Politics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

This year’s presidential debates drew attention to gun violence in Chicago, as well as the (merely?) short-term reversal in the decades-long decline in US violent crimes. In the process, it reignited the smoldering political dispute over whether gun violence is a public health problem.

Every year, US hospitals and morgues see a stream of around 32,000 preventable deaths and 67,000 preventable injuries from guns. Indeed, hospitals and morgues are where one finds the consequences of public health problems. Yet, Surgeon General Murthy nearly had his Senate confirmation blocked by National Rifle Association lobbying in 2014, because he had once Tweeted: “Tired of politicians playing politics w/guns, putting lives at risk b/c they’re scared of NRA. Guns are a health care issue.” The debate continues.

bullet hole in mirror

Image description: A bullet hole in a mirror. There are cracks extending out from the bullet, and a mirror shows the reflection of blue sky with clouds. Image source: Flickr user Jo Naylor.

Neglecting the medical and public health aspects of gun violence is a tragic lost opportunity to understand and respond to gun injuries and deaths. For example, only some jurisdictions require special permits to purchase handguns, but public health data indicate that adopting such polices helps to prevent both suicides and homicides. Thanks to NRA lobbying (again), the Centers for Disease Control is prohibited from doing any research that serves “to advocate or promote gun control.” The researchers who dare to work in the under-funded field “face emotional and financial demands” (Pettit 2016). Meanwhile, the 14-year-old National Violent Death Reporting System, the federal database for gun violence, still has zero data from ten states.

“Health in all policies”
Though its hands are partly tied, the CDC endorses the mainstream public health position that we must promote “health in all policies.” I.e. gun policies are (failed) health polices because the US continues to be plagued by gunshot wounds. Health is shaped by all manner of different causes, including laws and policies that were not explicitly designed to be health policies. For example, local commercial/residential zoning laws are public health issues. Why? Because they control the distribution of supermarkets, fast food restaurants and liquor stores in each neighborhood, affecting what the local population can/does eat and drink. Poorly designed city zoning laws are public health problems because they keep nutritious foods inaccessible and less nutritious alternatives abundant.

‘But, if guns are a public health problem then that would mean…’
The notion of promoting “health in all policies” has—surprisingly—faced some of the staunchest resistance from professional public health ethicists. Perhaps best illustrating the divide, the American Public Health Association has co-signed a letter with 57 other medical and public health organizations, calling for expanded gun violence monitoring data and gun control measures. Meanwhile, the ethics section editor of the association’s journal has opposed adding crime and other social ills “to the public health agenda”—doing so would make “public health… so broad as to be meaningless” (Rothstein, 2009). Similarly, an influential public health justice text resists calls to treat crime, war and various other social problems as public health problems, arguing that despite the desirability of a “broad scope of public health,” recognizing them as such would leave public health with “no real core, no institutional, disciplinary or social boundaries” (Powers and Faden, 2006).

Outside of the bioethics community, physician and free-market economics advocate Paul Hsieh echoes the idea that treating guns as a public health problem makes ‘public health’ unrecognizably broad, and it also “diverts us from genuine public health threats.” He scoffs that next we could even start thinking of issues like minimum wage and poverty as public health problems. Funny he should mention it; in fact, small differences in income are associated with drastic differences in life expectancy. An American man in the richest 1% has a life expectancy 14 years longer than a man in the poorest 1%! We now know that the causes of death and illness are complex and far-reaching—we must resist the urge to squeeze “public health” until its boundaries are neatly compressed and its efforts are hopelessly hobbled.

When the American Medical Association issued a statement in July that it considers guns “a public health crisis,” Keith Ablow, a member of the “Fox News Medical A-Team,” retorted that we don’t really know how many homicides could be prevented with gun control. But then he went on to say “they’re going to eat away at gun rights with medical research.” Like the NRA’s efforts to restrict CDC gun violence research, it appears that Ablow is very worried about what gun violence public health data would reveal. It would seem that he finds gun violence research more frightening than… gun violence.

It doesn’t have to be this way
But isn’t it foolish to think the medical and public health communities could help with a massive social problem like gun violence? It’s the reply I hear most often, and it always strikes me as an odd moment of pessimism. Odd, that is, in light of the widely-embraced moonshots of eradicating smallpox from every population on the planet (done!), and spending incredible sums to find treatments for the innumerable and mysterious varieties of cancer (optimistic!). Why do I so often see resigned shrugs when I insist we can make public health progress in the problem of Americans using guns to kill ourselves and each other almost five times more often than our Canadian neighbors? After all, when pediatricians talk to parents about gun safety during a child’s checkup, the parents become more likely to use a gun lock, which substantially reduces risks of gun accidents and gun suicides. Sounds like a good start.

