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  • My Sister’s Keeper

    Alex Fleming (Columbia University Libraries, 2017-07-01)
    The 2009 film My Sister’s Keeper, based on Jodi Picoult’s 2004 New York Times bestselling novel which bears the same name, is among other things, a controversial story about a young girl (Anna Fitzgerald) who sues her own parents in order to obtain legal rights to the use of her body. For as long as she can remember, Anna has unwillingly been providing blood and bone marrow to her older and critically ill sister, Kate. As the story unfolds, tension within the family arises as the 13 year-old Anna Fitzgerald becomes fully aware of her reason for existence, so to speak, which is to prevent the death of her older sister by providing a regular supply of blood and bone marrow, which she has done regularly for several years. Later on, as Kate’s condition worsens and her renal function begins to fail, the parents naturally turn to Anna to provide what could be a life-saving kidney transplant for her older sister. The climax of the story begins as Anna confidently and heroically refuses. The story raises a slew of bioethical issues which are beyond the scope of this essay; however, the story sheds light on a topic worthy of discussion: living organ donation among minors. 
 As the supply of organs suitable for transplantation decreases and the demand for them increases, the question of living organ donation among those yet of age has become a question of greater concern, primarily among those who point to the various ethical implications which such a procedure creates. Robert Veatch refuses to pair the term organ ‘donor’ with that of a minor and claims that “young children can never be “donors.” They cannot give consent to have their organs used for transplant. The younger ones cannot even comprehend the idea of transplantation.”[i] On the flip side, it is of general agreement among many professionals both domestically and internationally “that consent from the minor’s parents or legal guardian is a necessary condition to allow the donation [of organs among living minors].”[ii] As this requirement seems only natural and obvious, informed consent for living organ donation among minors presents many ethical gray areas, and can easily become a form of abuse at the expense of the child or children in question. Such was the case for Anna Fitzgerald, who was coerced into providing blood and bone marrow for her ailing sister after her parents had, on the surface, satisfied the criteria necessary for informed consent. The characters and the story which make up Picoult’s book are all but fictional; however, provide us with a glimpse into real-life issues which are certainly not out of reach and are deserving of further examination. 
 The challenges in obtaining consent from minors for living organ donation are not the least bit insignificant, and point to numerous areas within the organ procurement process which may be in need of revision if the practice is to respect the whole person in his or her totality. Such revisions are entirely possible; however, may require additional oversight and/or modifications in existing policy. Concerns related to the informed consent process and donation itself ask whether minors are capable of being truly autonomous, and whether a parent’s approval is more often than not a conflict of interest in disguise. Several professionals “question the capacity of minors to understand and balance the risks and benefits at stake and to make an autonomous decision.”[iii] Further, many “highlight the risk of family pressure when the intended recipient is a close relative of the minor donor.”[iv] 
 Apart from the fictional events contained in My Sister’s Keeper, which clearly present examples of family pressure, there have been some famous real-life instances where a conflict of interest among family members may have been present during the debate on whether living organ donation should be permitted. This is what presumably occurred in the legal case Strunk v. Strunk, where the court claimed that it was in the best interests of Jerry Strunk, a 27 year-old incompetent man and ward of the state, that he should donate his kidney to his ailing older brother Tommy, who suffered from kidney disease and was in need of a transplant. The court asserted that such a donation was necessary and “would not only be beneficial to Tommy but also beneficial to Jerry because Jerry was greatly dependent upon Tommy, emotionally and psychologically….”[v] This particular case does not involve children yet of age; however, brings to light an important issue within the organ procurement process as it involves vulnerable individuals incapable of giving true and informed consent. Moreover, this point is especially important if one is comparing the decision-making capacity of a child with that of a mentally incompetent adult.[vi] 
 Further challenges pertaining to living organ donation among minors have to do with psychosocial risks and benefits. Minors who donate major organs may experience a sense of “lower self-esteem, a sense of neglect, and lack of appreciation after the donation.”[vii] This is especially true among minors of the same family. The Organ Procurement and Transplantation Network (OPTN), which administers with the United Network for Organ Sharing (UNOS), lists several policies pertaining to psychosocial evaluation requirements for living organ donors. The psychosocial evaluation requirements “apply to living kidney, liver, pancreas, lung and intestine donors.”[viii] Some of the requirements, among others, involve evaluating potential mental health concerns, high-risk behaviors, possible therapeutic interventions, and a donor’s ability to make an informed decision and take on the stress and medical complications that donation may involve. 
