Bioethics for Breakfast: Medicare for All: What Should That Mean?

Bioethics for Breakfast Seminars in Medicine, Law and SocietyStacey Hettiger and Rick Murdock presented at the September 26th Bioethics for Breakfast event, offering perspectives and insight on the topic “Medicare for All: What Should That Mean?”

“Medicare for All” has become a contentious political slogan. Advocates for various versions of the slogan want to see everyone have access to needed and affordable health care. Critics see all versions of the slogan as unaffordable and hostile to individual liberty. Is compromise possible? Can we have some level of affordable health care for everyone in our society? Can this be accomplished in ways that are congruent with our most fundamental political values? Event speakers addressed these questions and more, inviting response and discussion from those in attendance.

This year’s Bioethics for Breakfast series centers on the theme “Is There a Cure for Our Sick Health Care System?”

About the Speakers

Stacey Hettiger
Stacey Hettiger is Director of Medical and Regulatory Policy at Michigan State Medical Society. Her responsibilities include developing materials, programming, and member communications in the areas of legal and regulatory compliance and State and Federal quality initiatives. This includes advocacy and outreach on issues affecting the delivery of health care such as HIPAA, physician payment models and incentives, and practice transformation. Prior to joining MSMS, Stacey worked for twenty years in the Michigan State Legislature.

Rick Murdock
Rick Murdock retired from the Michigan Association of Health Plans in 2017 after 12 years as executive director, and has since been consulting with the MAHP Foundation to coordinate the Michigan ACE (adverse childhood experiences) Initiative. Prior to joining MAHP, he spent three years working in the Michigan legislature, followed by 18 years in the State Budget Office (mental health and Medicaid and health planning). Additionally he spent 6 years in Medicaid administering the Medicaid managed care program. He has a master’s degree in public health from the University of Michigan School of Public Health.

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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Public Health Crisis Warrants Liberty Restrictions

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

By Parker Crutchfield, PhD

Preventing Harm
Suppose your colleague was diagnosed with tuberculosis on Friday but tried to come into work on the following Monday. You would be right to call local public health officials, and they would be warranted in isolating him. Now suppose instead that he was diagnosed with lung cancer on Friday but came into work Monday. You would be wrong to call local public health officials and they would be wrong to isolate him. When a person’s health or behavior are a threat to others’ well-being, there is greater moral justification for restricting the liberties of that person. This is just the converse of Mill’s Harm Principle, which states that the only time it is permissible to restrict a person’s actions is when those actions threaten to harm another person.

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Image description: A dry and cracked river bed in Sri Lanka. Image source: Bioversity International/S.Landersz/Flickr

Recently, the Australian Medical Association declared climate change a threat to the public’s health. This comes after a similar declaration was backed by organizations such as the American Medical Association, the American College of Physicians, the American Academy of Pediatrics, and the American Lung Association. Climate change is a health emergency that threatens the health and well-being of the public. Just as your colleague is a threat to the health and well-being of those around him, climate change is a threat to the public’s health and well-being. Thus, Mill’s Harm Principle applies—in principle it is permissible to restrict liberties to prevent the harm that ensues from climate change.

Public Health Ethics
When your colleague sees his oncologist about his lung cancer, the physician likely prioritizes the patient’s well-being. But public health ethics takes a more utilitarian approach: the individual’s interests are secondary to the greater good. Instead of balancing values such as patient autonomy and the physician’s judgment about what is most medically appropriate, public health ethics primarily balances liberty, equality, and utility (benefit). This to say that, for example, one person’s liberty may be justifiably restricted so that greater utility to the public may be achieved, or that it may be permissible to sacrifice some utility so that everyone can be subjected to the same treatment. Other values such as transparency or solidarity may be incorporated secondarily.

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Image description: A large stack billows dense smoke into the air that appears pink against blue sky. Image source: Billy Wilson/Flickr

Viewing climate change through the lens of public health ethics, which interventions best balance liberty, equality, and utility? There is significant disutility of not doing anything—there will be incalculable harm to very many people. The cost of doing nothing is so high that there is almost no benefit we might achieve presently that could outweigh it. Trading the harms we will suffer by doing nothing for the benefit we might achieve by doing nothing is a bad deal for us and a much worse deal for the next generation.

