Is “My Patient’s Agent” Always Justified?

Kelsey Berry

Is a physician always justified in acting as his or her patient’s agent?

This question is familiar to clinical and population-level bioethicists alike, though I hesitate to say that it is age-old. There are a variety of ways to approach a response to this question, as evidenced by extensive treatment of this topic in the philosophical and bioethics literature (which I will not survey here). One popular approach involves raising candidate circumstances that may justify deviations from the principal-agent relationship that obtains between physicians and patients* – for instance, ethicists might consider whether a physician is justified in deviating from acting as his or her patient’s agent under circumstances in which (a) the action that is in the best interest of the patient conflicts with the action that in the best interest of the population health, (b) the action that is in the best interests of the patient requires inefficient use of community resources on some criteria, or (c) what the patient perceives to be in his or her best interests conflicts with what the physician recommends, etc. This list is woefully inexhaustive, but it highlights a theme in this thread of argumentation. In each scenario, we’re invited to accept the initial assumption that the physician is justified, if not all of the time, at least most of the time, in acting as his or her patient’s agent. Then we are led to consider whether the candidate circumstances raised qualify as an exception to this rule.

The often-unarticulated premise, that the physician is typically justified in acting as his or her patient’s agent, is not without philosophical support from several prominent theories. We also have pragmatic reasons to begin with this premise, for there are few specific actors (to whom we can easily point) that compete with the patient for a principal-agent relationship of the type that obtains between a physician and his or her patient. Of course, other patients under care are obvious contenders, as are other potential patients. Though adjudicating between a physician’s obligations to both existing and potential patients raises interesting issues, the conflicts these principal-agent relationships give rise to still trade on the basic assumption that the physician has reason to maintain the basic fiduciary relationship in most circumstances. Continue reading

Sex Selection or Gender Selection? Queering the Ratio Question

I am at a fantastic event at Yale I co-organized on Intersections in Reproduction: Perspectives on Abortion, Assisted Reproductive Technologies, and Judicial Review with some amazing scholars present and excellent papers being presented. Like many people who have thought about sex selection, I would have imagined I have thought through most of the issues from most perspectives. What I love about these gatherings is that they always prove me wrong.

Today two very interesting questions were raised about a common argument raised about sex selection, the risk that it will result in unbalanced sex ratios. Our discussion, I would say, “queered” the typical claim in two interesting ways, and I am curious what others think (to be clear these were my thoughts on questions raised, not putting words in their mouths).

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Biomarker Epistemology, Cognitive Decline, and Alzheimer’s Disease

By Matthew L Baum

This past Sunday, a group of researchers reported in the journal, Nature Medicine, a preliminary technique that uses variation in blood levels of 10 fats to predict the likelihood that elderly individuals would develop mild cognitive impairment (MCI) or Alzheimer’s Disease in the following 2-3 years. The sample size was small and the results may not generalize beyond the narrow age-range and demographics of the study group (i.e. the assay is far from ready for “prime time”), but the study is an important first step towards a lower cost (vs PET imaging) and less invasive (vs spinal tap) predictive biomarker of cognitive decline*. Its publication has also triggered a flurry of discussion on possible ethical ramifications of this sort of blood biomarker. I will not attempt to address these ethical issues specifically here. Rather, I seek to highlight that how ethically troubling one views the technology to be may depend partly on the sort of knowledge one thinks these biomarkers reveal (applied epistemology at its best).

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Limits of Technological Solutions to Moral Problems

By Matthew L Baum

In my last blog post, I suggested that we consider incentivizing scientists and engineers to develop technologies that side-step ethical dilemmas entangling certain current technologies. I highlighted that these morally modifying technologies 1) neither resolve a moral debate nor do they take a side, 2) usually do not function empirically better than existing technology, and 3) make a moral dilemma less practically problematic by providing a technological work-around. I highlighted induced pluripotent stem cells, blood recirculators, and fixed-time ventilators as three examples of morally modifying technologies. But when is it a bad idea to encourage the development of morally modifying technologies?