 Beyond simply following policy, it is advisable that all involved in the organ procurement and donation process treat the donating child as holistically as possible, seeking insight into their personal values, wishes, history, and knowledge. For example, psychosocial red flags which could have precluded Anna Fitzgerald from donating one of her kidneys could have been her overall sense of detachment from the rest of her family. Having been born in-vitro for the sole purpose of aiding her older sister, Anna was left feeling as if she were not born out of true love, in comparison to her other siblings who were conceived via natural means and were apparently born for no other reason than for themselves alone. Given these factors, for Anna to donate her kidney may lead to stronger feelings of detachment and an even lower sense of self-worth, both having an impact on overall health. In order to ascertain whether living organ donation among minors is in fact prudent, professionals should feel encouraged to move beyond policy and try to understand the child in their whole essence, all while seeking to protect and affirm their inherent dignity. Such an approach can lead to greater psychosocial benefits for the donor and an ultimately greater understanding of organ donation as gift, and may further strengthen family bonds and/or the relationship between donor and recipient. 
 As with any medical or surgical procedure, organ donation is not without its risk. Medical complications during and after organ donation include but are not limited to: “pain, infection, blood loss, blood clots, allergic reactions to anesthesia, pneumonia, injury to surrounding tissue or other organs, and even death.”[ix] As a general rule in any medical or surgical intervention, a patient is not obligated to take on risks that he or she sees as disproportionate when compared to the intended or foreseen benefits. The United States Conference of Catholic Bishops advise the following: 
 “…no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens of the patient or excessive expense to the family or community.”[x] 
 This freedom from obligation becomes an even stickier situation when the decision to donate means possibly saving the life of a close relative (as was Anna’s predicament), even when the risks involved in donation are minimal. Robert Veatch often equates organ donation, when it concerns minors, to participation in medical research and believes that children, moral agents like ourselves, “have very limited responsibility to contribute to the community... [and] have a greater obligation to their family members than they do to participate in minimal-risk medical research.”[xi] 
 Lastly, it should be noted that not all transplants involve major organs. Sometimes children are faced with circumstances where there is not necessarily an organ to donate, and the donor and the recipient are the same person. In cases where a child is plagued with a musculoskeletal disease or has been involved in a tragic accident, an autotransplantation may be necessary. Autotransplantation, also known as an autograft, occurs when “Bone or tissue [is] transplanted from one part of a person's body to another part….”[xii] These sorts of procedures pose some minimal risk to the patient, including “theoretical risk for disease transmission….”[xiii] and should be given the same attention and scrutiny as organ transplantation procedures. In this case, in what is technically a living tissue transplantation, informed consent procedures still apply, and psychosocial factors are still relevant. Revision to current OPTN/UNOS policy is advisable, and addition of these living tissue transplantation procedures is encouraged if the goal is to create policies which are as inclusive as possible and respect the inherent dignity of donors, recipients, and families. However, regardless of the organ or tissue being transplanted, or whether the donor and recipient are one and the same person, it is vital that the gift of donation be just that, a gift, and not an obligation which we owe by default to others or ourselves.   
   
 [i] Robert M. Veatch, Transplantation Ethics, (Washington, DC: Georgetown University Press, 2000), 236. 
 [ii] Kristof Thys et al., “Could Minors be Living Kidney Donors? A Systematic Review of Guidelines, Position Papers and Reports,” Transplant International 26 (April 8, 2013): 955. 
 [iii] Ibid., 953. 
 [iv] Ibid. 
 [v] Jerry Menikoff, Law and Bioethics: An Introduction, (Washington, DC: Georgetown University Press, 2001), 472. 
 [vi] Veatch, Transplantation Ethics, 236. Robert Veatch chooses to combine infants, children and mentally incompetent adults in the same category in regard to their ability to give consent to have their organs used for transplant. Such a sweeping categorization is indeed a stretch and prevents the inclusion of minors and older children who may be capable of understanding the full implications of organ donation. Moreover, such a comparison undermines the principle of respect for the human person in that all mentally incompetent individuals are seen as incapable of making decisions for themselves. 