It is not commonly noted, but the same could be said for liberty—by doing nothing we trade future liberties for present ones. If we want to promote liberty in the future, we need to restrict it now. Currently those who are best positioned to intervene on climate change enjoy an extensive scheme of liberties. We can cool our houses to 68 degrees in the middle of summer; we can travel by jet to anywhere we might want to go; we can preserve our food in disposable plastic containers; we can mostly go outside without fear of catching a mosquito-borne illness; we can even use plastic rather than paper straws!

Inaction and Liberty
If we do nothing in the name of preserving these liberties, we stand to lose much more. It’s pointless to travel by jet to a place that’s underwater or that’s so hot it could kill you, to say nothing of the prospects of actually living there. When the changing climate displaces those living in New Orleans, Phoenix, Miami, the mid-Atlantic, or anywhere else in the world that will be uninhabitable, those people have to go elsewhere, increasing population density in those areas. Cooling our residences and workplaces may be prohibitively expensive, along with refrigerating our food, manufacturing plastic straws, or going outside in shorts and a t-shirt. Such effects will only exacerbate social inequalities.

Or consider the worst-case scenario, one in which climate change exerts too much pressure on governments, undermining their ability to uphold the laws that democracies have agreed to, such as laws prohibiting taking another person’s stuff. In such a scenario one’s scheme of liberties might be as extensive as it could possibly be. But in that case life is solitary, poor, nasty, brutish, and short—all conditions that make it impossible to exercise those liberties and that significantly limit one’s self-determination. The dead have no liberties. For people who want to preserve and promote individual liberty, it makes sense to intervene now.

To What Extent?
If ethical intervention upon threats to the public’s health requires finding the best balance of liberty, equality, and utility, then we have justification to restrict present liberties. Doing so not only promotes greater future utility, but it also promotes greater future liberties. I have not addressed equality, but as things stand now doing nothing will exacerbate social inequalities. But to what extent can present liberties be restricted?

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Image description: two brown and white cows are shown within a crowded group of cattle. Image source: Beatrice Murch/Flickr

Given the severity of the threat climate change presents to future liberties, it may be reasonable to prohibit air travel, driving vehicles that fail to meet certain emissions standards, eating beef, or even using plastic straws and incandescent light bulbs.

I mention above that there are other values that may be considered. If it is permissible for states—in the name of public health—to restrict present liberties to promote future liberties, how can they do so transparently? Does restricting present liberties promote or undermine solidarity among the population? If restricting present liberties undermines solidarity, does it do so to the degree necessary to outweigh the promotion of future liberty, equality, and utility?

parker-crutchfield-cropParker Crutchfield, PhD, is Associate Professor in the Program in Medical Ethics, Humanities, and Law at the Western Michigan University Homer Stryker M.D. School of Medicine, where he teaches medical ethics and provides ethics consultation. His research interests in bioethics include the epistemology of bioethics and the ethics of enhancement, gene editing, and research.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 10, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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Dr. Laura Cabrera and co-authors published in ‘Nature Biomedical Engineering’

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera and co-authors Charles Sadle and Dr. Erin Purcell have an article in the August 2019 issue of Nature Biomedical Engineering. In “Neuroethical considerations of high-density electrode arrays,” the authors state that “the development of implantable electrode arrays that broadly and seamlessly integrate with brain tissue will require innovation that responsibly considers clinically relevant neuroethical concerns.”

The full text is available online via Nature (MSU Library or other institutional access may be required to view this article).

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Exploring life with a spinal cord injury

Spinal Cord Injury: Everything You Wanted to Know But Were Afraid to Ask

Mark Van Linden photo

Mark Van Linden, MSA

Event Flyer

Look at him zip around in that wheelchair. He is so independent and inspirational. But I wonder how he goes to the bathroom, if he’s really as happy as he seems, does he have sex, how does that work, is he in pain, does he work? What are the health problems he has to deal with, what are medical expenses? There are many dimensions to a happy and healthy life, and everyone would agree that life is complicated. But when multiplied by a spinal cord injury (SCI), the complexity of life can be off the charts—what we used to take for granted becomes a monumental challenge. This talk will explore life with SCI from a first-person perspective.

