Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic (...) injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management. (shrink)

This article adopts a population-level bioethics approach to analyzing the ethical implications of novel deep-brain stimulation (DBS) technologies. I claim that a microlevel focus on costs and benefits is necessary but insufficient to address the concerns of social justice and health equity that attend the potential utilization of DBS technologies. A macrosocial, population-based analysis notes two ethically significant trends regarding novel health technologies: (1) that they are the prime mover of hyperinflationary health cost trajectories, and (2) that even where they (...) improve overall population health such technologies may expand health inequalities. Such an expansion could exacerbate what Powers and Faden have identified as “densely-woven patterns of disadvantage,” and therein could contravene mandates of social justice. Such concerns of justice and equity are sharpened by the fact that those populations that bear the highest risk of suffering the injuries and illnesses for which DBS technologies might be warranted are among the most disadvantaged groups in American society. Accordingly, ethical analysis of DBS technologies must include an assessment of the evidence suggesting that in their capacity to improve health and compress health inequalities, whole-population approaches that address the upstream factors that shape distributions of neuropsychiatric injuries and illness may be preferable to acute health interventions. However, the article warns against the false-choice fallacy, and notes that whole-population policies and acute care interventions can be simultaneously endorsed. The article concludes by suggesting that the ethical issue of relative priority between these approaches is best framed via a population-level analysis. (shrink)

If funding allocation is an indicator of a field’s priorities, then the priorities of the field of bioethics are misaligned because they perpetuate injustice. Social justice mandates priority for the factors that drive systematic disadvantage, which tend not to be the areas supported by funding within academic bioethics. Current funding priorities violate social justice by overemphasizing technologies that aim to enhance the human condition without addressing underlying structural inequalities grounded in racism, and by deemphasizing areas of inquiry most frequently pursued (...) by Scholars of Color. This lack of attention to upstream determinants of health in bioethics research perpetuates a gap in the resources needed to understand the experiences of communities disproportionately experiencing poor health, which is itself a form of epistemic injustice. Both social and epistemic injustices are apparent in the impact of these funding priorities on people of color, both in the public and in the bioethics community. (shrink)

Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic (...) injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management. (shrink)

This article argues that positioning disclosure as a primary remedy in addressing the ethical problems posed by conflicts of interest in medicine and health is an error. Instead, bioethical resources should be devoted to the problems associated with sequestration, defined as the elimination of relationships between commercial industries and health professionals in all cases where it is remotely feasible. The argument begins by arguing that adopting Andrew Stark’s conceptual framework for COIs leads to advantages in understanding COIs and in ordering (...) priorities for intervention. The article then draws on prior work establishing that COIs are, under ordinary epidemiologic standards, properly regarded as population health hazards. This justifies attention to possible remedies, of which disclosure generates by far the most analysis. Such primacy is unwarranted given the extensive evidence suggesting that disclosure as a remedy for COIs is at best ineffective. ‘At best’ is justified because the evidence also shows that disclosure may have a perverse effect, intensifying biased behaviors. Expending significant attention on an ineffective or even deleterious intervention is unjustified and also crowds out devotion of resources to the real problems that attend sequestration. Therefore, disclosure ought to be regarded as a lower priority among possible COI interventions. (shrink)

The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering (...) conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations, and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation. (shrink)

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January‐February 2013 issue.

