2. Chosen, Given, Taken – A Belmont Report

Choice factors into all ethical dilemmas. The point is to resolve a matter at issue to the best of our (collective) abilities from the myriad options circumstances present. Inherent to choice are twin poles: giving and taking. Given options, we must take action(s). Determining which is/are best is the practical pursuit of a worthwhile ethics. This second year began by reëstablishing the ethical reality of minds and bodies. Recognizing minds and bodies may be altered or absent, different from ours or in turmoil, we sought to understand the decisions of all moral actors from before their beginnings to their ever reverberating ends since only from the constellation of our choices can we end up with a view of ourselves. This view, our identity, can also be chosen, given, taken. As it is when one’s taken to task but not given a fair shake for their gender, as it is when rights are taken from those given others for their race, as it is when given to children by flesh taken through cultural happenstance. Our time ever fleeting, we make of it what we can and work to ensure others others can too. What the past dictates the present decides on behalf of the future. What is “a given” is also “taken for granted”. We must choose what we do within the biomedical landscape. In this series of discussions, participants shared with each other – giving and taking – so that after we might choose both well and good.

016. Neuroethics. A discussion on the origins of our moral situation.

017. Drugs. A discussion on the manipulation of our biochemical status.

018. Alternative medicine. A discussion at the boundaries of the medical sciences.

019. Zombies. A discussion of the living, the dead, and those in between.

020. Cloning. A discussion coping with copying, seeing double, and creating anew.

021. Animal experimentation. A discussion testing the limitations of our testing limitations.

022. Suicide. A discussion on our (chosen?) ends.

023. Race. A discussion on (in)equality that’s more than skin deep.

024. Gender. A discussion on who we are, who society sees, and who we want to be.

025. Circumcision. A discussion on health, tradition, and mutilation.

026. Pain. A discussion on what we (don’t want to) feel.

027. Mental health. A discussion on our internal (dys)functions.

028. Eugenics. A discussion on who ought to be here.

029. Replicability of medical studies. A discussion on the significance of our results.

030. Extinction. A discussion on our (inevitable?) ends.

Readings: Neuroethics: an agenda for neuroscience and society; Neuroethics: the practical and the philosophical; Neuroethics for the new millennium; Towards responsible use of cognitive-enhancing drugs by the healthy; Adverse health effects of marijuana use; Practical, legal, and ethical issues in expanded access to investigational drugs; The placebo effect in alternative medicine; The use of complementary and alternative medicine in pediatrics; Efficacy of complementary and alternative medicine therapies; Trends in the use of complementary health approaches among adults: United States, 2002-2012; Consciousness: the most critical moral (constitutional) standard for human personhood; CDC preparedness 101 – zombie pandemic; Zombies v. materialists; In vitro meat; Genetic encores; Human cloning and our sense of self; The ethics of reviving long extinct species; Uniqueness, individuality, and human cloning; Does animal experimentation inform human healthcare?; Ethical principles and guidelines for experiments on animals; The flaws and human harms of animal experimentation; Animal testing is still the best way to find new treatments for patients; Alternatives to animal testing; The myth of Sisyphus; The ethics of suicide; Suicide: rationality and responsibility for life; Suicide responsibility of hospital and psychiatrist; Racial disparity in emergency department triage; Dealing with the realities of race and ethnicity; Race/Ethnicity and success in academic medicine; Race and trust in the health care system; Why bioethics has a race problem; Doing gender; For whom the burden tolls; Performative acts and gender constitution; Resisting medicine, re/modeling gender; The restroom revolution: unisex toilets and campus politics; Male circumcision; Female genital alteration: a compromise solution; Female genital mutilation and male circumcision: toward an autonomy-based ethical framework; Rationalising circumcision; Current medical evidence supports male circumcision; Circumcision: case against surgery without medical indication; The undertreatment of pain; Moral agency in pain medicine; Suffering and the goals of medicine; The unequal burden of pain: confronting racial and ethnic disparities in pain; Pain medicine and its models: helping or hindering?; The myth of mental illness; Distinguishing between the validity and utility of psychiatric diagnoses; Diagnostic issues and controversies in DSM 5; How stigma interferes with mental health care; Identification of a common neurobiological substrate for mental illness; Eugenics: its definition, scope, and aims; The second international congress of eugenics; CC Little renaming resolution; Buck v. Bell Supreme Court opinion; Moderate eugenics and human enhancement; Reproducibility in science; Estimating the reproducibility of psychological science; How many scientists fabricate and falsify research?; Is the replicability crisis overblown?; The nature of extinction; Extinction risk from climate change; Extinction and overspecialization: the dark side of human innovation; The ethics of de-extinction