 [vii] Kristof Thys et al., “Could Minors be Living Kidney Donors? A Systematic Review of Guidelines, Position Papers and Reports,” Transplant International 26 (April 8, 2013): 955. 
 [viii] Organ Procurement and Transplantation Network, “Policies,” U.S. Department of Health & Human Services, June 1, 2017, https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf 
 [ix] American Transplant Foundation, “What to Consider Before Donating,” http://www.americantransplantfoundation.org/about-transplant/living-donation/becoming-a-living-donor/five-questions-to-ask-yourself/ 
 [x] Ethical and Religious Directives for Catholic Health Care Services: 5th ed., (Washington, DC: U.S. Conference of Catholic Bishops, 2009), n. 32. 
 [xi] Robert M. Veatch, Transplantation Ethics, (Washington, DC: Georgetown University Press, 2000), 195. 
 [xii] American Academy of Orthopaedic Surgeons, “Bone and Tissue Transplantation,” http://orthoinfo.aaos.org/topic.cfm?topic=a00115 
 [xiii] Ibid.
  • Leveraging Law as the Principal Instrument of Public Health Policy

    Donna Hanrahan (Columbia University Libraries, 2014-03-01)
    Michael Bloomberg has been touted as the nation’s first “public health” mayor. Mayor Bloomberg’s final term as New York City’s mayor has now come to a close, and it is important to reflect on the accomplishments and challenges he has faced in leveraging law as a tool to promote public health efforts. 
 In a 2006 address, Bloomberg boldly stated that law is the principal instrument of public health policy. Throughout his time in office, Bloomberg has been forthright about taking legal measures to improve public health in the city. His initiatives include banning trans fat, forbidding smoking in restaurants, and putting a cap on soda sizes. Bloomberg has received both praise for his work in public health and condemnation for his policies that may place restrictions on individual liberty and create a “nanny state.” Some argue that legal coercive measures should be substituted for lesser restrictive alternatives, such as persuasion through public information campaigns. Critics, like Richard Epstein, see modern public health law as overly inclusive, intrusive, and unduly infringing on individual freedom.[1] While less intrusive measures are certainly preferred as the first line of defense in public health, coercive measures such as laws are necessary to ensure the health and safety of the population. As Thomas Friedan posits, “When government fails to protect and improve people’s health, society suffers.”[2] Accordingly, governments are faced with the challenge of taking the most effective, yet least restrictive, means to maximize health benefit, even if it means taking coercive measures at the expense of individual liberty. 
 Salus Populi Suprema Lex: The Well-Being of the Public Is the Supreme Law 
 Democratically elected governments have legal authority to protect the public’s health.[3] It has been long established through Jacobson v Massachusetts that the state has the police power authority to create legislation to protect the health, safety, and general welfare of the population.[4]  While public health action is sometimes characterized as inappropriately intrusive, the population’s reliance on the state for protection implies an ethical obligation for the government to exercise its authority to ensure health and safety. Individual liberty must be subordinated to protect the common public health good. Accordingly, the state is justified to use public force to achieve this end.[5] 
 Be that as it may, regulation of individual behavior through laws and other coercive measures is often met with opposition. Under the Millian harm principle, which holds that “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others,” intervention and regulation on individual behavior is justified so long as it prevents harm and risk to others.[6] Liberalism, a dominant philosophy in the United States, centers on the values of freedom, self-determination, personal responsibility, and limited government. Champions of autonomy would argue that competent individuals should be free from controlling interferences. Any infringement on liberty, privacy, individual choice, and economic freedom can be seen as a violation of rights.Similarly, Kantian philosophers would argue that an individual cannot be used to further another’s objectives without regard to his own goals, or in other words, a man should not be used as a means to an end. Accordingly, interventions that intrude on individual freedom and do not offer any direct benefit to the individual can be viewed as unethical, regardless of the beneficent intent. 