In response to an excellent comment on that post by Joanna Sax, I would like to extend my initial description of technological solutions to moral problems to a discussion of their limits and the potential problems that might accompany them. I will begin here with the three externalities Joanna suggested and start a discussion on how they might be avoided.

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TOMORROW: Frances Kamm’s Bioethical Prescriptions: Book Talk and Panel Discussion

Please join us on February 27 at 2:00pm in Wasserstein 1019 at the Harvard Law School as we launch Professor Frances Kamm’s latest book, Bioethical Prescriptions: To Create, End, Choose, and Improve Lives (Oxford University Press, January 2014). The book showcases Professor Kamm’s articles on bioethics as parts of a coherent whole, with sections devoted to death and dying; early life (on conception and use of embryos, abortion, and childhood); genetics and other enhancements (on cloning and other genetic technologies); allocating scarce resources; and methodology (on the relation of moral theory and practical ethics).

Panelists include:

  • Frances Kamm, Littauer Professor of Philosophy & Public Policy, Harvard Kennedy School of Government; Professor of Philosophy, Faculty of Arts & Sciences, Harvard University; Former Senior Fellow, Petrie-Flom Center
  • Norman Daniels, Mary B. Saltonstall Professor of Population Ethics and Professor of Ethics and Population Health, Harvard School of Public Health
  • Thomas (Tim) Scanlon, Jr., Alford Professor of Natural Religion, Moral Philosophy, and Civil Polity, Faculty of Arts & Sciences, Harvard University
  • Moderator: Christopher T. Robertson, Visiting Professor of Law, Harvard Law School; Associate Professor, James E. Rogers College of Law, University of Arizona

This event is free and open to the public. For questions, please contact petrie-flom@law.harvard.edu or 617-496-4662.

Sponsored by the Petrie-Flom Center for Health Law Policy, Biotechnology, and BioethicsEdmond J. Safra Center for Ethics at Harvard University; and the Countway Library of Medicine at Harvard Medical School; with support from the Oswald DeN. Cammann Fund.

Public Lecture at Radcliffe Institute “The Ethicist’s and The Lawyer’s New Clothes: The Law and the Ethics of Smart Clothes” now Available on Youtube

As part of a public lecture series at the Radcliffe Institute on “Smart Clothes” I delivered a public lecture entitled “The Ethicist’s and the Lawyer’s New Clothes: The Law and Ethics of Smart Clothes.” The lecture is now available for viewing on youtube. As the promotional materials described the lecture: “From enhanced exosuits for members of the armed services to clothing that spies on you, I. Glenn Cohen focuses on legal and ethical issues pertaining to the future of smart clothes.” While CNN coverage of the lecture focused on the surveillance aspects of these clothes, I think the discussion of exosuits and enhancements may be more interesting to BOH readers.

2/27: Frances Kamm’s Bioethical Prescriptions: Book Talk and Panel Discussion

Please join us on February 27 at 2:00pm in Wasserstein 1019 at the Harvard Law School as we launch Professor Frances Kamm’s latest book, Bioethical Prescriptions: To Create, End, Choose, and Improve Lives (Oxford University Press, January 2014). The book showcases Professor Kamm’s articles on bioethics as parts of a coherent whole, with sections devoted to death and dying; early life (on conception and use of embryos, abortion, and childhood); genetics and other enhancements (on cloning and other genetic technologies); allocating scarce resources; and methodology (on the relation of moral theory and practical ethics).

Panelists include:

  • Frances Kamm, Littauer Professor of Philosophy & Public Policy, Harvard Kennedy School of Government; Professor of Philosophy, Faculty of Arts & Sciences, Harvard University; Former Senior Fellow, Petrie-Flom Center
  • Norman Daniels, Mary B. Saltonstall Professor of Population Ethics and Professor of Ethics and Population Health, Harvard School of Public Health
  • Thomas (Tim) Scanlon, Jr., Alford Professor of Natural Religion, Moral Philosophy, and Civil Polity, Faculty of Arts & Sciences, Harvard University
  • Moderator: Christopher T. Robertson, Visiting Professor of Law, Harvard Law School; Associate Professor, James E. Rogers College of Law, University of Arizona

This event is free and open to the public. For questions, please contact petrie-flom@law.harvard.edu or 617-496-4662.

