transplant could be substantially if donations were permitted in “uncontrolled” circumstances–that is, from people who die unexpectedly, often outside the hospital. According to projections from the Institute of Medicine, establishing programs permitting “uncontrolled donation after circulatory (...) determination of death,” or uDCDD, throughout the United States has the potential to provide 22,000 more donation opportunities annually. In contrast, U.S. controlled donation after circulatory determination of death, or cDCDD, cases have increased progressively over the past decade from 87 to 848 donors, but currently account for only 10.6 percent of all deceased donors. Following the IOM recommendations, several projects exploring the feasibility of uDCDD were funded by the federal government, including a grant from the Health Resources and Services Administration that supported a pilot project in New York City in which the authors of this article participated.A key feature of our protocol, and indeed of many uDCDD protocols, is the initiation of preservation methods such as chest compressions and extracorporeal membrane oxygenation shortly after death in order to perfuse and preserve the donor's organs. Critics of uDCDD argue that the means of determining death deviates from generally ascribed principles. They assert that reinstituting circulation in order to preserve organs has the effect of “undoing” the prior determination of death. The result is that cDCDD is widely accepted and practiced routinely even though it only marginally increases the number of organs available for transplantation, and uDCDD is widely considered unacceptable despite being ethically embraced and proven to significantly increase organ donation opportunities in other countries. This article explores the evolution of this counterintuitive state of affairs and calls for a policy that, in line with the IOM report, allows for both cDCDD and uDCDD protocols. (shrink)

I give an account how the principle of ‘respect for autonomy’ dominates the field of bioethics, and how it came to triumph over its competitors, ‘respect for persons’ and ‘respect for free power of choice’. I argue that ‘respect for autonomy’ is unsatisfactory as a basic principle of bioethics because it is grounded in too individualistic a worldview, citing concerns of African theorists and other communitarians who claim that the principle fails to acknowledge the fundamental importance of understanding persons within (...) the nexus of their communal relationships. I defend the claim that ‘respect for persons’ is a more appropriate principle, as it is able to acknowledge both individual decision making and the essential relationality of persons. I acknowledge that my preference for ‘respect for persons’ is problematic because of the important debate around the definition of ‘personhood’ in bioethics discourse. Relying on Thaddeus Metz's conception of moral status, I propose a relational definition of personhood that distinguishes between persons with agency and persons without agency, arguing that we have different moral obligations to these distinct categories of persons. I claim that this conception of personhood is better able to accommodate our moral intuitions than conventional approaches, and that it is able to do so without being speciesist or question-begging. (shrink)

Background Surgery for intersex infants should be delayed until individuals are able to decide for themselves, except where it is a medical necessity. In an ideal world, this single principle would suffice and such surgeries could be totally prohibited. Unfortunately, the world is not perfect, and, in some places, intersex neonates are at risk of being abandoned, mutilated or even killed. As long as intersex persons are at such high risk in some places, any ethical guidelines for intersex surgeries will (...) need to take these extreme risks of harm into account. Main text I therefore argue for five basic principles that ought to inform ethics guidelines for surgical interventions in intersex children, specifically in contexts in which such children are at risk of significant harm. What I set out to come up with is a set of principles that do not completely prohibit surgery, but only allow it where a strong case can be made for its necessity, in the best interests of the child, and where there is some kind of oversight to prevent misuse. The first principle is that interventions as drastic as these surgeries should only be performed when there is strong evidence that they are beneficial and not harmful. The second principle is that in surgeries should normally only be performed in cases of true medical necessity. Principle three is that surgeries should normally be delayed until such time as the intersex person is mature enough to assent to treatment or decide against it. Principle four is that the conventional ethical requirements regarding truth telling apply equally to intersex children as to anyone else. The final principle is that where physicians or parents think that surgery is in the best interests of the child, the burden of proof lies with them. Conclusion It is hoped that these principles might help medical teams and parents make better decisions about intersex surgeries on children, and they would make such surgeries very rare indeed, if they happen at all. (shrink)