We can do better, and some of my bioethics colleagues have been producing excellent work, making the case for why the deep-rooted social problems (violence, poverty, etc.) causing our public health ills must become national public health priorities, and also priorities for individual physicians. The first step though, is admitting that the roughly 100,000 people shot in the US each year each have gun violence medical problems, and that we in the US have a gun violence public health problem.

Sean Valles photoSean A. Valles, PhD, is an Associate Professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. He is a philosopher specializing in ethical and evidentiary issues in contemporary population health sciences.

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Dr. Fleck presents at Michigan State Medical Society Conference on Bioethics

Len Fleck photoCenter Professor Dr. Len Fleck presented at the 20th Annual Michigan State Medical Society Conference on Bioethics, held on November 12, 2016 in Ann Arbor. The theme of the conference was “Ethical Issues in the Pharmaceutical Industry: Current Controversies and Challenges.” Dr. Fleck’s presentation was titled “Curing Hepatitis C: Whose Cost? Whose Responsibility?” Dr. Fleck discussed several ethical and policy issues around the drug Sofosbuvir, otherwise known as the $1000 pill. This is a drug that requires 12 weeks of treatment at a cost of about $100,000.

There are about 3.2 million Americans who are Hepatitis C (HCV) -positive. About 30% of those individuals do not know they are HCV-positive. Unlike most drugs on the market today, this drug is actually curative for up to 95% of patients treated. But the cost of treating all Americans who are HCV-positive at current prices would be $300 billion.

About 800,000 HCV-positive individuals are covered by Medicaid. No Medicaid program can afford to provide this drug to all HCV patients without a massive shifting of resources that would be neither just nor justified. The relevant medical facts are that HCV could result in life-threatening liver problems for as many as 70% of these patients, but these outcomes would typically be ten to thirty years after infection (if ever). Many of these individuals will die of something else, which is one reason why Medicaid wants to avoid paying to treat these individuals. Also, the Medicaid population “churns” a lot from year to year, primarily because many individuals are successful in getting jobs and getting out of poverty. Consequently, someone else would become responsible for paying for the drug (if they have a job with employer-sponsored insurance). To limit costs most Medicaid programs require recipients of the drug to have advanced liver fibrosis, Stage F3 or F4. This is ethically problematic because Sofosbuvir will cure their HCV but not stop disease progression. Consequently, 7% of F3 patients will die of complications of liver disease and 22% of F4 patients will suffer that fate. This is not at all ethically or medically congruent with the way heart disease or cancer or other chronic degenerative conditions would be treated in these patients.

Dr. Fleck concluded three things: (1) The price of Sofosbuvir is unconscionable; there is no ethical or economic justification for that price. (2) Medicaid programs would be on sounder ethical ground if treatment were initiated no later than F2 where 3% of patients would still die of liver complications. (3) The deeper source of the ethical issues in this case is the fragmentation of the American system for financing access to needed and effective health care. That fragmentation encourages the diffusion and disavowal of responsibility for meeting the health care needs of these patients.

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Dr. Cabrera presents at 10th annual International Neuroethics Society Meeting

cabrera-crop-2015On November 10-11, 2016, Center Assistant Professor Dr. Laura Cabrera attended the International Neuroethics Society (INS) Annual Meeting held in San Diego, California. This year the INS meeting celebrated the 10th anniversary of the society, and it was a day and half of intense and engaging discussions of relevant neuroethics topics.

Dr. Cabrera presented a flash talk and a poster on “Neuroensanchamiento?: Perspectives and terms in the Latin American and Spanish Literature regarding neuroenhancement” (Colon-Ortiz and Cabrera), and also had another poster showcasing results from her S3 grant entitled “Psychiatric Deep Brain Stimulation: Recurrent and Neglected Ethical Issues” (Cabrera, Bluhm and McKenzie).

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Image description: Dr. Laura Cabrera with her poster “Psychiatric Deep Brain Stimulation: Recurrent and Neglected Ethical Issues.” Photo courtesy of Laura Cabrera.

