Despite its many strengths, Engelhardt’s After God displays two surprising features: an affinity for voluntaristic ethics and a tendency to oppose Eastern Orthodoxy to philosophy. Neither of these is in keeping with the mainstream of Eastern Orthodox tradition. Here, I offer a modest corrective. I begin with the figure of Socrates as presented in the Apology and Phaedo, highlighting the role that faith plays for Socrates and the reasons why he was widely admired by the early Church. I then describe (...) more broadly the attitude of the Greek Church Fathers to philosophy, showing that, although they were cautious of its potential errors, they nonetheless embraced the ideal of philosophy as a way of life dedicated to the pursuit of wisdom. For many, in fact, Christianity is itself simply the true philosophy, an attitude that led many of the most eminent patristic and Byzantine theologians to draw extensively on philosophical sources. Finally, I discuss the Euthyphro dilemma, contrasting the voluntaristic approach favored by Engelhardt with the Platonic approach adopted by the mainstream of Orthodox tradition. (shrink)

In After God: Morality & Bioethics in a Secular Age, Professor H. Tristram Engelhardt, Jr. argues that the now dominant intellectual culture of the West actively shuns any transcendent point of orientation, such as an appeal to God or to a God’s eye perspective on reality. Instead, it seeks to frame its understanding of reality and morality, and thus its bioethics, without reference to any foundation outside of particular human concerns. This article explores the implications of living in a secular (...) culture that eschews any appeal to a fully objective perspective on reality. Drawing on Engelhardt’s analysis, it argues that absent access to a binding moral standpoint that is not already conditioned by a particular society, culture, or place in history, all moral and bioethical commitments are merely contingent, subject to particular human interests, aesthetic inclinations, personal intuitions, idiosyncratic choices, and political objectives. (shrink)

This article argues that values that apply to health care allocation entail the possibility of “spectrum arguments,” and that it is plausible that they often fail to determine a best alternative. In order to deal with this problem, a two-step process is suggested. First, we should identify the Strongly Uncovered Set that excludes all alternatives that are worse than some alternatives and not better in any relevant dimension from the set of eligible alternatives. Because the remaining set of alternatives often (...) contain more than one element, we need some complementary method of selecting a unique alternative. In order to address this issue, I suggest that we must invoke caps on the values that are used to evaluate alternatives, and that these caps must be grounded in collective commitments. (shrink)

On Monday, June 25, 2018, H. Tristram Engelhardt, Jr., PhD, MD, co-founder of The Journal of Medicine and Philosophy, was laid to rest in the beautiful Hill Country of Texas near Comal County. Professor Engelhardt co-founded The Journal of Medicine and Philosophy in 1976 with Dr. Edmund Pellegrino. Engelhardt first served as Associate Editor, and then Editor and Senior Editor from 1976 until 2018. The Journal thrived for more than four decades through his energy, vision, and dedication. One of the (...) intellectual founders of the fields that would become known as bioethics and the philosophy of medicine, Engelhardt’s seminal scholarship has framed the philosophical debates surrounding healthcare policy and medical practice throughout the world. The Journal of Medicine and Philosophy mourns his passing. (shrink)

In a spirit of critical appreciation, this essay challenges several core aspects of the critique of secular morality and the defense of Orthodox Christianity offered by H. Tristram Engelhardt in After God. First, I argue that his procedurally driven approach to a binding morality based solely on a principle of permission leaves morality without any substantive definition in general terms, in ways that are both conceptually problematic and also at odds with Engelhardt’s long-standing distinction between non-malevolence and beneficence. Second, I (...) question the accuracy or adequacy of Engelhardt’s critique of the Enlightenment project for his unwarranted privileging of a particular version of Enlightenment thinking at the expense of other Enlightenment perspectives less amenable to Engelhardt’s working generalizations. Third, I challenge the theoretical cogency of Engelhardt’s insistence on the ubiquity and intractability of moral controversies and his depiction of moral strangers and moral friends as, in effect, mutually exclusive terms. Finally, I question Engelhardt’s embrace of a divine command model of ethics as the appropriate resolution of Euthyphro’s dilemma and suggest that there may be intermediate approaches to the usual starkly drawn contrasts between divine command and naturalist accounts. (shrink)