October 16 calendar iconJoin us for Mark Van Linden’s lecture on Wednesday, October 16, 2019 from noon until 1 pm in person or online.

Mark Van Linden grew up in Lansing, MI and had a very stable and nurturing childhood. Raised by his Dad, Mark attended a private high school, played basketball in college, graduated with a BS in manufacturing, and started out in his career as a manufacturing engineer in the automotive industry. His career was going very well; seemingly right on schedule he met a girl, got married, started a family, and the American Dream was well on its way to reality. Then in 2009, it was discovered that he had an aortic aneurysm, and the required surgery would replace his entire aorta from the arch to the femoral artery. During that surgery, at age 39 with two kids ages 2 and 4, he became paralyzed from the waist down. Everything he knew was now turned upside-down, and a new life was about to begin.

In person: This lecture will take place in C102 Patenge Room in East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

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Should we trust giant tech companies and entrepreneurs with reading our brains?

This post is a part of our Bioethics in the News seriesBioethics-in-the-News-logo

By Laura Cabrera, PhD

The search for a brain device capable of capturing recordings from thousands of neurons has been a primary goal of the government-sponsored BRAIN initiative. To succeed would require developing flexible materials for the electrodes, miniaturization of the electronics and fully wireless interaction. Yet this past summer, it was corporately funded Facebook and Elon Musk’s Neuralink that stepped forward with announcements regarding their respective technological investment to access and read our human brains.

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Image description: A black and white graphic of a person’s head with an electric plug extending out of the brain and back of the head. Image source: Gordon Johnson from Pixabay

Elon Musk, the eccentric technology entrepreneur and CEO of Tesla and Space X, made a big announcement while at the California Academy of Sciences. This time it was not about commercial space travel or plans to revolutionize city driving. Instead Musk presented advances on a product under development at his company Neuralink. The product features a sophisticated neural implant which aims to record the activities of thousands of neurons in the brain, and write signals back into the brain to provide sensory feedback. Musk mentioned that this technology would be available to humans as early as next year.

Mark Zuckerberg’s Facebook is also funding brain research to develop a non-invasive wearable device that would allow people to type by simply imagining that they are talking. The company plans to demonstrate a prototype system by the end of the year.

These two corporate announcements raise important questions. Should we be concerned about the introduction of brain devices that have the capacity to read thousands of neurons and then send signals to our brains? The initial goal for both products is medical, to help paralyzed individuals use their thoughts to control a computer or smartphone, or in the case of Facebook to help those with disabling speech impairments. However, these products also are considered to be of interest to healthy individuals who might wish to “interact with today’s VR systems and tomorrow’s AR glasses.” Musk shared his vision to enable humans to “merge” with Artificial Intelligence (AI), enhancing them to reach superhuman intelligence levels.

Time will tell whether or not these grand visions, that currently veer into science fiction, will be matched by scientific progress. However, if they ultimately deliver on their promise, the products could change the lives of those affected by paralysis and other physical disabilities. Yet, if embraced by healthy individuals such technologies could radically transform what it means to be human. There are of course sound reasons to remain skeptical that they will be used. First off there are safety issues to be considered when implanting electrodes in the brain, including damage to the vasculature surrounding the implant as well as tissue response surrounding the device. And that is what is currently known about inserting brain-computer interfaces with only a couple of electrode channels. Consider what might happen with thousands of electrodes. There remain simply too many unknowns to endorse this intervention for human use in the next year or so. There also are salient issues regarding brain data collection, storage, and use, including concerns connected to privacy and ownership.