 Regardless of these ethical concerns, public health laws are still created and generally accepted with the understanding that people enter into a social contract and willingly forgo some self-interest in exchange for protection, or otherwise face a tragedy of the commons.[7] The tragedy of the commons is a dilemma that arises when multiple individuals, each acting independently and rationally according to their own self-interest, ultimately deplete a shared limited resource even when it is clear that it is not in anyone's long-term interest for this to happen.[8]  One case that illustrates public health efforts to avoid the “tragedy of the commons” is the case of mandatory vaccination laws and herd immunity. Herd immunity occurs when a significant portion of a community is immunized against a contagious disease, thereby protecting most members of the community against that disease because there is little opportunity for an outbreak. Once a certain proportion of the community is immunized, those who are not eligible for certain vaccines, including infants, pregnant women, and immunocompromised adults, have some protection because the spread of contagious disease is contained. This is also known as community immunity. 
 While opinions vary about whether different health behaviors should be regulated, one need only look at the success of the New York City series of anti-smoking laws to understand the success of law-based public health campaigns. While these laws were first seen as an infringement on individual liberty and potentially detrimental to business, they gained wide public acceptance throughout the years as they proved to be efficient, cost-effective, and life saving. 
 Persuasive and Coercive Measures in Public Health 
 All public health measures aiming to affect individual behavior lie on the spectrum between persuasion and coercion. Law is essentially an act of coercion, as laws limit, by threat or penalty, individual choice through eliminating, restricting, or burdening an option, thereby diminishing autonomy.[9] On the other hand, acts of persuasion, such as public information campaigns, are intended to change individual action through appeals to reason.[10] 
 Critics like Epstein argue in favor of a narrower conception of public health and limiting the scope of coercive government intervention.[11] Persuasive measures, such as educational public health campaigns, are certainly less restrictive than laws. However, it is important to consider whether these campaigns are as efficacious or cost-effective. While intervention through public health communications is effective in raising awareness of health risks and promoting the adoption of recommended treatment regimens, interventions alone often do not have enough clout to change health behavior on a mass scale.[12] Furthermore, education-based campaigns in public health are not without ethical concerns. Such campaigns are often sullied by issues of manipulation, stigma, responsibility, and stereotyping, thereby compromising individual autonomy in persuasive health measures.[13] 
 While persuasion is preferable over coercion from a bioethics and human rights perspective, it is not without ethical concerns. Persuasive public health campaigns may contain elements of manipulation or nonargumentative influence through reason countering or reason bypassing, causing the campaigns to have undue influence on autonomy. Reason-countering nonargumentative influence occurs when methods of manipulation change one’s affective state, including playing on social pressures and personal desires. Similarly, reason-bypassing nonargumentative influence occurs when a person's reasoning capacities or awareness through framing (setting up an environment a certain way) is primed using subconscious cues.[14] 
 
 Beyond the ethical concerns that accompany persuasive public health campaigns, it is said that persuasion alone through educational public health campaigns is not enough for effective change in health behavior on a mass scale. As Willard Gaylen and Bruce Jennings posit, “Coercion is usually quicker and surer than education.”[15] In other words, law is more effective and efficient in achieving public health goals than public health campaigns. 
 Risk Proportionality, Least Restrictive Means, and Public Trust 
 The state’s fundamental authority to protect the population’s safety and welfare is limited by the individual’s legally protected rights to autonomy, privacy, liberty, and property. To intrude on individual liberties, the state must first demonstrate a rational and legitimate interest in intervention. Accordingly, one must assess the nature, duration, probability, and severity of the risk at hand. For example, in the case of bioterrorism, there is uncertain risk but potentially high magnitude of harm.[16] In cases where public health risks may be unknown, responses must be swift and bold. In such cases, it is best to adhere to the precautionary principle. In the absence of certainty, coercive action is acceptable to protect the public, so long as the action is proportional to the suspected risk of harm. 