>Engelhardt’s After God gives a comprehensive perspective on the deepest and hardest issues in both moral philosophy and bioethics of our time. Although the book is an intelligent critique of contemporary moral philosophy in favor of a kind of traditionalism rooted in the perspective of the Orthodox Church, containing numerous forceful arguments, I ultimately disagree with Engelhardt on several main points stemming from his pessimistic view of our current culture and society. I have neither the pretense to open new perspectives, (...) nor to put forward new arguments, and I am aware that I might be wrong. I simply want to present a different position on the quest for meaning. (shrink)

Suppose, we could take a pill that would turn us into morally better people. Would we have a duty to take such a pill? In recent years, a number of philosophers have discussed this issue. Most prominently, Ingmar Persson and Julian Savulescu have argued that we would have a duty to take such a pill. In this article, I wish to investigate the possible limits of a duty to take moral enhancement drugs through investigating the related question of whether it (...) would be desirable to create a world populated entirely with morally perfect people. I argue, drawing on the work of Bernard Williams, Susan Wolf, and Michael Slote, that we have reason to be grateful that we do not live a world in which everyone is morally perfect, as this would prevent people from dedicating their lives to valuable nonmoral projects. I then argue that this thought should serve as a limitation on attempts to morally improve people through the use of technology. Finally, I explore the implications of this discussion for some of the less ambitious forms of moral enhancement currently being explored in the literature. I argue that these forms of enhancement give us no reason to worry about preventing valuable, morally imperfect ways of life. In fact, by acting as a shortcut to moral development, they might serve as an aid to help people fulfill valuable nonmoral goals in a way that is morally permissible. (shrink)

Over the coming century, the accelerating advance of bioenhancement technologies, robotics, and artificial intelligence may significantly broaden the qualitative range of sentient and intelligent beings. This article proposes a taxonomy of such beings, ranging from modified animals to bioenhanced humans to advanced forms of robots and AI. It divides these diverse beings into three moral and legal categories—animals, persons, and presumed persons—describing the moral attributes and legal rights of each category. In so doing, the article sets forth a framework for (...) extending the concept of personhood well beyond its current boundaries, assigning moral standing to a variety of biological and nonbiological beings. The author concludes that six of the eight subgroups of such beings deserve to be treated as persons or as if they were persons, with full consideration for their presumed interests, rights, obligations, and capabilities for ethically significant agency and patiency. (shrink)

There is recent empirical evidence that personal identity is constituted by one’s moral traits. If true, this poses a problem for those who advocate for moral enhancement, or the manipulation of a person’s moral traits through pharmaceutical or other biological means. Specifically, if moral enhancement manipulates a person’s moral traits, and those moral traits constitute personal identity, then it is possible that moral enhancement could alter a person’s identity. I go a step further and argue that under the right conditions, (...) moral enhancement can constitute murder. I then argue that these conditions are not remote. (shrink)

Some bioethicists have argued that moral bioenhancement, complementing traditional means of enhancing individuals’ moral dispositions, is essential if we are to survive as a species. Traditional means of moral enhancement have historically included civil legislation, socially recognized moral exemplars, religious teachings and disciplines, and familial upbringing. I explore the necessity and feasibility of pursuing methods of moral bioenhancement as a complement to such traditional means, grounding my analysis within a virtue-theoretic framework. Specifically, I focus on the essential intellectual virtue for (...) proper moral reasoning, prudence, and whether proposed methods of moral bioenhancement could facilitate the cultivation of this virtue within the psyches of moral agents. I conclude that certain means of bioenhancement may serve to augment the ability to reason prudentially and assist moral agents to align their wills with their higher-order rational desires, though such means require those higher-order desires to already have been formulated independently. (shrink)

In this article, I argue that as we learn more about how we might intervene in the brain in ways that impact human behavior, the scope of what counts as “moral behavior” becomes smaller and smaller because things we successfully manipulate using evidence-based science are often things that fall outside the sphere of morality. Consequently, the argument that we are morally obligated to morally enhance our neighbors starts to fall apart, not because humans should be free to make terrible choices, (...) but because morality is not something subject to such manipulation. To illustrate my argument, I shall use the rise of veteran diversion courts in the United States as a putative instance of an intervention designed to change human behavior for the better. Part of my purpose in working my way through this case study is to demonstrate that many philosophers have the psychology of immoral action wrong. (shrink)