The point of departure for this essay is the question of why pain is seriously undertreated in the United States. Some kinds of pain (for example, chronic nonmalignant pain) are treated worse than others (acute pain secondary to cancer), but there is excellent evidence that no matter what kind of pain, astonishingly large percentages of pain sufferers are undertreated (Furrow 2001; Hill 1995; Kirou-Mauro et al. 2009; Martino 1998; Morris 1991; NCHS 2006; Resnik, Rehm, and Minard 2001). Although some kinds (...) of pain are difficult to treat, we generally possess the technical armamentarium to significantly ameliorate the vast majority of pain experiences. Yet we do not. And, for as long as anyone in the United States .. (shrink)

The primary claim of this paper is that intellectual conflicts of interest (COIs) exist but are of lower ethical priority than COIs flowing from relationships between health professionals and commercial industry characterized by financial exchange. The paper begins by defining intellectual COIs and framing them in the context of scholarship on non-financial COIs. However, the paper explains that the crucial distinction is not between financial and non-financial COIs but is rather between motivations for bias that flow from relationships and those (...) that do not. While commitments to particular ideas or perspectives can cause all manner of cognitive bias, that fact does not justify denying the enormous power that relationships featuring pecuniary gain have on professional behaviour in term of care, policy, or both. Sufficient reason exists to take both intellectual COIs and financial COIs seriously, but this paper demonstrates why the latter is of higher ethical priority. Multiple reasons will be provided, but the primary rationale grounding the claim is that intellectual COIs may provide reasons to suspect cognitive bias but they do not typically involve a loss of trust in a social role. The same cannot be said for COIs flowing from relationships between health professionals and commercial industries involving financial exchange. The paper then assumes arguendo that the primary rationale is mistaken and proceeds to show why the claims that intellectual COIs are more significant than relationship-based COIs are dubious on their own merits. The final section of the paper summarizes and concludes. (shrink)

Svirsky, Howard, and Berman’s paper “E-Cigarettes and the Multiple Responsibilities of the FDA” offers a significant contribution to a knowledge domain that might be called “harm reduction e...

Pain policy is not drug policy. If society wants to improve the lives of people in pain and compress the terrible inequalities in its diagnosis and treatment, we have to tailor policy to the root causes driving our problems in treating pain humanely and equitably. In the United States, we do not. Instead, we have proceeded to conflate drug policy with pain policy, relying on arguably magical thinking for the conclusion that by addressing the drug overdose crisis, we are simultaneously (...) addressing the pain crisis. This is a category error, decades of commitment to which have resulted mostly in a worsening of both public health problems. Disentangling our problems in treating pain fairly and equitably from our problems with drugs and substance use is the only path to humane and ethical policy for each. (shrink)

In this book, public health ethicist Daniel S. Goldberg sets out to characterize the subjective experience of pain and its undertreatment within the US medical establishment, and puts forward public policy recommendations for ameliorating the undertreatment of pain. The book begins from the position that the overwhelming focus on opioid analgesics as a means for improving the undertreatment of pain is flawed, and argues instead that dominant Western models of biomedicine and objectivity delegitimize subjective knowledge of the body (...) and pain in the US. This general intolerance for the subjectivity of pain is part of a specific American culture of pain in which a variety of actors take part, including not only physicians and health care providers, but also pain sufferers, caregivers, and policymakers. Concentrating primarily on bioethics, history, and public policy, the book brings a truly interdisciplinary approach to an urgent practical ethical problem. Taking up the practical challenge, the book culminates in a series of policy recommendations that provide pathways for moral agents to move beyond contests over drug policy to policy arenas that, based on the evidence, hold more promise in their capacity to address the devastating and inequitable undertreatment of pain in the US. (shrink)

The framing of the risks of experiencing mild traumatic brain injury in American football and ice hockey has an enormous impact in defining the scope of the problem and the remedies that are prioritized. According to the prevailing risk frame, an acceptable level of safety can be maintained in these contact sports through the application of technology, rule changes, and laws. An alternative frame acknowledging that these sports carry significant risks would produce very different ethical, political, and social debates.