Questions to ponder

On neuroethics
1. To what extent do our brains determine our ethics? To what should they?
2. “[I[t has been suggested that a large proportion of inmates on death row may have damaged or injured brains. If careful epidemiologic studies establish that this is the case, how should our views about moral and legal responsibility change, if at all, to accommodate this surprising fact?”
3. Do we have a right to know when someone is lying?
4. “If someone knows that he or she is at some risk for, for example, a psychotic episode, should he or she be held legally responsible for actions undertaken while delusional in virtue of not having prevented the episode?”
5. Is there an ethical distinction to be made between “death” and “brain death”? Would you wish to have one without the other?
6. “Traditional ethical theory has centered on philosophical notions such as free-will, self-control, personal identity, and intention. These notions can be investigated from the perspective of brain function.” Is this a useful perspective to take on these matters? Why?
7. Imagine, if you will, that you work at a government weapons lab working on a mind-altering technology, such as a long-term neural prosthetic meant to enhance memory encoding. One day, your advisor asks you to begin looking into its converse, the selective elimination of previously encoded memories. What do you do?
8. What does it mean to change one’s self?
9. In some sciences there are facts and theories that yield accurate and worthwhile predictions. For example, knowing how diseases spread gives you both population-level anticipatory power and suggests remedies at the person-level. Some forms of ethics provide the same (e.g., the most good for the most people most of the time at least provides a bearing on the moral compass even if it doesn’t put a pin in the moral map). Does neuroethics – either as a field of science or as a field of ethics – provide comparable accurate and worthwhile predictions?
10. Do we have free will?
11. Is there a “ghost in the machine”?
12. Have the shifts in our biological and ethical perspectives throughout history generally been to the benefit or the detriment of the human experiment?
13. Is “neuroethics” the right word for what we’re talking about here?
14. Who are you? And does it matter?
On drugs
1. How do drugs differ from other things?
2. What does responsible drug use and administration require of the user and the administrator? Should such responsibilities be codified in a nation’s laws?
3. After Congress mandated that the U.S. Food and Drug Administration (the “FDA”) “validate substantial evidence of safety and effectiveness for new drug products based on adequately controlled clinical trials,” Darrow et al states “the average development time for a new drug predictably rose from 2.5 to 8 years.” Assuming these are the two reasonable bounds, towards which of these time points would a healthier society’s drug approval rate skew?
4. “Three categories of expanded access now exist” Darrow et al tells us. “The most common request is for individual use, a subset of which involves emergency circumstances leading to treatment even before a formal written request has been submitted to the FDA. The second situation relates to requests by intermediate-size patient populations (tens to hundreds) who are eligible to receive a drug early in its development. The final situation is widespread use under a treatment protocol, such as might occur after a successful trial of an experimental agent has been concluded but before it has received FDA approval.” Should these levels of expanded use be met with different ethical and regulatory standards? If so, how should they differ? If not, why should there be uniform standards?
5. How much would it cost for you to take a random pill?
6. Volkow et al. notes, “The regular use of marijuana during adolescence [can be] of particular concern, since use by this age group is associated with an increased likelihood of deleterious consequences”. Such consequences include those from short-term use (e.g., impaired short-term memory, impaired motor coordination, altered judgment, paranoia, and psychosis) and long-term use (addiction¹, altered brain development, cognitive impairment, diminished life satisfaction and achievement). With the ever-burgeoning “legalize it” movement pushing for a loosening of federal restrictions on marijuana use, sale, and distribution, what restrictions should remain (particularly with respect to adolescent)? What should accompany them?
7. Is it better to use more drugs or fewer?
8. On the subject of using a substance like Adderall to do “better” on an assignment: “Whether the cognitive enhancement is substantially unfair” Greely et al contends, “may depend on its availability, and on the nature of its effects. Does it actually improve learning or does it just temporarily boost exam performance? In the latter case it would prevent a valid measure of the competency of the examinee and would therefore be unfair. But if it were to enhance long-term learning, we may be more willing to accept enhancement. After all, unlike athletic competitions, in many cases cognitive enhancements are not zero-sum games. Cognitive enhancement, unlike enhancement for sports competitions, could lead to substantive improvements in the world.” Do you agree?