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Image description: a black and grey illustration of a brain in two halves, one resembling a computer motherboard, the other containing abstract swirls and circles. Image source: Seanbatty from Pixabay

Beyond these concerns, we have to think about what happens when such developments are spearheaded by private companies. Privately funded development is at odds with the slow, careful approach to innovation that most medical developments rely upon, where human research subject regulations and safety measures are clear. It is the “move fast and break things” pace that energizes start-up companies and Silicon Valley entrepreneurs. The big swings at the heart of these entrepreneurial tech companies also bring considerable risks. When addressing sophisticated brain interfaces, the stakes are quite high. These products bring to mind scenarios from Black Mirror, a program that prompts a host of modern anxieties about technology. On one hand, the possibility of having a brain implant that allows hands-free device interaction seems exciting, but consider the level of information we then would be giving to these companies. It is one thing to track how individuals react to a social media post by clicking whether they “like” it or not, or by how many times it has been shared. It is another thing altogether to capture which parts of the brain are being activated without us having clicked anything. Can those companies be trusted with a direct window to our thoughts, especially when they have a questionable track record when it comes to transparency and accountability? Consider how long it took for Facebook to start addressing the use of customer’s personal information. It remains unclear just how much financial support Facebook is providing to its academic partners, or whether or not volunteers are aware of Facebook’s involvement in the funding-related research.

The U.S. Food and Drug Administration as well as academic partners to these enterprises may act as a moderating force on the tech industry, yet recent examples suggest that those kinds of checks and balances oftentimes fail. Thus, when we hear about developments by companies such as Facebook and Neuralink trying to access the thoughts in our brains, we need to hold on to a healthy skepticism and continue to pose important challenging questions.

Laura Cabrera photoLaura Cabrera, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Neuroscience at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, September 26, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Cabrera: Should we improve our memory with direct brain stimulation?Can brain scans spot criminal intent?Forgetting about fear: A neuroethics perspective

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Philosophy, Mental Illness, and Mass Shootings

This post is a part of our Bioethics in the News seriesBioethics in the News logo

By Robyn Bluhm, PhD

Over the past month, mass shootings have occurred in Gilroy, CA, in Chicago, in El Paso, and in Dayton. Most recently, the FBI has arrested a man in Las Vegas who had been planning a shooting spree. It’s common, after such a shooting occurs, to speculate about the mental health of the shooter. In a way, this is understandable: we cannot help but feel that anyone who could do such a thing is not mentally well. We can’t imagine what it would be like to be someone who is capable of meticulously planning and carrying out a mass killing like the one in Charleston, or Parkland, or Sandy Hook, or Pittsburgh, or Las Vegas, or so very many other places in the United States.

It’s true that some of the people who have become mass shooters have been diagnosed with a serious mental illness. But there are many reasons to reject the narrative of the mentally ill mass shooter. For one thing, it does not really fit the facts: the relationship between mental illness and mass shootings is murky at best. For another, it does a grave disservice to people who have a mental illness. As Devan Stahl has shown, associating mass shooting with mental illness stigmatizes people living with mental health conditions, who already face significant stigma.

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Image description: multiple rifle-style gun are shown laying on a green surface. Image source: Phanatic/Flickr Creative Commons

Mental illness stigma is a complex phenomenon reflecting multiple beliefs. Research has shown that people tend to view those with mental illness as dangerous and unpredictable. Biological explanations of mental illness, in particular, can lead people to think that those with mental illness are fundamentally different from those who do not have such a diagnosis. Again, these beliefs are not supported by data. But they do provide people with the comforting sense that there is an explanation for mass shootings. Notably, it’s an “internal” explanation that focuses on the shooter himself, rather than on broader social and policy issues relevant to the phenomenon. And for some, that fact, too, is comforting.

How philosophy can help us think about mass shootings and mental illness

But, I think, there is another way of thinking about the link between mental illnesses and mass shootings that may actually be helpful. Rather than focusing on whether individual mass shooters (or the majority of mass shooters) are mentally ill, we can think about the similarity between mass shootings and (some) kinds of mental illness. The philosopher Ian Hacking has written about the phenomena of transient mental illness, by which he means: “an illness that appears at a time, in a place, and later fades away. It may spread from place to place and reappear from time to time. It may be selective for social class or gender, preferring poor women or rich men. I do not mean that it comes and goes in this or that patient, but that this type of madness exists only at certain times and places.”