Sponsored by the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics; Edmond J. Safra Center for Ethics at Harvard University; and the Countway Library of Medicine at Harvard Medical School; with support from the Oswald DeN. Cammann Fund.

Prioritizing Parks and Patients

By Nathaniel Counts

During the government shutdown in October 2013, a battle in part over the future of healthcare reform, a non-negligible amount of media attention focused on the shutdown of public parks.  Perhaps because the parks were the least expected casualty of the shutdown, or the most ludicrous – many are, after all, large outdoor spaces that functioned for millions of years before there were federal funds for them – Americans were frustrated or amused that they could not walk around outside some places because politicians in D.C. could not agree on a budget.

The healthcare reform debate pitted those who believed that everyone should have health insurance or that access to healthcare was a right against those who believed that health spending was already too high or that everyone does not have a right to access to healthcare.  In a world of infinite resources, where everyone could have complete access to healthcare without anyone having to give up anything of their own, it is difficult to imagine that anyone would say that there should not be universal access to healthcare, that some are not deserving of the service.  It would be strange to require a threshold public showing of effort to obtain health insurance through employment if there was no cost to giving the healthcare – if fairness is an issue, as it appears to be a concern for some, there are certainly other services that could be denied.  It is likely that for most the fairness concern only becomes salient in the face of resource constraints where these same funds could fund other programs or allow others to pursue their interests.

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Now Available: Bioethical Prescriptions by Frances M. Kamm

Bioethical Prescriptions: To Create, End, Choose, and Improve Lives

By Frances M. Kamm, Littauer Professor of Philosophy and Public Policy at Harvard’s Kennedy School of Government, Professor of Philosophy in the Harvard University Faculty of Arts and Sciences, and Petrie-Flom Academic Fellow alumna

This book is a collection of Frances M. Kamm‘s articles on bioethics, which have appeared over the last twenty-five years and which have made her among the most influential philosophers in this area. Kamm is known for her intricate, sophisticated, and painstaking philosophical analyses of moral problems generally and of bioethical issues in particular. This volume showcases these articles – revised to eliminate redundancies — as parts of a coherent whole. A substantive introduction identifies important themes than run through the articles. Section headings include Death and Dying; Early Life (on conception and use of embryos, abortion, and childhood); Genetics and Other Enhancements (on cloning and other genetic technologies); Allocating Scarce Resources; and Methodology (on the relation of moral theory and practical ethics).

Peter Singer on Animals and Ethics

Video of the lecture is now available online.

By Chloe Reichel

Last Friday, Princeton ethicist Peter Singer joined Petrie-Flom for a lecture on “Ethics and Animals: Where are we now?” Singer began his talk with a historical look back at various religious and philosophical views of the relationship between humans and animals. He traced the lineage of thought from the view of dominion, which entails the idea that man has been granted free reign over animals by God (first found in Genesis, and also espoused by Aristotle); to the notions developed by Thomas Aquinas and Immanuel Kant, who believed that abuse of animals was not itself morally problematic except to the extent that it may inculcate bad habits in those who practice it; to the early English Utilitarians, who recognized the capacity of animals to suffer; to Charles Darwin, whose groundbreaking theory of evolution muddied previous distinctions between human and non-human animals.

Singer went on to discuss modern views of proper animal treatment. He articulated the prevailing view that humans have some obligations to treat animals well and without cruelty, but that human interests exceed those of animals. Singer then laid out his main principle regarding the treatment of animals—that of equal consideration of interests. In other words, the interests of non-human animals should be considered equally with human interests. To favor human interests over animal interests is a speciesist stance, similar in nature to other –isms, like racism and sexism, and equally morally indefensible, in Singer’s view. Singer carefully noted that while equal consideration of interests would mandate better treatment of many animals, such as those raised as livestock, his principle does not imply that humans and animals should receive the same treatment.