9. What is it that drugs do to us that gets us so curious about them?
10. “Popular weed killer may be to blame for honey bee deaths, study suggests” a headline from today that were but two words flipped would have made for an excellent discussion.
On alternative medicine
1. What makes medicine “alternative”?
2. Is “alternative medicine” distinct from “complementary medicine”? Are either or both situated at odds with “traditional”/”Western” medicine?
3. In their review of 18 trials involving alternative medicines, Bardia et al conclude that “[t]here is paucity of multi-institutional RCTs [randomized controlled trials] evaluating CAM [complementary and alternative medicine] interventions for cancer pain with adequate power, duration, and sham control. Hypnosis, imagery, support groups, acupuncture, and healing touch seem promising, particularly in the short term, but none can be recommended because of a paucity of rigorous trials. Future research should focus on methodologically strong RCTs to determine potential efficacy of these CAM interventions.” To what extent to do you agree with that conclusion given what you know about “alternative” medicines?
4. I have an aunt who swears by acupuncture. She has had some of the worst pain you can ever imagine in her life, has gone everywhere, consulted every doctor, undergone every treatment, every therapy. She goes to an acupuncturist and the pain is gone and onlywhen she goes to said acupuncturist does this horrible pain get treated to her satisfaction. Should we recommend she keep going?
5. On placebo. Is it dismissive to attribute a portion of the efficacy of alternative medicine to the placebo effect? Placebo treatments have often proven slightly effective in alleviating certain disorders––to what extent should medical professionals feel comfortable giving them to their patients?
6. It is estimated that at least one-third of all adults in the United States have used complementary and alternative medicine. It is an industry generating tens to hundreds of billions of dollars in revenue, accounting for likely over one billion trips to “healthcare” providers. This is not the case in other countries. What are we to make of this?
7. Do you think more or less CAM therapies should be given CPT codes?
8. If someone told you snake oil really had a curative effective, who would that someone have to be for you to believe them? And why?
9. Where does something like yoga fall on the Improving Health Spectrum? Do its effects extend beyond those associated with any other form of exercise?
10. If I gave you a bottle of homeopathic medicine, how many would you feel comfortable taking?
11. Is there something approaching what we might call the “mind-body-soul” being that medicine should ultimately be treating? We already incorporate quality of life as a factor into most medical decisions, would it really be any different to perhaps take a more “holistic” approach to medical treatment/therapy/devices?
12. How important is it that we/someone police the boundaries between “medicine” and “not-medicine”? “Science” and “non-science”? Sense and nonsense?
On zombies
1. Would you ever eat a human being?
2. There is generally something we might call “humanness” – a set of behaviors, mammalian situationality, biological facts, etc. – that approximately every human has. How much of this “humanness” is to be found in “zombies”? What about those in comas? Under sedation?
3. The boring definition question: what are “zombies”?
4. When are quarantines ethical justifiable? Does the precision brought to bear by modern day mathematical biology allow us to be more or less ethical? Put somewhat orthogonally: is it better to include too many or too few in a quarantine?
5. What are one’s rights in a pandemic?
6. Who are we when we are sick?
7. Is the patient that comes in for treatment the same as the one who leaves after being treated? What if major organs were replaced? What about faces, hands, brains? How much can a person withstand medical treatment while remaining the same? If/When does that patient become significantly different?
8. Are you satisfied that a government such as the one that has jurisdiction over you is capable of dealing with something equivalent to a zombie outbreak?
9. Who do zombies think they are? Does it matter? Does it matter “what it’s like to be a bat”?
10. Monsters are often those beings which patrol the boundaries between the acceptable and the unacceptable, the normal and the grotesque, the healthy and the sick. Vampires, demons, werewolves, ghosts, they all comment upon some of life-itself’s very borders. What boundaries do zombies patrol that are biomedically relevant?
11. Right now, in a few labs around the world, the most dangerous viruses/bacteria/organisms are being studied by a few individuals. What sort of screening should there be to make sure the “right” people are studying these issues? If something were to go wrong in one of these labs, do think the people involved are sufficiently prepared?
12. How much would you have to be paid to let a random person/animal bite you?
13. What do you do in a zombie outbreak?