 According to the principle of proportionality, the least restrictive means should be exercised so as not to unduly compromise the rights and liberties of an individual. While persuasive measures, such as public health campaigns, are certainly less restrictive, it is difficult to demonstrate efficacy or cost-effectiveness compared to coercive measures. Many would argue that if a persuasive measure is proven to be equally effective and cost-efficient as a coercive measure, it should be taken over a coercive measure. Similarly, the principle of proportionality purports that in nonemergency cases, measures should be made voluntary before legal mandates or sanctions are issued. This theory rests on the concept that if a government requires citizens to sacrifice their own liberties for the good of others, then the government has a reciprocal obligation to provide a safe, habitable environment. Moreover, it is essential that public health policies are applied across society equally, in a nondiscriminative fashion.[17] This is essential for maintaining public trust and cooperation.[18] With only 40 percent of Americans reporting trust in public health officials, this will be no easy task.[19] At minimum, authorities should clearly communicate measures and their justifications in a timely fashion and allow for a process of appeal.[20] Low levels of trust translate into low rates of public cooperation, which may make a community more vulnerable to harm during states of public health emergencies. These concerns call for public discourse on coercive measures by the majority affected so that the laws are mutually agreed upon within the community. 
 Conclusion 
 Achieving a just balance between maintaining individual liberties and ensuring health and safety of the population is an enduring problem for public health authorities. Champions of autonomy see public health law as an unwarranted violation of one’s autonomy and personal liberties. On the other hand, utilitarian thinkers consider law as a way to ensure the health and welfare of the community. As public health threats become increasingly complex, it is important to ensure that new laws keep pace with ethical principles. Trade-offs must be made to ensure that collective benefits of population health warrant infringement on individual rights, while balancing competing ethical, health, economic, and political concerns. As New York City says goodbye to Mayor Bloomberg, we reflect on the progress made in public health policy during his tenure as mayor. Much has changed in the field of public health in the last decade, but it stands that fair and effective law remains the cornerstone of successful public health policy. 
   
 References: 
 [1] Richard Allen Epstein, “Let the Shoemaker Stick to His Last: A Defense of the "Old" Public Health,” Perspectives in Biology and Medicine 46 (2003): S138-S159. 
 [2] Thomas Frieden, “Government's Role in Protecting Health and Safety,” N Engl J Med. 368 (2013): 1857-1859. 
 [3] Lawrence Gostin, “Jacobson v Massachusetts at 100 Years: Police Power and Civil Liberties in Tension,” Am J Public Health 95, no. 4 (2005): 576–581. 
 [4] Jacobson v. Massachusetts, 197 U.S. 11 (1905). 
 [5] Epstein, Perspectives, S138-S159. 
 [6] Gostin, Public Health Law: Power, Duty, Restraint (2009). 
 [7] Gaylen and Jennings, “The Perversion of Autonomy, Revised and Expanded Edition: The Perversion of Autonomy: Coercion and Constraints in a Liberal Society,” (2003). 
 [8] Garrett Hardin, “Tragedy of the Commons,” Science 162, no. 3859 (1968):1243-1248. 
 [9] Gaylen and Jennings, “The Perversion.” 
 [10] Ruth Faden, “Ethical Issues in Government Sponsored Public Health Campaigns.” 
 [11] Blumenthal-Barby, “Between Reason and Coercion: Ethically Permissible Influence in Health Care and Health Policy Contexts,” Kennedy Institute of Ethics Journal, 22, no. 4 (2012): 345–366.  By The Johns Hopkins University Press. 
 [12] Gaylen and Jennings, “The Perversion.” 
 [13] Epstein, Perspectives, S138-S159. 
 [14] Nurit Guttman, “Guilt, Fear, Stigma and Knowledge Gaps: Ethical Issues in Public Health Communication Interventions,” Bioethics 18, no 6 (2004): 531-52. 
 [15] Ruth Faden, “Ethical Issues,” 27-37. 
 [16] Lawrence Gostin, “Jacobson,” 576–581. 
 [17] Lawrence Gostin, “Ethical and Legal Challenges Posed By Severe Acute Respiratory Syndrome,” JAMA 290, no. 24 (2003): 3229-37. 
 [18] RJ. Blendon, “Attitudes Toward The Use Of Quarantine In A Public Health Emergency In Four Countries,” Health Affairs 25, no. 2 (2006): 15-25. 
 [19] Ibid. 
 [20] Lawrence Gostin, “Ethical,” 3229-37.