Children in North America, some as young as eleven or twelve, routinely don helmets and pads and are trained to move at high-speed for the purpose of engaging in repeated full-body collisions with each other. The evidence suggests that the forces generated by such impacts are sufficient to cause traumatic brain injury among children. Moreover, there is only limited evidence supporting the efficacy of interventions typically used to reduce the risks of such hazards. What kind of risk assessment enables such (...) activities to be a relatively common feature of childhood in Canadian and American society?In order to understand this state of affairs, we must examine the particular risk frame under which such hazards are commonly assumed. Risk assessments are embedded in the cultures in which they are situated and must be evaluated in their social contexts. (shrink)

Corresponding Author, Health Policy & Ethics Fellow, Chronic Disease Prevention & Control Research Center, Department of Medicine, Baylor College of Medicine, 1709 Dryden, Suite 1025, Houston, TX 77030, USA. Tel.: 713.798.5482; Fax: 713 798 3990; Email: danielg{at}bcm.edu ' + u + '@' + d + ' '//--> . Abstract This article defends a broad model of public health, one that specifically addresses the social epidemiologic research suggesting that social conditions are primary determinants of health. The article proceeds by critiquing one (...) of the strongest arguments in favor of a narrow model, advanced by Mark Rothstein. The critique sets up the argument that a model of public health that does not address what actually causes health and disease is unlikely to improve public health. Assessing the substantial evidence regarding the social determinants of health, the article engages the policy paradox that precludes utopian prescriptions but demands more than mere expedience. CiteULike Connotea Del.icio.us What's this? (shrink)

In the first of a trilogy of articles published in the New England Journal of Medicine in May 2015, physician–journalist Lisa Rosenbaum observes that the crucial question regarding conflicts of interest between physicians and commercial industry is the extent to which interactions between the two are “beneficial or harmful to patients?”. She goes on to note that the answer to this question “depends on how you define harm,”1 and argues that many of the claims of harm flowing from COI are (...) incomplete, insufficient, or are based on “suggestive extrapolations from data”. If there are benefits to be gained from physician–industry relationships, and if the evidence... (shrink)

The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering (...) conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations, and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation. (shrink)

The primary claim of this paper is that COVID-19 stigma must be understood as a structural phenomenon. Doing so will inform the interventions we select and prioritize for the amelioration of such stigma. Thinking about stigma as a macrosocial determinant of health driven by structural factors suggests that downstream remedies are unlikely to be effective in significantly reducing stigma. This paper develops and defends this claim, setting up a recommendation to use a “bundle” of legal and policy levers at meso- (...) and macro- levels to reduce the adverse and inequitable impact of COVID-19 stigma.Historians of public health have long pointed out that outbreaks of communicable disease track social fault lines (Rosenberg... (shrink)

This paper analyzes S. Weir Mitchell and his son John Kearsley Mitchell’s views on phantom limb pain in late 19th c. America. Drawing on a variety of primary sources including journal articles, letters, and treatises, the paper pioneers analysis of a cache of surveys sent out by the Mitchells that contain amputee Civil War veterans’ own narratives of phantom limb pain. The paper utilizes an approach drawn from the history of ideas, documenting how changing models of medicine and objectivity help (...) explain the Mitchells’s attitudes, practices, and beliefs regarding the enigma of phantom limb pain as experienced by their patients. The paper also assesses concerns over malingering, pain, authenticity, and deception through these intellectual frameworks of somaticism and mechanical objectivity. The paper concludes that much of relevance to the ways in which the Mitchells and other late 19th c. neurologists regarded and treated their patients’ pain is explicable in terms of the larger intellectual frameworks that structured these healers’ ideas about lesionless pain. (shrink)

Bioethics, Volume 36, Issue 8, Page 819-820, October 2022.

This essay explores the long Western history of anxieties about feigned illness connected specifically to social policy. There is a remarkable consistency of such anxieties across time, as they appear in almost every major historical period in the West since the Middle Ages.