14. Would you want to be as zombie?
15. Favorite zombie movie?
On cloning
1. If you found out you were a clone of some “original person”, how would that make you feel? What if you found out you were a twin? A quintuplet?
2. If the technology existed right now, how would you use complete and perfect “cloning”?
3. Would you ever want your clone to exist? If your clone came into being, how would you deal with it?
4. Is a clone more like a twin or a child?
5. If twins are raised in separate wombs are they still twins? What if genetically modify each in different ways? What if we never let them or their mothers/fathers/families/anyone they ever knew interact? If such a twin of yours existed out there, what would you want to say to them? What would you want them to say to you? Who are they to you?
6. Often fears concerning human cloning (especially those with a more reproductive bent) arise out of the technique’s/technology’s possible undermining of our ( or at least their) sense of self. To this end, three arguments are traditionally given: (1) cloning would undermine our sense of individuality and/or uniqueness; (2) cloning would undermine the value or worth of human beings; and (3) a clone’s freedom and/or autonomy and/or liberty to construct her or his own life is undermined by the presence of an earlier “original”. How do you feel about each of these arguments? Do you agree with Brock on the issues?
7. Should we resurrect long-dead species? What about the recently extinct?
8. Should someone be allowed to make their own clone?
9. Should you be allowed to clone yourself?
10. What traits are important to define “the self”?
11. Assume a dystopian future. It is common place (“the norm”) to clone oneself towards the end of life to transfer “the self” that is “you” upon death into a younger clone, and to carry on. This cycle is expected to repeat until the end of time now that world peace has been achieved. Do you keep your “self” going through this cycle?
On animal experimentation
1. Would you personally ever participate in experiments involving animals? To what extent and why?
2. Do we “own” animals? Can we do to animals anything that we can do to other “property” we own (e.g., a chair, a pencil, a burrito, etc.)?
3. For many people “pain” and “suffering” mark the bounds of “acceptable research”. Why should these be the bounds and how much of a buffer ought we to keep between them and ourselves?
4. Are we more (un)comfortable with certain kinds of animal experimentation? Why? Is there something to the notion of “higher” animals? Or is that just something we as ideal versions of said “higher” animals made up? To what extent does/should genetic relatedness play a role in our ethical understanding of a particular animal model?
5. A strategy of “3 Rs” (reduction, refinement, and replacement) is currently applied for laboratory use of animals. Is there anything about this approach that you would revise?
6. Roberts et al. note that “it is essential that [our] results are valid and precise. Biased or imprecise results from animal experiments may result in clinical trials of biologically inert or even harmful substances, thus exposing patients to unnecessary risk and wasting scarce research resources.” Do you believe this is an appropriate dimension by which to measure / lens through which to observe the heart of the matter when it comes to animal experimentation?
7. This weekend a great many dead bird will be eaten around this country (and indeed around the world). Would the world be “better” if it collectively ate less or more of these birds?
8. Garattini and Grignaschi claim that “There is no magic recipe” to improving our (animal) experiments, “only trial and error.” Are they right?
9. Ahktar forcefully states that “[t]he unreliability of animal experimentation across a wide range of areas undermines scientific arguments in favor of the practice [and] often significantly harms humans through misleading safety studies, potential abandonment of effective therapeutics, and direction of resources away from more effective testing methods. The resulting evidence suggests that the collective harms and costs to humans from animal experimentation outweigh potential benefits and that resources would be better invested in developing human-based testing methods.” Is she right?
10. Section 4.5 of the Ethical Principles and Guidelines for Experiments on Animals from the Swiss Academy of Medical Sciences and Swiss Academy of Sciences says that “animal[s] must be able to express [their] sensations” to “where possible avoid painful sensations.” If animals could express their sensations with us, do you think they would be satisfied with our treatment of them? How could we improve interspecies relations?
11. Myriad forms of vegetarianism seem to be cropping up across the country. Why is that?
12. To what degree are we responsible for animals?
13. How can we do better?
On race
1. What is race? Does it have a biological meaning we should concern ourselves with?
2. What do we think about what James Watson thinks about race? And what are we to make of the fact that we have to consider the thoughts of a ninety-year-old white man on the subject?