The first day of the meeting started with the INS presidential address, which emphasized the fact that the society was celebrating its 10th anniversary. As part of this celebration a new logo for the society was presented. The keynote of the first day was given by Steven E. Hyman on “Emerging Genetics of Human Cognition and Behavior: New Challenges for Ethics and Policy.” After his engaging talk, there was the international ambassador session and breakouts with representatives from China, Japan, Europe and the US discussing the state of neuroethics in the brain initiatives within their respective countries. The first day closed with the public program on “Meet Tomorrow’s World: A Meeting on the Ethics of Emerging Technologies.” Panelists at this event covered topics ranging from the neurobiology of storytelling, social robots, privacy, virtual reality, moral enhancement, and brain stimulation.

The second day of the INS meeting started with a keynote plenary by Walter J. Koroshetz on “Neuroethics and the BRAIN Initiative.” Dr. Koroshetz highlighted the importance of the BRAIN Initiative in the context of other big American projects and its focus on exciting new discoveries and new technologies to better understand the brain. The following session was on “Mind-Brain and the Competing Identities of Neuroethics” with Paul Appelbaum, Tom Buller, Jennifer Chandler and Ilina Singh as panelists. This session explored three main questions: (1) is it important to discuss questions related to the status and identity/ies of neuroethics?, (2) are there avoidable pitfalls created by the multiple identities of neuroethics and can they be avoided?, and (3) what could INS do to help answer some of the issues discussed at the meeting?

Just before lunch there was the flash talk presentations, where nine selected top abstracts were given three minutes each to present. Dr. Cabrera presented, on behalf of her graduate student Celizbets Colon-Ortiz, the work they have been carrying out on cross-cultural neuroethics.

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Podcast: Dr. Cabrera on Human Enhancement, Communication and Values

cabrera-crop-2015Center Assistant Professor Dr. Laura Cabrera was interviewed for episode #13 of the podcast “Algocracy and the Transhumanist Project,” created by John Danaher. Topics discussed include human enhancement, communication and values, and Dr. Cabrera’s book Rethinking Human Enhancement: Social Enhancement and Emergent Technologies.

Visit this blog post to learn more about the episode and to listen to the interview.

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Bioethics for Breakfast: Compassionate Use: What Is in a Name?

bioethics-for-breakfastAnas Al-Janadi, MD, and Jennifer Carter-Johnson, JD, PhD, presented at the Bioethics for Breakfast event on November 17, 2016, offering perspective and insight on the topic, “Compassionate Use: What Is in a Name?”

Jennifer Carter-Johnson notes that The United States has a history of dangerous unregulated “medicines” that led to today’s drug regulations. Indeed, no drug is completely safe, and drug effects must balance safety against efficacy to win market approval for patients. Today’s drug regulatory process, in which 90% of drug candidates fail during clinical trials, and the potential desperation of end-stage patients requires that compassionate use balance protecting the public, encouraging new drug development and respecting patient autonomy. But Dr. Al-Janadi believes that we should think of this issue as an “early/expanded access opportunity” rather than “compassionate use.” One of his concerns is that there are presently lengthy delays in drug approval when drugs have shown some promising efficacy, thereby depriving patients of their benefit.

How do you believe a balance ought to be struck? Should there be public policies that reflect this balance? Or should this be left to the judgment of clinicians and patients, or the pharmaceutical industry? Does the current “right to try” legislation in many states need to be amended? These and other questions were addressed by the speakers and guests, creating a respectful and thoughtful discussion.

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Left to right: Len Fleck, Jennifer Carter-Johnson, Anas Al-Janadi, and Libby Bogdan-Lovis pose for a photo following the event. Photo courtesy of the Center for Ethics.

Anas Al-Janadi, MD
Anas Al-Janadi is Associate Professor and Section Chief of the Division of Hematology and Oncology in the Department of Medicine at the Michigan State University College of Human Medicine.

Jennifer Carter-Johnson, JD, PhD
Jennifer Carter-Johnson is an Associate Professor of Law at the Michigan State University College of Law and holds both a JD and a PhD in Microbiology. Professor Carter-Johnson uses her interdisciplinary training to study the intersection of law and scientific research.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
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Pharmacological and Neurosurgical Psychiatric Interventions: Through the Looking Glass

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera is the Team Leader on the project “Psychiatric Interventions: Values and Public Attitudes,” funded by the Michigan State University group Science and Society at State (S3). Dr. Cabrera’s team members are Dr. Robyn Bluhm of the Philosophy Department and Lyman Briggs College, and Dr. Mark Reimers of the Neuroscience Program and the College of Human Medicine.

home_1On October 28, 2016, Dr. Cabrera and team held the workshop “Pharmacological and Neurosurgical Psychiatric Interventions: Through the Looking Glass” as part of their S3 project. Participants included faculty, health professionals, researchers, and students from multiple institutions across the state.