Two aspects of his analysis may be useful here. First, he draws an analogy between these conditions and the concept of an ecological niche, which provides a place in which a species can thrive, whereas other places do not allow it to live at all.

Second, he emphasizes that categories of human beings are different from other categories: a tiger, for example, does not care whether we classify her as a tiger, whereas human beings often care deeply about how we are categorized. Because of this, categories of human beings are prone to what Hacking calls “looping effects.” He means that people and the categories into which they put them interact with and change each other. Once a category is “out there” in the world, people may come to identify with it and behave accordingly. During the 1980s, for example, mental health professionals began to see increasing numbers of people with multiple personality disorder, in part as a result of numerous books, televisions shows, and media stories that described this phenomenon. But groups of people also behave in ways that change the characteristics associated with a category. Over time, people who were diagnosed with multiple personality disorder began to exhibit more, and more differentiated, personalities.

Hacking’s analysis is useful even if we don’t think that “being a mass shooter” is a form of mental illness. (It’s also worth noting that even those who think that mass shootings are caused by mental illness don’t think that “being a mass shooter” is a kind of mental illness.) In fact, multiple personality disorder is not recognized as an illness by mental health professionals. Instead, what matters is that it was a recognizable way to behave, or, in Hacking’s words, to be a person – and also that it came into being in a particular kind of social context that, somehow, fostered this way of being a person.

Thinking about mass shootings in Hacking’s terms may help us to understand them. For one thing, mass shooters occupy a very specific niche: they exist almost uniquely in the United States during the past few decades. Appeals to mental illness as a cause can’t explain this fact. Moreover, mass shootings tend to follow a pattern – now that the category exists, members of the group tend to behave according to its rules. But (and this is the other half of the looping effect), we should also be alert to ways that the rules of the category may be changing over time. Recent mass shootings, for example, have been linked to white supremacy. It also seems to be becoming more common for mass shooters to leave a manifesto.

Perhaps most importantly, Hacking gives us a way to think about preventing mass shootings. Blaming mass shootings on mental illness implies that we can do nothing about them, especially if we view people who have a mental illness as essentially different from those who don’t have one. If men who become mass shooters do so in a very particular niche, then the way forward is to destroy the niche which lets them thrive.

Robyn Bluhm photoRobyn Bluhm, PhD, is an Associate Professor with a joint appointment in the Department of Philosophy and Lyman Briggs College. She is a co-editor of The Bloomsbury Companion to Philosophy of Psychiatry.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 29, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Bluhm: “Ask your doctor” – or just check Instagram?Antibiotics: No Clear CourseTo Floss or Not to Floss? That’s not the question

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Announcing the Fall 2019 Bioethics Brownbag & Webinar Series

Green brownbag/webinar iconThe Center for Ethics and Humanities in the Life Sciences at Michigan State University is proud to announce the 2019-2020 Bioethics Brownbag & Webinar Series. The series will begin on October 16, 2019. You are invited to join us in person or watch live online from anywhere in the world! Information about the fall series is listed below. Please visit our website for more details, including the full description and speaker bio for each event.

Fall 2019 Series Flyer

Oct 16 calendar iconSpinal Cord Injury: Everything You Wanted to Know But Were Afraid to Ask
Wednesday, October 16, 2019

There are many dimensions to a happy and healthy life, and everyone would agree that life is complicated. But when multiplied by a spinal cord injury (SCI), the complexity of life can be off the charts—what we used to take for granted becomes a monumental challenge. This talk with explore life with SCI from a first-person perspective.

Mark Van Linden, MSA, is President of Adversity Solutions LLC and a spinal cord injury patient since 2009.

Nov 13 calendar iconSpeaking for the Dying: Life-and-Death Decisions in Intensive Care
Wednesday, November 13, 2019

Seven in ten older Americans who require medical decisions in the final days of life lack capacity to make them. For many of us, our biggest life-and-death decisions—literally—will therefore be made by someone else. But how will they decide for us?

Susan P. Shapiro, PhD, is a Research Professor at the American Bar Foundation.

In person: These lectures will take place from 12:00-1:00 PM in C102 (Patenge Room) East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

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