3. Kaplan et al. conclude that underrepresented minority faculty members had fewer publications and were less likely to be promoted and retained in academic careers. Why do you think that is?
4. We can perhaps accept as a given that currently most “races” tend to share similar environments, cultures, rituals, foods, etc. Given a shared set of circumstances/happenstances associated in a biomedically relevant way with “race”, should we study the concept scientifically and investigate potential health consequences?
5. Could the funding of race-based research be used to justify “racist” beliefs? Could there ever be a legitimate scientific conclusion that could “justify” such racism?
6. The CDC reports that uterine cancer rates have risen 0.7 parent per year from 1999 to 2015, while deaths from uterine cancer in that same time have risen 1.1 percent per year. What should we make of the fact that black women were twice as likely as other women to be diagnosed with uterine cancer that’s harder to treat and therefore were more likely to die from uterine cancer?
7. Is the fact that we don’t remember the “noose incidents” described in footnote 4 of Malinowski – “more than 50 to 60 noose-hanging incidents”, incidents that began with “a black student” asking to “sit under a shady tree on campus where the white students usually hung out” only to find “two nooses dangled from the tree” the next day and included “a noose hanging in the Hempstead, Long Island police department”, “across the country […] during fall 2007” – more or less disturbing than the incidents themselves?
8. Malinowski “proposes that applied bioethics and scientific pragmatism favor recognizing race and ethnicity as a preferred [sic] methodology for population genetics because this approach is most sensitive to personal impact on and
  1. self-identification by study subjects,
  2. communication with individual members of groups under study,
  3. realization of individual consent, recognition and assessment of group impact,
  4. the development of group consent in contemporary population genetics, and
  5. a means for inclusion for groups historically overlooked in pharmaceutical research and development and subject to health care disparities.”
    Do we agree that these are the things we ought to emphasize in our bioethical approach to race? Are there others?
9. Civil rights and liberties seem to blossom along contentious racial bounds (at least as it has kinda-sorta in the United States and increasingly elsewhere). Why do you think that is?
10. Hoberman notes that much of the bioethical literature on race “locate medical racism in the American past or in colonial Africa, while others analyze the medical disorders of fictional characters.” Why is it so hard to talk about the real, true, obvious, and sad facts of racism in the fields of medicine and healthcare?
11. Analyzing 19,726 patient-visits to an emergency department of “a large, urban-based academic teaching hospital”, Schrader and Lewis found that “African Americans had a significantly longer wait time to a treatment area compared to case-matched Caucasians (10.9min; p<0.001), with much larger differences in wait times noted within certain specific chief complaint categories.” What are we to make of that? That is, how do we fix this situation?
12. Carrese and Rhodes write that “Historically, the Navajo relationship with dominant society has been marked by conflict. Prominent examples include the military campaign of Kit Carson in 1863, the 300-mile Long Walk and subsequent incarceration of tribal members at the Bosque Redondo in New Mexico from 1864 to 1868, and the livestock reduction program of the 1930s.” Have Americans ever properly atoned for their treatment of Native Americans?
13. Black lives matter.
On gender
1. Do there exist inequalities/disparities between genders in current American healthcare? Are such inequalities/disparities unjust?
2. Should “biological” mothers have a greater say in any given situation due to the unique biological toll/exchange/interactions with their children (e.g., through pregnancy, breastfeeding, etc.) that all other parental units lack? If so, when so? If not, why not?
3. Did you ever “choose” your gender? What do you think it would be like if you, personally, were suddenly transformed into another gender? You can put this in your mind at least one of two ways: (1) one day you awaken to the all-encompassing feeling that you are not the gender that is currently stamped on your driver’s license or (2) imagine if Who You Are Up In Your Head was transferred into The Body That Is The Person of someone of a different gender than the one to which you currently identify. What’s that like?
4. West and Zimmerman posit that:“When we view gender as an accomplishment, an achieved property of situated conduct, our attention shifts from matters internal to the individual and focuses on interactional and, ultimately, institutional arenas. In one sense, of course, it is the individuals who “who” gender. But it is a situated doing, carried out in the virtual or real presence of others who are presumed to be oriented to its production. Rather than as a property of individuals, we conceive of gender as an emergent feature of social situations.”