Although many bioethicists have given attention to the special health issues of Africa and to the ethics of research on the continent, only a handful have considered these issues through the lens of African moral thought. The question has been for the most part neglected as to what a distinctively African moral perspective would be for the analysis and teaching of bioethics issues. To address the oversight, the authors of this paper describe embarking on a project aimed at incorporating African (...) moral perspective, values and philosophy into a teaching curriculum. The authors clarify the rationale for the project and discuss the strategies employed in Africanizing the bioethics curriculum. (shrink)

The Children’s Act and its associated regulations allow for virginity tests to be performed on male and female children over the age of 16. This is subject to a number of legislated conditions, including that informed consent should be obtained. In this article I argue that, whilst it is important that the right to social and cultural practice be protected in South Africa, virginity testing is a practice that cannot be morally justified. Firstly, I defend the claim that the practice (...) is inherently unjust. At least some of those subjected to the tests will inevitably experience the undesirable consequences of a false test result. The practice is also discriminatory as it typically and unjustly targets girl children, since boys are far less commonly tested. I argue further that the practice perpetuates a harmful patriarchal social order. Finally, I contend that any attempts to justify this legislation are fatally flawed, because it is fundamentally irrational, since there is no reliable means of testing for virginity. (shrink)

Contributing reviewersThe editors of Philosophy, Ethics, and Humanities in Medicine would like to thank all our reviewers who have contributed to the journal in Volume 10.

A recent study using a crossmodal matching task showed that the identity of a talker could be recognized even when the auditory and visual stimuli that were being matched were different sentences spoken by the talker. This finding implies that general temporal features of a person's speech are shared across the auditory and visual modalities.

The book is divided into three sections. In the first section, Lynch presents what he calls “truisms about truth.” The first truism is that truth is objective. Accepting a kind of Aristotelian realism, Lynch defines “true beliefs” as “those that portray the world as it is and not as we may hope, fear, or wish it to be”. The second truism is that truth is good. The point here is not that truth is morally good, but that it is generally (...) pursued, and the opposite is generally avoided and even ridiculed. Closely related to this is the third truism: truth is a worthy goal of inquiry. The fourth truism is that truth is worth caring about for its own sake. To help recognize this, he refers the reader to the movie, The Matrix. While some may choose to enter the matrix for a short period of bliss, most would prefer to live an authentic life of truth, in the real world. (shrink)

Background: Post-traumatic stress disorder is a prevalent, debilitating, and costly psychiatric disorder. Evidenced-based psychotherapies, including Cognitive Processing Therapy, are effective in treating PTSD, although a fair proportion of individuals show limited benefit from such treatments. CPT requires cognitive demands such as encoding, recalling, and implementing new information, resulting in behavioral change that may improve PTSD symptoms. Individuals with PTSD show worse cognitive functioning than those without PTSD, particularly in acquisition of verbal memory. Therefore, memory dysfunction may limit treatment gains in (...) CPT in some individuals with PTSD. Methods and Analysis: Here, we present a protocol describing the Cognition and PsychoTherapy in PTSD study, a prospective, observational study examining how cognitive functioning affects treatment response in CPT for PTSD. The study aims to recruit 105 outpatient veterans with PTSD between the ages of 18 and 70 years. Prior to beginning 12 sessions of CPT, Veteran participants will have standardized assessments of mood and functioning and complete a comprehensive neurocognitive battery assessing episodic learning, attention and speed of processing, language ability, executive control, and emotional functioning. This study aims to fill gaps in the current literature by: examining the specificity of memory effects on treatment response; exploring how baseline cognitive functioning impacts functional outcomes; and examining potential mechanisms, such as memory for treatment content, that might explain the effects of baseline memory functioning on PTSD symptom trajectory. Discussion: If successful, this research could identify clinically relevant neurocognitive mechanisms that may impact PTSD psychotherapy and guide the development of individualized treatments for PTSD. (shrink)