John Harris recently argues that the moral bioenhancement proposed by Persson and Savulescu can damage moral agency by depriving the recipients of their freedom to fall (freedom to make wrongful choices) and therefore should not be pursued. The link Harris makes between moral agency and the freedom to fall, however, implies that all forms of moral enhancement, including moral education, that aim to make the enhancement recipients less likely to “fall” are detrimental to moral agency. In this paper, I present (...) a new moral agency-based critique against the moral bioenhancement program envisaged by Persson and Savulescu. I argue that the irresistible influences exerted by the bioenhancement program harms our capabilities for conducting accurate self-reflection and forming decisions that truly express our will, which subsequently undermine our moral agency. (shrink)

What is morality? Is “morality” something that admits of technological enhancement? What could it possibly mean for a society to have a moral imperative to morally enhance? We are compelled to take up questions like these as we move into the future of moral bioenhancement. Each article in this issue of the Journal of Medicine and Philosophy attempts to bring some clarity as to what is meant by morality, such that one could be morally obligated to morally enhance. These articles (...) broaden the scope of the question as to the nature of human morality, what might and what might not be permitted in terms of moral bioenhancement, and explore the nature of the kinds of beings humans might become—whether human or post-human—and the moral obligations that may exist toward them. (shrink)

Arguments in favor of greater research-practice integration in medicine have tended to be ethical, political, or pragmatic. There are good epistemic reasons to pursue greater integration, and it is important to think through these reasons in order to avoid inadvertently designing new systems in ways that replicate the epistemic elitism common within current systems. Meaningful transformation within health care is possible with close attention to all reasons in favor of greater research-practice integration, including epistemic reasons.

This article explores Foucault’s two different notions of power: one where the subject is constituted by power–knowledge relations and another that emphasizes how power is a central feature of human action. By drawing out these two conceptualizations of power, Foucault’s work contributes three critical points to the formation of medicalized subjectivities: the issue of medicalization needs to be discussed both in terms of both specific practices and holistically ; we need to think how we as human beings are “disciplined” and (...) “subjectivated” through medicalization, as discourses, practices, and institutions are all crystallizations of power relations; and we need to reflect on how we can “resist” this process of subjectification, since “power comes from below” and patients shape themselves through “technologies of the self.” Ultimately, Foucault’s work does not merely assist us in refining our analysis; rather, it is essential for conceptualizing medicalization in contemporary society. (shrink)

Whereas theories on health generally argue in favor of one specific concept, we argue that, given the variety of health practices, we need different concepts of health. We thus approach health concepts as a Wittgensteinian family of thick concepts. By discussing five concepts of health offered by theory, we argue that all capture something that seems relevant when we talk and think about health. Classifying these concepts reveals their family resemblances: each of these concepts differs from the others in at (...) least one respect and resembles the others in several respects. Moreover, our classification shows that “health” always both describes a condition and evaluates that condition at the same time. Having both descriptive and evaluative dimensions, we can see health concepts as “thick concepts.” It is because of this evaluative dimension that it is important to reflect on the question of what understanding of health guides specific practices. We show that the distinctions revealed by our classification can serve as a conceptual toolbox for reflection on the assumptions and purposes of particular health practices. Finally, we illustrate how such reflection could work out by briefly exploring three specific health practices. (shrink)

There has been much debate about whether the concept of disease articulated in Boorse’s biostatistical theory is value-neutral or value-laden. Here, I want to examine whether this debate matters. I suggest that there are two basic respects in which value-ladenness might be important: it could threaten either scientific legitimacy or moral permissibility. I argue that value-ladenness does not threaten the scientific legitimacy of our disease-concept because the concept makes little difference to the formulation and testing of scientific hypotheses. Likewise, even (...) if our disease-concept is value-laden, this does not show it is morally impermissible. To determine its permissibility, we must regard it as a tool to structure social institutions. Seen in that way, whether our disease-concept is morally permissible is a consequentialist matter and depends exquisitely on unanswered empirical questions. (shrink)

The themes of this issue—which include the meaning of our health and disease concepts, the so-called “medical gaze” and its embedded power relations, and the epistemic value of mixing therapy with research—are introduced by reflecting on a case about an infant girl whose head is observed to be somewhat flat.