  Do you agree? In “doing” your gender, how much of what you “do” arises from you exclusively as an individual human being and how much arises from your social environment. That is, when we put “gender” as a biomedical idea on the nature v. nurture scales, how do they tip?
5. Butler contends:“The authors of gender become entranced by their own fictions whereby the construction compels one’s belief in its necessity and naturalness. The historical possibilities materialized through various corporeal styles are nothing other than those punitively regulated cultural fictions that alternately embodied and disguised under duress.”
  Do you agree? Is gender closer to a “necessary and natural” part of life or is it more akin to a “punitively regulated cultural fiction”?
6. Do you believe generally polite, public language should be gender-neutral? If so, what strategies do you employ to do so? If not, why not? What should the gender-neutral plural in American English be?
7. What should a parent do if their child has gender dysphoria and wishes to have their puberty suppressed?
8. Is there something worse about preferential abortion of children on the category of sex/gender than there is for such an abortion for another reason? Do the societal (and thus medical) consequences seen in countries in which such population dynamics have been at work for a significant period of time (e.g., China) sway your opinion on the matter?
9. Is it morally acceptable to preferentially select an embryo for in vitro fertilization for reasons stemming solely from the category of sex/gender?
10. I believe that eventually the greatest of civilizations will all have people pissing and shitting in approximately the same places. That is, I think gender-neutral bathrooms – those in which persons of any gender can come and do their business – are essentially a hallmark of progress. Is there a biomedical/ethical reason why bathrooms ought to be categorized by gender? Is it merely practical?
11. It was the indelible Mr. Hitchens who once quipped, “The cure for poverty has a name, in fact: it’s called the empowerment of women. If you give women some control […] and then if you’ll throw in a handful of seeds perhaps and some credit, the floor of everything in that village, not just poverty, but education, health, and optimism will increase. It doesn’t matter; try it in Bangladesh, try it in Bolivia, it works—works all the time.” I can’t help but see the equal empowerment of all people everywhere as a generally good thing towards which we should be striving. As such, news such as which is conveyed by this recent headline, “Women in Iran are pulling off their headscarves – and hoping for a ‘turning point’” as a thing I’m compelled to support. How do you feel?
12. Spade begins “Resisting Medicine, Re/modeling Gender” by noting:“Everywhere that trans people appear in the law, a heavy reliance on medical evidence to establish gender identity is noticeable. Try to get your birth certificate amended to change your sex designation, and you will be asked to show evidence of the surgical procedures you have undergone to change your sex. Try to change your name to a name typically associated with the “other gender,” and in many places you will be told to resubmit your petition with evidence of the medical procedures you have completed. Try to get your drivers’ license sex designation changed, and again you will be required to present medical evidence.”
  Should the existence of and due process/equal protections under the law to transgendered individuals be necessarily bound up in the medical examination of, ultimately, the genitals of strangers.
13. Are the genders in America equal? If not, when will they be?
On circumcision
1. If circumcision did not already exist, would it be necessary for our society to invent it?
2. Christopher Hitchens once quipped, “Religion forces nice people to do unkind things and also makes intelligent people say stupid things. Handed a small baby for the first time, is it your first reaction to think, ‘Beautiful, almost perfect, now please hand me the sharp stone for its genitalia that I may do the work of the Lord’?” Do you think circumcision is inextricably bound up in religious tradition? Should the practice/procedure be secularized?
3. Should biomedical procedures only ever be performed to the reasonable biomedical benefit of the patient (or at the very least to the minimal harm of the patient)?
4. What do you find to be the most convincing reason to alter the genitals of one’s children and/or the children of others?
5. As Earp points out, “The official position of such influential bodies as the World Health Organization and the United Nations is that any kind of medically unnecessary, non-consensual alteration of the female genitalia – no matter how minor the incision, no matter what type of tissue is or is not removed, no matter how slim the degree of risk, and no matter how sterile the equipment used – is by definition an impermissible “mutilation.”” Why do you think this is the case for procedures on female children and not male children?