Men often make riskier decisions than women across a wide range of real-life behaviors. Whether this sex difference is accentuated, diminished, or stable under stressful conditions is, however, contested in the scientific literature. A critical blind spot lies amid this contestation: Most studies use standardized, laboratory-based, cognitive measures of decision making rather than complex real-life social simulation tasks to assess risk-related behavior. To address this blind spot, we investigated the effects of acute psychosocial stress on risk decision making in men (...) and women using a standardized cognitive measure and a novel task that simulated a real-life social situation. Participants were exposed to either an acute psychosocial stressor or an equivalent control condition. Stressor-exposed participants were further characterized as high- or low-cortisol responders. Results confirmed that the experimental manipulation was effective. On the IGT, participants characterized as low-cortisol responders made significantly riskier decisions than those characterized as high-cortisol responders. Similarly, in the online chatroom, participants characterized as low-cortisol responders were, relative to those in the Non-Stress group, significantly more likely to make risky decisions. Together, these results suggest that at lower levels of cortisol both men and women tend to make riskier decisions in both economic and social spheres. (shrink)

Perhaps the most fundamental principle of legal interpretation is the presumption that terms should be given their “ordinary” (i.e., general, non-technical) meanings. This principle is a central tenet of modern textualism. Textualists believe a universal presumption of ordinary meaning follows from their theory’s core commitment: A law should be interpreted consistently with what its text communicates to the ordinary public. This Article begins from this textualist premise, empirically examining what legal texts communicate to the public. Five original empirical studies (N (...) = 4,365) reveal a surprising finding: Ordinary people consider genre carefully and regularly take terms in law to communicate technical legal meanings, not ordinary ones. -/- This discovery carries implications for legal interpretation’s theory and practice. Modern textualists—especially at the Supreme Court—justify their theory through “democratic,” fair notice, and rule-of-law appeals to ordinary people. But the empirical studies reveal that fidelity to ordinary people does not imply an unwavering commitment to ordinary meaning. Instead, it requires interpreters to also look to technical meanings. On a practical level, the results support a new presumption of legal meaning and ground a new challenge to textualism’s claim to promote fair notice. As a case study, we consider Bostock v. Clayton County, Georgia, which held that both sexual orientation and gender identity discrimination are prohibited forms of sex discrimination. The Article’s empirics and theory offer a new justification of the Court’s landmark decision. (shrink)

The current Ebola epidemic has presented challenges both medical and ethical. Although we have known epidemics of untreatable diseases in the past, this particular one may be unique in the intensity and rapidity of its spread, as well as ethical challenges that it has created, exacerbated by its geographic location. We will look at the infectious agent and the epidemic it is causing, in order to understand the ethical problems that have arisen.

Phylogenies are increasingly prominent across all of biology, especially as DNA sequencing makes more and more trees available. However, their utility is compromised by widespread misconceptions about what phylogenies can tell us, and improved tree thinking is crucial. The most-serious problem comes from reading trees as ladders from left to right - many biologists assume that species-poor lineages that appear early branching or basal are ancestral - we call this the primitive lineage fallacy. This mistake causes misleading inferences about changes (...) in individual characteristics and leads to misrepresentation of the evolutionary process. The problem can be rectified by considering that modern phylogenies of present-day species and genes show relationships among evolutionary cousins. Emphasizing that these are extant entities in the 21st century will help correct inferences about ancestral characteristics, and will enable us to leave behind 19th century notions about the ladder of progress driving evolution. (shrink)

Morality – the subjective sense that humans discern between right and wrong – plays a ubiquitous role in everyday life. Deontological reasoning conceptualizes moral decision-making as rigid, such that many moral choices are forbidden or required. Not surprisingly, the language used in measures of deontological reasoning tends to be rigid, including phrases such as “always” and “never.” Two studies drawn from two different populations used commonly used measures of moral reasoning and measures of morality to examine the link between individual (...) differences in deontological reasoning and language on the endorsement of moral foundations. Participants low on deontological reasoning generally showed less endorsement for moral principles when extreme language was used in the measures. (shrink)