  • Global health equity

    Awele Utomi (Columbia University Libraries, 2020-06-01)
    During the COVID-19 pandemic, one of the earliest positives some asserted was COVID-19’s status as an “equal-opportunity killer.” The coronavirus does not distinguish between culture, race, class, or country and will infect everyone it can as opposed to diseases that typically infect the most vulnerable in our society. While the vulnerable population might be different based on geographical area, vulnerability typically intersects with socio-economic status and race. Despite the fact that everyone can be affected by this virus, people who are already economically and socially disadvantaged will suffer the pandemic’s greatest burdens.[i] In the 1918 pandemic, in both wealthy and developing countries, disadvantaged groups (lower social classes and oppressed groups) had substantially higher mortality rates than more privileged groups.[ii] Even in the absence of vaccines and antiviral medications, a pandemic has the potential to produce profound inequalities in burdens, both within and across countries.[iii] These burdens affect morbidity and mortality  which are  dependent on the socio-economic status of the individual or community. 
             Social justice is concerned with how features of the social structure result in systematic inequalities and disadvantages in well-being. While social justice theories and their practical implications differ, all agree that there are some basic obligations to minimize or prevent harm to others, especially when the others  are vulnerable to harm or injuries and the cost of doing so is not unreasonable. The rationale for social distancing during this pandemic is the same: take reasonable precautions to protect the public and especially the vulnerable. The principle of justice demands that we ensure fair distribution, not only of social benefits and opportunities, but also of burdens and risks. Although all countries must attend to the urgent concerns that affect their own citizens, none of us is exempt from moral obligations toward the world's vulnerable population.[iv] Already, the pandemic and the response, be it containment, suppression, or social distancing, are exposing class divides among and within countries. 
             The field of bioethics has not fully addressed global health equity or population health. As COVID-19 spreads in countries with high population densities like India, social distancing is challenging to implement.[v] We must be careful to ensure that responses account for local circumstances and cultural values to recognize differences between places and endeavor to protect the interests and rights of disadvantaged groups in this difficult period. 
             The recent statistics in the US show that we are not doing a good job of protecting these groups. For instance, ProPublica reports that the pandemic is already disproportionately affecting people with intellectual disabilities, the black community, and people with English language barriers.[vi] In places like Washington and Alabama, pandemic preparedness plans discriminate against people with intellectual disabilities by designating them low priority  when medical care is rationed. In Wisconsin, Chicago, and Detroit, the mortality rate for black people far exceeds the percentage of black people there. While black people are at higher risk of preexisting health conditions, we can do more to ensure our planning guidelines involve representatives of marginalized groups. In addition, social distancing as a response policy does not effectively address the people who must work during this time, and these are more likely to be vulnerable populations. A report from the Economic Policy Institute emphasizes, “Only 9.2 percent of workers in the lowest quartile of the wage distribution can telework, compared with 61.5 percent of workers in the highest quartile.”[vii] 
                         The principles of beneficence and non-maleficence dictate that we must do the most good and avoid harm. In this case, the principles would require inclusion of disadvantaged groups in decisions as opposed to a one-size-fits-all response. Engaging these groups is in everyone’s best interest as an effective response to a pandemic will require widespread cooperation throughout society with a range of government recommendations.3 Disadvantaged groups have the best understanding of  their own interests and priorities making them crucial in pandemic response policy. Involving these groups would also engender their trust and cooperation as they historically have sound, deep-rooted reasons for distrusting their governments. Secondly, more information and data need to be provided on these disparities including race-specific data on cases and deaths. Knowing which communities are most impacted allows public health officials to tailor their approach and work on overcoming the distrust these groups have had for government. Health officials in different countries can address inequities in health outcomes and testing that may emerge by focusing on marginalized communities as well. Ultimately, COVID-19 has shown that the field of bioethics should become more engaged in reducing global health inequities and that we must emphasize the importance of investing globally in emergency preparedness that will include protections for vulnerable groups during emergencies such as pandemics. 