The aim of the workshop was to bring together an interdisciplinary group of individuals with common interests, specifically in social and ethical issues within psychiatry. The workshop was useful as a way to obtain feedback regarding the pilot data that the team has been gathering and analyzing. Moreover, the workshop served as an opportunity to foster further collaborations and explore other grant proposal venues, as well as explore issues that need to be addressed regarding somatic psychiatric interventions.

The first session in the morning opened with two keynote presentations. First, Dr. Jed Magen, Associate Professor and Chair of the Department of Psychiatry, presented a talk entitled “Why We Don’t Know Much.” Dr. Magen addressed key issues related to pharmacological interventions in psychiatry, such as what the limits are of disease entities, the role of the pharmaceutical industry, and the importance of not only considering somatic psychiatric interventions, but also considering psychosocial approaches. The second presentation was by neurosurgeon Hayden M.K. Boyce of Spectrum Health, who spoke on “Ethical Considerations for DBS in Psychiatric Disorders.” Dr. Boyce’s presentation touched on five main issues: the complexity in deciding which areas to target, ethical treatment in trial, clinical trial design, issues connected to personality changes as well as issues around agency, and resource allocation.

During the question and answer session the discussion revolved around topics such as whether deep brain stimulation was particularly problematic in ways that pharmacological interventions where not, changes to self, and issues of uncertainty.

The second session presented the first part of the results of the project “Psychiatric Interventions: Values and Public Attitudes.” Dr. Bluhm talked about the aims, methods and results of the academic literature analysis. Session three covered the second part of the project results, in which Dr. Cabrera presented the aims, methods and results of the online public comment analysis. The final session transitioned to a large group discussion, in which the participants debated various relevant issues connected to somatic psychiatric interventions, such as the role of values and risk, the meaning of treatment refractory, and validation of the disorder. This last session also served as a space to discuss conceptual and practical issues related to how to move forward with the project.

To learn more about Science and Society at State and their funded projects, visit s3.msu.edu.

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Dr. Tomlinson presents at 3rd Annual Great Lakes Biorepository Network Scientific Meeting

tomlinson-crop-2016The 3rd Annual Great Lakes Biorepository Network (GLBRN) Scientific Meeting was held on October 28, 2016 at the University of Michigan in Ann Arbor. Center Director and Professor Dr. Tom Tomlinson spoke on “Preferences for Biobank Consent Policy are Sensitive to Concerns about Future Research Uses.”

The current research ethics framework gauges the level of ethical protections to the degree of risk to the participant. The lower the risk, the less stringent the requirements for informed consent; when the risk is virtually zero, as with the research uses of de-identified biospecimens and related clinical and demographic data, it is no longer research on a human “subject.”

This framework forgets why people donate their specimens and data to biobanks. They are not merely concerned with what later research will do to or for them. They are hoping their donation may do some good; and correlatively, assuming that it will do no wrong, in ways they would find morally concerning:

  • Some research might threaten a donor’s world view –such as research to better understand human evolution and history.
  • Some donors might be concerned by research that might lead to the stigmatization of others –such as research that looks at genes associated with violence.
  • Or some research may be contrary to the moral, cultural, or political values of the donor – such as research related to abortion or research leading to large commercial profits.

To emphasize the contrasts with the conventional framework, Dr. Tomlinson and his colleagues call these people’s non-welfare interests in later research uses of their donations.

In the talk Dr. Tomlinson presented evidence that such concerns affect people’s preferences among various biobank consent policies, drawn from both a national survey that his research team conducted in 2014 and a series of democratic deliberations held in 2015. The evidence shows that the more people are aware of the range of possible research uses of biobank donations that might be of concern to them or others, the more negative their attitudes are toward blanket consent. In this consent, a donor gives permission up front to any future uses that the biobank would allow, without any further consent or information provided. This is the most common form of biobank consent, but their research shows that a bare majority finds it “acceptable,” and a sizeable minority (38%) think it’s the “worst” option among those presented. Interestingly, the team found similar attitudes expressed toward specific, study-by-study consent, the option that gives each donor the most control over later research uses.

For more analysis of the national survey, see: De Vries RG, Tomlinson T, Kim HM, Krenz C, Haggerty D, Ryan KA, Kim SY. Understanding the Public’s Reservations about Broad Consent and Study-By-Study Consent for Donations to a Biobank: Results of a National Survey. PLoS One. 2016 Jul 14;11(7).

Dr. Tomlinson is an Executive Board Member of the Great Lakes Biorepository Network and Incoming President for 2017.

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