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A disenfranchising effect of the right to health?

By Julian Urrutia

Human rights embody the humanist egalitarian principle that all human beings are morally important, and that they are morally important simply because of their humanity. Princes and paupers, bankers and bums, women and men . . . we’re all subjects of human rights that are not contingent on anything other than our humanity.

There is widespread agreement that the rise of humanism is one of the most important milestones in the history of moral progress. However, it also clear that the rise of humanism did not, by itself, bring us all the way down the path of progress to where we are today: throughout colonial history, for example, humanism failed to deliver us from outrageous discrimination when the boundaries of humanity were delineated too narrowly.

Humanists are just as prone to inhumane conduct when they fail to recognize other’s humanity. When we determine what is human (and must therefore be treated with respect), we tacitly also determine what is un-human (and can therefore be exploited). As Carl Schmitt put it “Given the coherence of this two-sided aspect of humanity, it should be remembered that Bacon opposed the axiom homo homini deus to that of homo homini lupus.” (The nomos of the earth, 1950)

That’s why contemporary, liberal constitutions that recognize human rights are so great. All people are recognized as being equally human, and therefore equally subjects of human rights. This is certainly a form of moral progress. However, narrow human rights-based approaches to politics, legislation and policy-making can have similarly perverse consequences as narrow forms of humanism. Instead of delivering us from outrageous discrimination, marginalization and exploitation, a narrow focus on rights might confine us to them. For example, there is growing evidence that human-rights-based legislation and litigation often fails to achieve an effective enjoyment of the right to health to among those who need it most. Even more troubling is the possibility that, sometimes, rights-based approaches not only have little positive effects, but might in fact lead to further marginalization and disenfranchising of the poor.

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Economics, Morality, and End of Life Care (Part II)

By Nathaniel Counts

[Part I is here.]

First, let us consider whether opting for end of life care is morally problematic on its own, without reference to its resource costs.  Certainly wanting to live longer on its own is not morally problematic in our society – we do not consider exercise or healthy eating wrong and many tout it as a social good.  On the other hand, wanting to die early, for example through suicide, has traditionally been viewed as a moral wrong and is illegal in many areas.  It similarly seems that there is nothing problematic with wanting even a short amount of additional time, even with arguably compromised quality.  If end of life care involved only pressing a button for an additional day of life, even in severe pain, it is unlikely that anyone would consider the pressing of the button good or bad morally.

It may be that opting for intensive curative end of life care is irrational, even if it is were cost-free.  If palliative and hospice care would have led to greater overall life enjoyment for that time period, regardless of its length, then opting for the intensive treatments would not have been the right choice, even for that individual.  This does not make it immoral however – individuals are generally allowed to make choices that are worse for themselves as long as they do not violate norms, and the pervasiveness of these intensive treatments at end of life may indicate that they are in fact the norm.

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10/17 lecture, “Which Careers Do the Most Good?”

You’ll spend over 80,000 hours of your life working—you should make the most of them. But if you want to make a difference, what should you do? Work for nonprofits? Try to change policy? Find a malaria vaccine? Go into finance and give it all away? 

 Which Careers Do the Most Good?

a lecture by William MacAskill

Founder, 80,000 Hours and the Centre for Effective Altruism

 Thursday, October 17, 7:30PM

Science Center A

please RSVP here

80,000 Hours founder and Bill of Health guest blogger William MacAskill will tell you about his organisation’s research into this question, and explain how it can help you find the career where you’ll have the biggest impact. You might leave with some surprising conclusions.