 [i] M.E. Dyson, Come Hell or High Water: Hurricane Katrina and the Color of Disaster (New York: Basic Books, 2006); D. Atkins and E.M. Moy, "Left Behind: the Legacy of Hurricane Katrina," British Medical Journal 331 (2005): 916-18; A. Rafi, S. Doocy, and C. Robinson, "Tsunami Mortality and Dis- placement in Aceh Province, Indonesia," Disasters 30, no. 3 (2006): 340-50; M. Fordham, "The Intersection of Gender and Social Class in Disaster: Balancing Resilience and Vulnerability," International Journal of Mass Emergency Disasters 17, no. 1 (1999): 15-37; Y.J. Chou et al., "Who Is at Risk of Death in an Earthquake?" American Journal of Epidemiology 160, no. 7 (2004): 688-95; A. Montazeri et al., "Psychological Distress among Bam Earthquake Survivors in Iran: A Population-Based Study," BMC Public Health 5 (200) 
 [ii] I.D. Mills, "The 1918-1919 Influenza Pandemic: The Indian Experience," Indian Economic and Social History Review 23, no. 1 (1986): 1-40; H. Phillips, Black October: The Impact of the Spanish Influenza Epidemic of 1918 on South Africa (Pretoria, South Africa: CTP Book Printers, 1990); E. Sydenstricker, "The Incidence of Influenza among Persons of Different Economic Status During the Epidemic of 1918," Public Health Reports 46, no. 4 (193) 
 [iii] Planning for an Influenza Pandemic: Social Justice and Disadvantaged Groups. Author(s): Lori Uscher-Pines, Patrick S. Duggan, Joshua P. Garron, Ruth A. Karron and Ruth R. Faden Source: The Hastings Center Report, Vol. 37, No. 4 (Jul. - Aug., 2007), pp. 32-39 Published by: The Hastings Center Stable URL: https://www.jstor.org/stable/4625761                      
 [iv] T. Pogge, World Poverty and Human Rights: Cosmopolitan Responsibilities and Reforms (Oxford, U.K.: Polity Press, 2002) vii, 284; T. Pogge, "Real World Justice," Journal of Ethics 9, no. 1/2 (2005): 29-5 
 [v]https://www.usnews.com/news/best-countries/articles/2020-05-18/india-struggles-to-maintain-social-distancing-amid-coronavirus-pandemic 
 [vi] Johnson, A, Buford, T. (2020). Early Data Shows African Americans Have Contracted and Died of Coronavirus at an Alarming Rate. From https://www.propublica.org/article/early-data-shows-african-americans-have-contracted-and-died-of-coronavirus-at-an-alarming-rate?utm_source=pardot&utm_medium=email&utm_campaign=majorinvestigations; Silverman, A. (2020). People with Intellectual Disabilities May Be Denied Lifesaving Care Under These Plans as Coronavirus Spread. From https://www.propublica.org/article/people-with-intellectual-disabilities-may-be-denied-lifesaving-care-under-these-plans-as-coronavirus-spreads 
 [vii] Gould, E, Shierholz H (2020). Not Everybody can work from home. Economic Policy Institute. https://www.epi.org/blog/black-and-hispanic-workers-are-much-less-likely-to-be-able-to-work-from-home/?referringSource=articleShare 
  
  • “Its Not Enough”—Mental Illness and U.S. Gun Policy

    Andrew Hawkins (Columbia University Libraries, 2015-10-01)
    A senseless act of violence carried out in a public setting has once again profoundly disturbed the people of the United States. On October 1st, 2015, 26-year-old gunman Christopher Harper-Mercera killed nine people and wounded nine others at Umpqua Community College using six guns purchased through a federally licensed arms dealer.[1] President Barack Obama in a White House Press Conference connected the tragedy to a slew of mass shootings that have taken place in the U.S. in recent years while pointing out their appalling frequency compared to the rest of the world. 
 We are not the only country on Earth that has people with mental illnesses who want to do harm to other people.  We are the only advanced country on Earth that sees these kinds of mass shootings every few months.[2] 
 Since ethics is concerned with values, we must consider whether the exercise of a “fundamental right” outweighs the danger it poses to the public. Unfettered autonomy is a common notion that has been debated in bioethics: does a patient’s right to make treatment decisions outweigh its futility and negative consequences? Our scholarly community has the tools to properly analyze policy decisions in the case of mental illness and gun violence to propose a moral solution. My suggestion is to frame this as a discussion of human rights, morality and health—a familiar discourse in the bioethics community—to form the basis for political compromise and greater public awareness. 