This article comments on a collection of remarkable narratives authored by fat writers addressing the American Medical Association’s decision to label obesity a disease. Endeavoring to avoid what has been termed “thinsplaining,” the commentary examines the voices of the writers in the hopes of identifying key themes and points that emerge from these fat narratives. The commentary canvasses the writers’ perspectives on topics such as the medicalization and pathologization of fat, the Western and especially American tendency to emphasize individual culpability (...) for fatness, and, of course, the horrific commonality and intensity of fat stigma. Stigma is a particular focus for the commentary, both because it is a principal theme in the collection, and also because it is important to understand precisely what stigma is and its deep connections to larger macrosocial structures. The commentary concludes with a simple admonition, gleaned from the narratives: we should strive to do better. (shrink)

Commentary on Angelo E. Volandes & Michael K. Paasche-Orlow, Health Literacy, Health Inequality and a Just Healthcare System.

The parasitic nematode Ascaris lives in the low‐oxygen intestinal folds of over one billion people world‐wwide. The worm has an octameric hemoglobin that binds oxygen four orders of magnitude more tightly than does human hemogobin. Our studies have focused on elucidating the molecular mechanism of oxygen avidity, the basis of multimerization and the function of this remarkable molecule. We now believe that we understand a fair amount about the molecular interactions that result in enhanced avidity, have some preliminary ideas on (...) octamer formation, and have some hypotheses about possible function. Along the way we have stumbled into the disciplines of intron evolution, sterol biosynthesis and oxygen‐regulated gene expression. (shrink)

Public health agencies regularly survey randomly selected anonymous students to track drug use, sexual activities, and other risk behaviors. Students are unidentifiable, but a recent project that i...

Volume 20, Issue 10, October 2020, Page W4-W7.

On or about June 5, 1895, in Denver, Colorado, a 23-year-old law clerk named James Smith fell off a ladder and injured his left thigh near the hip. Three days later, on June 8, 1895, Smith consulted a physician named George Gibson. Gibson saw Smith twice.1 After several weeks of continued pain, on June 24, 1895 Grant consulted a different physician named W. W. Grant. Grant was already a well-known railway surgeon in the local medical community, and would go on (...) to even greater prominence. Grant treated Smith, but did not attempt to immobilize Smith’s leg. Rather, Grant “advised exercise of various kinds as though treating a contusion” (Withers 1931, p. 99). On April 14, 1896, Smith filed a lawsuit against .. (shrink)

This essay uses Solzhenitsyn’s Cancer Ward to explore the exilic effects of illness and pain. The novel is uniquely suited for such an analysis given the theme of exile that predominates both in the narrative and in the composition of multiple characters within that narrative. I argue that illness, and in particular pain, is a liminal state, an existential hinterlands. The ethical approach to literature and medicine may suggest, as a response to these exilic effects, the need to cultivate connection (...) and empathy by sharpening the moral imagination. If pain and illness exile the sufferer, the imperative to reach out takes on ethical content. (shrink)

In the past 40 years, a global shift has taken place towards a constellation of values known as “expansive values”, which de-emphasize pursuits of money, possessions, and status, and instead focus on quality of life and humanistic goals. This study investigated what students holding expansive values desired in business school course content and student quality of life, and how these preferences differed from students holding materialistic values. Results revealed a number of different factors that were associated only with expansive values, (...) though on a few factors the two student values cohorts shared similar preferences or had inverse preferences. One clear implication of this study is that business schools need to consider offering more ethics classes in order to satisfy the growing number of students with expansive values. (shrink)

Philip Pettit has argued that all semantically basic terms are learned in response to ostended examples and all non-basic terms are defined via them. Michael Smith and Daniel Stoljar maintain that this “global response-dependence” entails noumenalism, the thesis that reality possesses an unknowable, intrinsic nature. Surprisingly Pettit acknowledges this, contending instead that his noumenalism, like Kant’s, can be construed ontologically or epistemically. Moreover, Pettit insists, construing his noumenalism epistemically renders it unproblematic. The article shows that construing noumenalism epistemically prevents (...) Pettit from knowing whether members of different communities respond to different properties in the world or the same properties differently. Pettit then faces a trilemma. He can construe noumenalism ontologically and confront Smith and Stoljar’s charge. He can construe noumenalism epistemically and confront the author’s charge. Or he can reject global response-dependence. After explaining why Pettit should choose the middle horn, the article closes with lessons about global response-dependence generally. (shrink)