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept (...) is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept. (shrink)

What is medicine? One obvious answer in the context of the contemporary clinical tradition is that medicine is the process of curing sick people. However, this “curative thesis” is not satisfactory, even when “cure” is defined generously and even when exceptions such as cosmetic surgery are set aside. Historian of medicine Roy Porter argues that the position of medicine in society has had, and still has, little to do with its ability to make people better. Moreover, the efficacy of medicine (...) for improving population health has been famously doubted by historians and epidemiologists. The curative thesis demands that we have mostly been stupid, duped, or staggeringly hopeful, given that medicine has not until recently offered more than a handful of effective cures. I suggest, in this article, that the core medical competence is neither to cure, nor to prevent, disease, but to understand and to predict it. I argue that this approach does a better job than the curative thesis at explaining why not all medicine is concerned with curative efforts and that it enjoys historical support from the ancient entanglement of prophecy and medicine and from the fact that medicine thrived for centuries with almost no effective cures and continues to thrive today in various forms that are mostly without curative efficacy. I suggest that this approach grounds a fairer approach to alternative, traditional, and other medical practices, as well as some fresh lessons for the development of mainstream medicine. (shrink)

This article is a reply to two critics of my “Prediction, Understanding, and Medicine,” published elsewhere in this journal issue. In that essay, I argued that medicine is best understood not as essentially a curative enterprise, but rather as one essentially oriented towards prediction and understanding. Here, I defend this position from several criticisms made of it.

Leder, D. 2016. The Distressed Body. Chicago: University of Chicago Press.

In “Prediction, Understanding, and Medicine,” Alex Broadbent rejects the curative thesis, the view that the core medical competence is to cure, in favor of his predictive thesis that the main intellectual medical competence is to explain and the main practical medical competence is to predict. Broadbent thinks his account explains the phenomenon of multiple consultation, which is the fact that people persist in consulting alternative medical traditions despite having access to mainstream medicine. I argue that Broadbent’s explanation of multiple consultation (...) makes sense only from the perspective of patients who migrate from mainstream to alternative consultation. His explanation is not as convincing when we consider alternative-to-mainstream migration. I also provide an argument against Broadbent’s view that prediction is medicine’s main practical competence and argue that, when it comes to explaining most cases of multiple consultation, the curative thesis provides a more convincing explanation than the predictive thesis. (shrink)

There is broad agreement among research ethicists that investigators have a duty to obtain the informed consent of all subjects who participate in their research trials. On a common view, the duty to obtain this informed consent follows from the need to respect persons and their autonomous decisions. However, the nature of informed consent and the demands it places on investigators are open to dispute and recently have been challenged. Respect for persons, it has been claimed, does not require investigators (...) to guarantee that the subjects enrolled in their trials comprehend the risk/benefit information disclosed to them or even that they appreciate the difference between research and therapy. According to this critique, the significance of defects in informed consent, like therapeutic misconception or unrealistic optimism, has been greatly exaggerated. This article reevaluates informed consent in clinical research in light of this critique. It not only rebuts the main points the critics raise, but also shows that other points they raise can be accepted by a doctrine of informed consent that resembles the common view in maintaining that autonomous authorization is central to informed consent. (shrink)

Part of a symposium devoted to ‘Prediction, Understanding, and Medicine’, in which Alex Broadbent argues that the nature of medicine is determined by its competences, i.e., which things it can do well. He argues that, although medicine cannot cure well, it can do a good job of enabling people not only to understand states of the human organism and of what has caused them, but also to predict future states of it. From this Broadbent concludes that medicine is (at least (...) in part) essentially a practice of understanding and predicting, not curing. In reply to this bold position, I mount two major criticisms. First, I maintain that the reasons Broadbent gives for doubting that medicine can cure provide comparable reason for doubting that medicine can provide an understanding; roughly, the best explanation of why medicine cannot reliably cure is that we still lack much understanding of health and disease. Second, I object to the claim that a practice is medical only if it facilitates understanding and prediction. Although Broadbent has brought to light certain desirable purposes of medicine that are under-appreciated, my conclusion is that he has not yet provided enough reason to think that understanding and prediction are essential to it. Instead of supposing that medicine has an essence, in fact, I suggest that its nature is best understood in terms of a property cluster. (shrink)

The first part of a symposium devoted to Alex Broadbent's essay titled ‘Prediction, Understanding and Medicine’, this article notes the under-development of a variety of issues in the philosophy of medicine that transcend bioethics and the long-standing debates about the nature of health/illness and of evidence-based medicine. It also indicates the importance of drawing on non-Western, and particularly African, traditions in addressing these largely metaphysical and epistemological matters.