William MacAskill is the founder of Oxford’s Centre for Effective Altruism and of 80,000 Hours, a personal advisory service on using your time to do the most good. Formerly a Fulbright scholar at Princeton University, and currently a PhD candidate at Oxford University, he has been featured on BBC News On-line, The Today Programme, NPR, CNBC and The Washington Post. Between them, his non-profits have raised over $3 million for the most cost-effective charities, with a further $130 million pledged.

Educating ELSI

By Matthew L Baum

“Examining the intersection of law and health care, biotech & bioethics”

- the subtitle of the Bill of Health blog.

I approach this intersection like many of my fellow students: outfitted with the tools and spectacles of a specific discipline. Whether that is health law, policy, medicine, engineering, philosophy, genetics, or cognitive science, none of us have had the ideal education that would enable not only an approach, but an inhabitation of this intersection.

What would that ideal education be? To consider the ideal education for a citizen, Rousseau conducts an elaborate thought experiment giving that education to a fictional young boy named Emile (hence the title of the work: Emile, or On Education). Let us begin a similar experiment to consider the ideal education for someone to inhabit the intersection of law and health care, biotech & bioethics.

Let’s call our fictional young person, ELSI.

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The Whitehall Studies and Human Rights

By Nathaniel Counts

Professor M. G. Marmot et al. conducted two studies, Whitehall I and Whitehall II, in which they studied morbidity and mortality in the British civil service sector in the 1960s and the 1980s.  British civil servants are under the same plan with the National Health Service, so the studies controlled for access to healthcare.  But what these famous studies found was that morbidity and mortality still correlated with income.  Further research and analysis has concluded that it is job satisfaction and social status more so than income that determines health outcomes.  Does an individual feel like she has control over the work she does?  Is she stressed out a lot?  How does she feel about herself in relationship to those around her?  Does she feel healthy?  Does she like her life?  Those who feel in control of their lives, feel valued by society, and feel good about their health actually end up living longer and healthier lives on average compared to those who don’t share these beliefs.

Deep structural inequalities exist in every society, and social justice groups work toward greater social equality everywhere.  Does the notion that social inequalities are hurting people in a physiological way change the way we feel about the mission of equality?  Is health so fundamentally different that individuals who accept economic inequality might mobilize over health inequality?  It is certainly implicated in the right to a dignified life, a concept underpinning the human rights movement as whole.  It may be though that the social inequalities on their own terms are an equal evil, because the limitations on one’s abilities to pursue her interests are as inimical to human rights as worse health.

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Upcoming Event: Larry Temkin speaking on “Global Poverty: Why Should We Care?”

Want to know more about the ethics of aid? Want to hear the inspiring talk that’s convinced students across the northeast to take global poverty seriously? Join Harvard High-Impact Philanthropy for our first talk of the semester with ethicist Larry Temkin! RSVP here for

Global Poverty: Why Should We Care?

a talk by Larry Temkin

 Thursday, September 12

8 PM

Science Center E 

Each year, millions of children die from readily preventable causes. This raises an obvious and poignant question. What, if anything, should our reaction be to the apparent fact that each one of us could easily prevent the deaths of many innocent people who are not responsible for their unfortunate plight?

Larry Temkin is a professor of philosophy at Rutgers. He holds a Ph.D. from Princeton and is the author of “Rethinking the Good: Moral Ideals and the Nature of Practical Reasoning” (OUP, 2012) and “Inequality” (OUP, 1993). He has received seven fellowships and eight major teaching awards.

The lecture will take place in Harvard’s Science Center, Hall E (in the basement), and will be followed by a Q&A period.

This lecture is also the kick-off event for our Philanthropy Fellowship, a new program this year. Fellows will attend talks and private dinners/receptions with many speakers on effective altruism, including Princeton ethicist Peter Singer, Skype co-founder Jaan Tallinn, and cosmologist Max Tegmark. At the end, we’ll pick a cause that we think is important and raise funds for it ourselves, to be matched by an anonymous donor. To apply, fill out this short application by Sunday, Sep. 15!

Does Individuality Save Eugenics?