Within the Judeo-Christian tradition, Sodom and Gomorrah represent locales in which threats to national formation are couched in sexual terms. The biblical narrative insists on a particular social invisibility for those sexual activities not blessed by the bonds of matrimony. Reclaiming Sodom surveys a number of institutions that have had an interest in perpetuating these views: the police, the state, the church and the law. The collection ranges through biblical scholarship, an investigation of the Founding Fathers' beliefs, the legal mobilization (...) towards the category of sodomy in 18th and 19th century England, and the US Supreme Court's 1986 Bowers vs. Hardwick decision. Analysis is provided of the ways in which the Judeo-Christian tradition has shaped anthropological accounts of the same-sex practices of non-Western people, as well as essays on how colonial gestures have marked lesbian identity in the Carribean, and derformed narratives about the racial geography of AIDS. Reclaiming Sodom explores alternatives to the force of the Sodomitic biblical narrative in Islamic, non-western, and western traditions, and discusses the ways in which sodomy calls into question normative definitions of sexuality and gender. The collection pursues the "pleasures and dangers" of these alternatives, and takes on Proust's refusal to imagine a social movement founded on the "stigma" of Sodom. The collection examines the relations between sex/gender identities and sexual acts in important and provocative ways, and argues for the political use and usefulness of both Sodom and sodomy. Reclaiming Sodom makes an important and controversial contribution to the literature on sexuality and gender, as well as the nature of sex in our culture. Contributors: Dorothy Allison, Robert Alter, Neil Bartlett, Leo Bersani, Gerald Creed, Marc Daniel, Lee Edelman, Janet E. Halley, Jonathan Ned Katz, Pierre Klossowski, Rocky O'Donovan, Guy Hocquenghem, Cindy Patton, Marquis de Sade, David Shannon, Makeda Silver, Jonathan Goldberg. (shrink)

This volume collects twelve essays by Sanford C. Goldberg on the topic of social epistemology. The collection falls into two halves: the first half develops a proposal for a programme for social epistemology, its animating vision, foundational questions, and core concepts; the other half focuses on applications of this programme to particular topics. Goldberg characterizes the research programme as the exploration of the epistemic significance of other minds. This programme is dedicated to an examination of the various ways (...) in which we depend epistemically on others, and to describe the proper way to evaluate beliefs according to the sort of dependence they exhibit. It thus provides the basis for identifying and characterizing various dysfunctions of our epistemic communities. The programme is put into practice by exploring such topics as the epistemic agency exhibited in inquiry, the practices that constitute news coverage, the basis for allegations of what we or others should have known, how reliance on another's testimony contrasts with reliance on an instrument, our reliance on others as consumers of testimony, and the epistemic significance of non-epistemic social norms--moral, political, professional, or relationship-based. (shrink)

In Relying on others [Goldberg, S. 2010a. Relying on others: An essay in epistemology. Oxford: Oxford University Press], I argued that, from the perspective of an interest in epistemic assessment, the testimonial belief-forming process should be regarded as interpersonally extended. At the same time, I explicitly rejected the extendedness model for beliefs formed through reliance on a mere mechanism, such as a clock. In this paper, I try to bolster my defense of this asymmetric treatment. I argue that a (...) crucial assumption lying behind the argument I used to establish interpersonal extendedness in testimony cases does not apply to beliefs formed through reliance on instruments. In this respect, at least, there appears to be something epistemically distinctive about relying on another epistemic agent. (shrink)

In this paper I formulate the thesis of the Division of Epistemic Labor as a thesis of epistemic dependence, illustrate several ways in which individual subjects are epistemically dependent on one or more of the members of their community in the process of knowledge acquisition, and draw conclusions about the cognitively distributed nature of some knowledge acquisition.