Currently in the United Kingdom, anyone donating gametes has the status of an open-identity donor. This means that, at the age of 18, persons conceived with gametes donated since April 1, 2005 have a right to access certain pieces of identifying information about their donor. However, in early 2015, the UK Parliament approved new regulations that make mitochondrial donors anonymous. Both mitochondrial donation and gamete donation are similar in the basic sense that they involve the contribution of gamete materials to (...) create future persons. Given this similarity, this paper presumes that both types of donor should be treated the same and made open-identity under the law, unless there is a convincing argument for treating them differently. I argue that none of the existing arguments that have been made so far in favor of mitochondrial donor anonymity are convincing and mitochondrial donors should therefore be treated as open-identity donors under UK law. (shrink)

Moral status ascribes equal obligations and rights to individuals on the basis of membership in a protected group. Substance change is an event that results in the origin or cessation of individuals who may be members of groups with equal moral status. In this paper, two substance changes that affect the moral status of human embryos are identified. The first substance change begins with fertilization and ends with the formation of the blastocyst, a biological individual with moral status comparable to (...) that ascribed to human organs. The second substance change begins at implantation and ends late in embryological development with the formation of the human body, an organism with moral status as a human being. The bioethical implications of each substance change are explored. The Two Substance Change theory is contrasted with continuity theories, which recognize no substance change in embryological development and with fertilization-only substance change theories. (shrink)

The prospect of creating and using human–animal chimeras and hybrids that are significantly human-like in their composition, phenotype, cognition, or behavior meets with divergent moral judgments: on the one side, it is claimed that such beings might be candidates for human-analogous rights to protection and care; on the other side, it is supposed that their existence might disturb fundamental natural and social orders. This paper tries to show that both positions are paradoxically intertwined: they rely on two kinds of species (...) arguments, “individual species arguments” and “group species arguments,” which formulate opposing demands but are conceptually interdependent. As a consequence, the existence of HACHs may challenge exactly those normative standards on which the protection of HACHs may eventually be based. This ethical paradox could constitute the ultimate source of the “moral confusion” that some authors have suspected HACHs to provoke. (shrink)

This article defends the criterion of permanence as a valid criterion for declaring death against some well-known recent objections. We argue that it is reasonable to adopt the criterion of permanence for declaring death, given how difficult it is to know when the point of irreversibility is actually reached. We claim that this point applies in all contexts, including the donation after circulatory determination of death context. We also examine some of the potentially unpalatable ramifications, for current death declaration practices, (...) of adopting the irreversibility criterion. (shrink)

I have argued that substance ontology cannot be used to determine the moral status of embryos. Patrick Lee, Christopher Tollefsen, and Robert George wrote a Reply to those arguments in this Journal. In that Reply, Lee, Tollefsen, and George defended and clarified their position that their substance ontology arguments prove that the zygote and the adult into which it develops are the same entity that share the same essence. Here, I show the following: Even using the substance ontology framework to (...) which Lee, Tollefsen, and George subscribe, we cannot know when in development substance changes cease. Substance ontology cannot therefore be used to assign moral status to embryos. The Lee, Tollefsen, and George substance ontology framework should not be applied to the study of development or to biological discourse in general, because this framework depends on premises that do not apply. (shrink)

The articles in this issue cover a wide range of topics, including the moral status of human embryos and human-animal chimeras and hybrids, the determination of death, theories of human cognition, and policies on the identity of mitochondrial donors. Despite this variety, there are two underlying questions that tie the articles together: what is a human being? And, what is the basis of moral status? First, I discuss these two questions and why they are important for bioethics. Then I provide (...) summaries of the six articles in this issue and explain how each of them is connected to the questions of human nature and moral status. (shrink)