Dov Fox

So asks medical historian Nathaniel Comfort in today’s Scientific America, echoing Ross Douthat’s New York Times inquiry into Eugenics, Past and Future. Comfort and Douthat are skeptical of the view, articulated by an emerging class of academics, that individual parents should use reproductive technologies to select or enhance certain genetic traits in their children.

“Hitler gave eugenics a bad name,” is how I expressed this view in the first scholarly examination of that ideal, “but there is nothing objectionable as such about the eugenic ambition to produce people of a particular type.” Comfort illuminates two centuries of developments in the medicine, society, and culture of “eugenics.” But he offers little analysis of why individuality fails to “save” the new eugenics, beyond his two assertions, heard often in these debates, that it risks “unforeseeable consequences” and might “dissolve into a species of collective eugenics.” What more might be said in support of this second suggestion, that a political theory that privileges freedom, equality, and fairness cannot accommodate individual choice about offspring characteristics?

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Chimpanzee Research and Animal Rights

Last month, two federal agencies took steps that together may come close to ending research on chimpanzees in the United States.

First, the Fish and Wildlife Service (FWS) proposed to list all chimpanzees, including those in captivity, as endangered.   (Currently, only wild chimpanzees are listed as endangered, while captive chimpanzees are listed as threatened).  This would require that almost all research on chimps be done with a permit, and the agency has suggested that these permits may only be granted for research that enhances the propagation or survival of the chimpanzee species.

Second, the National Institutes of Health (NIH) decided that more than 300 of the approximately 360 research chimpanzees that it owns will be retired and moved into sanctuaries.  This decision was based on an Institute of Medicine report finding that most current research on chimpanzees is unnecessary, and that chimps should be used only when public health is on the line, no other animals are appropriate, and ethical experiments on humans are not possible.  On the basis of these findings, the NIH is planning to keep a colony of about 50 chimps available for research that is not possible in any other way.

Comparing these two agency actions raises an interesting question:  In evaluating whether research on chimpanzees is ethical, does it matter whether the beneficiary of the research is the chimpanzee or the human species, and if so, on what grounds?   Continue reading

Anthony Weiner, Sexting, Medicalization, and Legal Moralism, Or (To Be Provocative) “What’s So Wrong About Sexting?”

Like most people, I am both amused and shocked by the latest Anthony Weiner sexting revelations and scandal. It is like a car crash where it is hard to look away even though you know you should.

Most germane to Bill of Health’s readership, I am fascinated by the “medicalization” of Weiner’s behavior by some sectors, this CNN clip with therapists is to me a good example. The words “sexual addiction,” “exhibitionism,” comparisons to alcoholism, “not in control of his actions” are bandied about. This to me has fascinating echoes of the medicalization of homosexuality in the 70s and also the medicalization of the choices made by the transgendered. There like here the strategy is fraught. The patient has to perform the “sick role” as a way of excusing himself from responsibility and/or earn governmental support.

The comparison, though, prompts the following question (and yes I am purposefully trying to be provocative so take it with the appropriate grain of salt): As with homosexuality, what is the underlying problem here that calls out for condemnation? Is this merely legal moralism rearing its head again? What’s so Wrong About Sexting?

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Bioethicist Edmund Pellegrino Has Passed

On June 13, 2013 Dr. Edmund Pellegrino died at the age of 92.  (Obituaries are available here and here.)  For bioethicists this is a time to reflect, but in particular affiliates of the Petrie Flom Center will recall that one of the very first events that that the PFC hosted was a distinguished panel to discuss the concept of human dignity in bioethics, featuring Martha Nussbaum, Nick Bostrom, Dan Brock, and Edmund Pellegrino.  (I recall attending the event as a student.)  The webcast is still available, at the bottom of the page, here.  This event commemorated the release of the Presidential Bioethics Advisory Commission’s new book on the topic of human dignity.  Dr. Pellegrino chaired the PBAC, and his contribution to the book is available online here.

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