6. Generally, there are four types of ‘female genital alteration’: Type I includes removal of the prepuce or clitoral hood with or without clitorectomy; Type II is the removal of the entire clitoris as well as part or all of the labia minora; Type III, known as infibulation, involves the removal of the labia majora and/or labia minora, possible removal of the clitoris, and stitching together of the vulvar tissue to cover the urethra and introitus, leaving only a small opening for urine, menstrual flow and intercourse; Type IV includes pricking, nicking or incisions of the external genitalia, stretching of the clitoris or labia, cauterization or the introduction of corrosive substances into the vagina. Are any of them acceptable in the sort of society you want to live in? Do you agree with Arora and Jacobs recategorization based on the outcome of the procedure, rather than what is specifically done?
7. “After a comprehensive review of the scientific evidence,” the American Academy of Pediatrics punted the bioethical conclusion by finding that “the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision.” If the benefits are not great enough to recommend for all children, how should we categorize the medical procedure describing the physical alteration of children’s genitals? Enhancement? (Pre-)Treatment? Cosmetic?
8. Often the medical benefits of (particularly male) circumcision are made, as done ad nauseam by Morris and Cox in their “Current Medical Evidence Supports Male Circumcision”, use studies that fail to disentangle lots of socio/cultural/economic/ethno/religious lines inherent in asking a question such as “is male circumcision medically beneficial?” We note here in passing that most of the benefits of circumcision come hand in hand with Christendom on a map. And so how much do you really “trust” studies and even meta-analyses such as these on the topic of changing the way children’s genitals look/function?
9. What do you find to be the most convincing reason not to alter the genitals of one’s children and/or the children of others?
10. In the United States, a general legal and ethical standard when dealing with children is the ‘best interests standard’ wherein “the best interests of a child are determined by judicial and quasi-judicial decisions in individual cases, rather than arising from an established heuristic that would almost always predict the decision prospectively.” Three key Supreme Court cases triangulate the balance interests of a child against parental beliefs and rights: Meyer v. Nebraska (1923); Pierce v. Society of Sisters (1925); and Troxel v. Granville (2000). How do you think the ‘interests’ of children ought to compared against the ‘rights’ of parents?
11. To what degree ought we as citizens of this nation and/or budding biomedical professionals respect cultural traditions of our centuries-long multicultural experiment? If someone told you they wanted to cut the tip of child’s penis off and have a leader in their community suck the blood off, with his mouth, all because it said somewhere that “circumcis[ing] the flesh of your foreskin […] shall be a token of the covenant betwixt” the gods and their community, what would you think? If that community held that all eight day olds “must needs be circumcised” lest his “soul shall be cut off from his people”, what would you think? If they told you that a ninety-nine year old man cut off a portion of his penis and a portion of the penis of his thirteen year old son that same day, because he heard the gods telling him that such a genital alteration would “make thee exceedingly fruitful” and “indeed” lead to “a child be[ing] born unto him that is an hundred years old”, what would you think? Do you think that is a practice we, ourselves, living the noble lives of the good citizens of the Great Society, ought to adopt as our own and that of [y]our future children?
12. If we didn’t circumcise children, do you think we would have circumcised adults?
On mental health
1. What does it mean to be healthy mentally?
2. From whence arises the stigma(s) of mental health?
3. Is there something that is meant by “mental health” that has no physical (i.e., anatomical, physiological, biology, chemistry, atoms, quarks, gluons) correlate? Put differently, do all “mental disorders” correspond to some set of “physical disorders”, with no exception?
4. Must a diagnosis of health have both validity and utility to be used by physician/healthcare provider/healer/psychiatrist?
5. Five criteria have been generally agreed upon to establish the validity of psychiatric diagnoses: (1) clinical description, (2) laboratory studies, (3) delimitation from other disorders, (4) follow-up studies, and (5) family studies. Are these sufficient?
6. Kendell and Jablensky note that “Even though the authors of contemporary nomenclatures may be careful to point out that “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder” (DSM-IV, p. xxii), the mere fact that a diagnostic concept is listed in an official nomenclature and provided with a precise, complex definition tends to encourage this insidious reification.” To what extent can we avoid “pathologizing” disorders with misclassification?
7. Szasz asserts, somewhat boldly that, “[t]he belief in mental illness, as something other than man’s trouble in getting along with his fellow man, is the proper heir to the belief in demonology and witchcraft. Mental illness exists or is “real” in exactly the same sense in which witches existed or were “real.”” Do you agree with his assertion?