Often drawing on the phenomenological tradition, a number of philosophers and cognitive scientists working in the field of “embodied cognition” subscribe to the general view that cognition is grounded in aspects of its sensorimotor embodiment and should be comprehended as the result of a dynamic interaction of nonneural and neural processes. After a brief introduction, the paper critically engages Lakoff and Johnson’s “conceptual metaphor theory”, and provides a review of recent empirical evidence that appears to support it. Subsequently, the paper (...) underscores some of the limitations of CMT, points to some philosophical problems that require further attention, and explores possible implications for understanding and treating of mental disorders. (shrink)

According to the Standard View, a doctor who withdraws life-sustaining treatment does not kill the patient but rather allows the patient to die—an important distinction, according to some. I argue that killing can be understood in either of two ways, and given the relevant understanding, the Standard View is insulated from typical criticisms. I conclude by noting several problems for the Standard View that remain to be fully addressed.

With the new and highly accurate noninvasive prenatal test, new options for screening become available. I contend that the current state of the art of NIPT is already in need of a thorough ethical investigation and that there are different points to consider before any chromosomal or subchromosomal condition is added to the screening panel of a publicly funded screening program. Moreover, the application of certain ethical principles makes the inclusion of some conditions unethical in a privately funded scheme, even (...) if such screening would enhance a woman’s reproductive autonomy. On the one hand, a screening program aimed solely at the detection of Down syndrome is subject to the technological imperative and should be reassessed in the light of technologies that allow for the detection of conditions that are at least as severe. On the other hand, some chromosomal conditions should not be included in any screening programs, because this would violate certain ethical principles, such as the right of the future child to genetic privacy. (shrink)

In this essay, we defend the design of the Salk polio vaccine trial and try to put some limits on the role schemata should play in designing clinical research studies. Our presentation is structured as a response to de Freitas and Pietrobon who identified the CONSORT statement as a schema that would have, had it existed at the time, ruled out the design of the Salk polio vaccine trial of 1954 in favor of a completely randomized controlled clinical trial. We (...) argue that large-scale public health interventions often require evidence beyond simple efficacy, the limit of what an RCT can provide, and that the design actually adopted for the Salk trial represented a reasonable—albeit imperfect—compromise. This is of more than historical interest in that many contemporary studies are of the scale and scope to require a more pragmatic, rather than explanatory, approach to study design. (shrink)

Philosophers who specialize in bioethics face a distinctive set of challenges in our work: to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. This article describes some of the key contributions that philosophy can make to the field of bioethics. It also identifies some of the pitfalls that can undermine the value of a philosophical approach when used to analyze questions arising in the real world. Recognition of the (...) importance of individual context, practical implications, and social considerations can help successfully bridge the gap between theory and practice. Using this wide-angle lens to view bioethical problems can enable philosophers working in our field to offer insights that are both rigorous and relevant. (shrink)

Advances in DNA sequencing technology open new possibilities for public health genomics, especially in the form of general population preventive genomic sequencing. Such screening programs would sit at the intersection of public health and preventive health care, and thereby at once invite and resist the use of clinical ethics and public health ethics frameworks. Despite their differences, these ethics frameworks traditionally share a central concern for individual rights. We examine two putative individual rights—the right not to know, and the child’s (...) right to an open future—frequently invoked in discussions of predictive genetic testing, in order to explore their potential contribution to evaluating this new practice. Ultimately, we conclude that traditional clinical and public health ethics frameworks, and these two rights in particular, should be complemented by a social justice perspective in order adequately to characterize the ethical dimensions of general population PGS programs. (shrink)

Phase 1 healthy volunteer clinical trials—which financially compensate subjects in tests of drug toxicity levels and side effects—appear to place pressure on each joint of the moral framework justifying research. In this article, we review concerns about phase 1 trials as they have been framed in the bioethics literature, including undue inducement and coercion, unjust exploitation, and worries about compromised data validity. We then revisit these concerns in light of the lived experiences of serial participants who are income-dependent on phase (...) 1 trials. We show how participant experiences shift attention from discrete exchanges, behaviors, and events in the research enterprise to the ongoing and dynamic patterns of serial participation in which individual decision-making is embedded in collective social and economic conditions and shaped by institutional policies. We argue in particular for the ethical significance of structurally diminished voluntariness, routine powerlessness in setting the terms of exchange, and incentive structures that may promote pharmaceutical interests but encourage phase 1 healthy volunteers to skirt important rules. (shrink)