The present research examines whether the perceived uniqueness of one’s thoughts and salience of uniqueness motivations can influence attitude strength and resistance. Participants who rated their thoughts as relatively unique formed attitudes that showed greater correspondence with behavioral intentions to act on the attitude (Study 1). In Study 2, participants who recalled a previous purchase motivated by the desire to be unique (versus to fit in) after generating message counterarguments were less persuaded (more resistant) and reported greater willingness to act (...) on their (negative) attitude. Moreover, attitudes mediated the effect of the purchase manipulation on intentions to act on the attitude. (shrink)

As moral injury is a still-emerging concept within the area of military mental health, prevalence estimates for moral injury and its precursor, potentially morally injurious events (PMIEs), remain unknown for many of the world’s militaries. The present study sought to estimate the prevalence of PMIEs in the Canadian Armed Forces (CAF), using data collected from CAF personnel deployed to Afghanistan, via logistic regressions controlling for relevant sociodemographic, military, and deployment characteristics. Analyses revealed that over 65% of CAF members reported exposure (...) to at least one event that would be considered a PMIE. The most commonly PMIEs individuals reported included seeing ill or injured women and children they were unable to help (48.4%), being unable to distinguish between combatants and non-combatants (43.6%), and finding themselves in a threatening situation where they were unable to respond due to the rules of engagement under which they were required to operate (35.4%). These findings provide support for both the presence of exposure to PMIEs in CAF members and the need for formal longitudinal data collection regarding PMIE exposure and moral injury development. (shrink)

Psychologists wish to identify and study the mechanisms and implications of nomothetic constructs that reveal truths about human nature and span across operationalizations. To achieve this goal, psychologists should spend more time carefully describing and measuring constructs across a wide range of methods and measures, and less time rushing to explain and predict.

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

The U.S. federal government provides two tracks for eligible patients to obtain access outside clinical trials to investigational interventions currently under study for potential clinical benefits: the Food and Drug Administration’s expanded access pathway and the pathway created by the more recent Right to Try Act. In this issue of the Hastings Center Report, with a critical focus on patients, industry, and the research enterprise, Kelly Folkers and colleagues frame the inherent challenges that these pathways are meant to solve and (...) have also inadvertently created. But an additional key focus is how the relevant situations should be managed at the bedside and how the system risks both inefficient and inequitable access to options at the institutional level. Although either pathway could be helpful to patients, the challenges of having the pathways coexist are greater than the sum of their parts. Individual clinicians represent the front line of the regulatory and eligibility challenges of expanded access and right to try, making clinical education a critical component of a comprehensive approach to using them well. But it is medical institutions that must take the lead on supporting access to investigational options in the most equitable and effective manner possible. (shrink)

Psychobiography has been a topical area and an applied research specialty in psychology since Freud’s influential psychoanalytic psychobiography of Leonardo da Vinci. Throughout the last century, psychobiographers have emphasized the importance of anchoring interpretations of life histories in established psychological theories and rigorous historiographic research methods. One topical area receiving less attention in psychobiography is the critical relationship between the psychobiographer and her or his subject as it relates to the process of psychobiographical writing. The present article explores the phenomenology (...) and challenges of this relationship in order to ultimately propose practical strategies for navigating countertransference issues throughout the subject selection, research and publication phases of psychobiography. Freud’s psychobiography of Leonardo da Vinci is used as a model of the stages of psychobiography, the evolution of the psychobiographer-subject relationship, and the challenges of countertransference. (shrink)

Marshall et al. (2024) identify a potential ethical conflict between the principles of beneficence and respect for patient autonomy when patients refuse to remain in an emergency department (ED) fo...