8. “The term “mental illness””, Szasz says, “is widely used to describe something which is very different than a disease of the brain. Many people today take it for granted that living is an arduous process. Its hardship for modern man, moreover, derives not so much from a struggle for biological survival as from the stresses and strain inherent in the social intercourse of complex human personalities.” Going on further to note that the very “concept of illness, whether bodily or mental, implies deviation from some clearly defined norm.” [Emphasis in original.] Does such “abnormalization” add to our problems?
9. How ought we be mentally healthy?
On replicability of medical studies
1. Must (medical) science be replicable?
2. Pashler and Harris address three (3) general arguments made against the replicability crisis in science:
3. The adoption of a low alpha level (e.g., 5%) puts reasonable bounds on the rate at which errors can enter the published literature, making false-positive effects rare enough to be considered a minor issue;
4. Though direct replication attempts are uncommon, conceptual replication attempts are common—providing an even better test of the validity of a phenomenon; and
5. Errors will eventually be pruned out of the literature if the field would just show a bit of patience.
6. Do you believe the mechanisms currently in place are sufficiently self-correcting or should something be done to compensate for possible inadequacy?
7. As Begley and Ioannidis point out, “The estimates for [scientific[ irreproducibility based on [] empirical observations range from 75% to 90%. These estimates fit remarkably well with estimates of 85% for the proportion of biomedical research that is wasted at-large.” If so much of our time and efforts are wasted, why put any (or much) of our time/effort into these endeavors?
8. The cost of medical care has ballooned to over $10,000 per person (~3.2 trillion, 16.9% U.S. GDP), the average life expectancy in the United States has declined year-over-year, and medical technologies – rather than decreasing in cost with scale and history – seem to get more expensive by the day (note the 700% increase in an EpiPen over the past decade). All the to ask, is it (at) all worth it?
9. The rate of positive results in psychological science (as in many biomedical fields) hovers between 90% to 100%, giving the (false) impression that 90% to 100% of the experiments yield such results. Given that most ends in failure, should we publish negative results? Should they get the same space on the page?
10. Have you noticed that you get invitations to a lot of junk journals? How can we address that scourge?
11. The Open Science Collaboration, in attempting to replicate the results “100 experimental and correlational studies published in [] psychology journals”, found that “[a] large portion of replications produced weaker evidence for the original findings despite using materials provided by the original authors, review in advance for methodological fidelity, and high statistical power to detect the original effect sizes”. Will there always be the selective bias for “better than average” when publishing that can only be routed out via regression to the mean via replication?
12. How can we incentivize (and possibly fund) medical/scientific reproduction?
13. Should taxpayers have to pay to repeat experiments? How many times?
On extinction
1. We began this year’s discussions by asking ourselves “to what extent do our brains determine our ethics?” to which myriad answers tended towards “a great deal”. What are we to make of a time when every single one of those brains is gone
2. Question 1 asks about a time when our brains are absent. What about spaces in which they are? Must one be moral on Mars?
3. Question 2 asks about absence in time and space. What if we were to replace it with mere sparsity? That is, what effect does the density of human beings have on those human beings’ (ideal) morality?
4. Is it better to have more extinctions or fewer? More de-extinctions or fewer?
5. Do human beings (and/or their ethical equivalents) have an obligation towards species stewardship?
6. Is there an alternative to extinction?
7. On the brink of species wide extinction, would you eat another human being to survive?
8. Would you want to survive a near human extinction?
9. Human extinction as a result of human action is known as “omnicide.” Could there ever be a time in which a species like ours should commit omnicide?
10. “By the year 2050,” according to the Pew Research Center (2010), “41% of Americans believe that Jesus Christ definitely (23%) or probably (18%) will have returned to earth. However, a 46%-plurality of the public does not believe Christ will return during the next 40 years. Fully 58% of white evangelical Christians say Christ will return to earth in this period, by far the highest percentage in any religious group.” How ought we to make policy when 2/5ths of the population believes armageddon is just around the corner?
11. How important is it that human beings prevent extinctions?
12. Who are you? And, if you will one day be extinct, does it matter?