 If we look at the health consequences of proliferation of arms in the United States, the data paints a dismal picture. The Centers for Disease Control and Prevention report ~33,000 gun-related deaths per year,[3] the International Action Network on Small Arms (IANSA) tallies ~10,000 annual gun homicides in the U.S.[4] and for the first time since 1994, annual gun deaths for people under 26 is projected to overtake motor vehicle deaths according to the Center for American Progress.[5] The statistics draw a clear conclusion: the amount of guns per capita is strongly correlated with the number of people who are murdered.[6] 
 Not only is our experience with gun violence abnormal but also the prevalence of mental illness in the U.S supersedes that of comparable countries. According to the National Institute of Health, the average American has a 47.4 percent of having any kind of mental health disorder while 27 percent of adults during any 12-month period experience a variation of mood disorders, anxiety, anxiety disorders, attention deficit/hyperactivity disorders, or substance abuse.[7] The countries with the next highest rates of mental health disorders fall between 18.9 percent and 21.4 percent. Our nation seems to be a peculiar outlier. It is important, however, to note that since the 1980s, diagnostic categories have expanded greatly for the “mentally ill”.[8] 
 The modern gun rights movement is based upon principles that are summarized by Historian J.G.A Pocock: the bearing of arms is the essential medium through which the individual asserts both his social power and his participation in politics as a responsible moral being.[9] Although there is an obvious need for an ethical argument in opposition to this radical form of individualism, the process of blaming deviant members of society is more dangerous. Current popular and political discourse—“guns don’t kill people, people do”—assumes mental health causes mass shootings thus exacerbating public anxiety about the mentally ill. Examples of articles confirming this correlation follow each of these tragic events. A combination of mental illness, guns and psychiatric medication was seen as the cause of Eric Harris’ actions in the 1999 Columbine High School mass shooting.[10] Adam Lanza was assigned to a “subgroup of persons with mental illness who were perpetrators of gun crimes.”[11] The healthcare community must recognize the transition of “mental illness” from medical designation to a signifier of violent intentions. 
 The association between mental illness and gun violence is not as clear. Availability of guns was found to be a more predictive factor than psychiatric diagnoses in the 19,000 annual cases of gun suicide.[12] Brekke et al., illustrated that for individuals diagnosed with serious mental illness their risk of being assaulted increases rather than their tendency to assault others.[13]Metzl and MacLeish in a novel literature review, Mental Illness, Mass Shootings and the Politics of American Firearms, argue that a public policy that explains the pervasiveness of gun violence in the U.S by attributing it to mental illness would be reactionary and detrimental to society.[14]Their proposal suggests that cultural stereotypes and social determinants such as race/ethnicity, social class and politics are in closer relation to mass shootings than mental illness. Interestingly, a recent Washington Post article alluded to strongly conservative politics in Western Oregon and a decline in employment in the local lumber industry as possible contextual influences.[15] 
 Gun control advocates and gun rights activists are increasingly communicating to the body politic that we must either oppose or support gun control based upon our opinions about these mass shootings. Without adequate consideration of empirical evidence, which calls into question whether mental illness causes gun violence, it is quite easy to draw an incorrect conclusion. For example, a distinction is often made in the U.S between African-American and White assailants when theorizing about the etiology of violence. The White male brain is pathologized as a “loner” who is mentally disturbed and obsessed with guns whereas black gun violence is often blamed on “inner city culture.”[16] According to this logic, policies such as the National Instant Criminal Background Check System Improvement Act, instituted in 2008 should identify individuals with a previous history of criminal offenses, a majority of which are African-American, but “wont prevent another Newtown” shooting by an “insane” White gun fanatic.[17] This conjecture, colored by implicit bias, ignores the widespread symptoms of the environment and obfuscates what is an effective public health intervention. If this aberrant line of thinking is taken to its logical conclusion, policies such as those advocated by the National Rifle Association, allowing guns to be present on school property, can be seen as “commonsense.”[18] 
 Those concerned about the health and well-being of our citizens, especially you the reader, cannot remain silent assuming that partisanship concerning gun control will stagnate any legislation brought before Congress. Your knowledge about the current crisis and its affects on our collective health means that you are ethically obligated to speak out. We must ask: do we have a serious right to bear arms? Is mental illness the cause of gun violence? Can gun control prevent mass shootings? As summarized by Metzl, “gun crimes, mental illnesses, and gun access issues are complexly interrelated, and not reducible to simple cause and effect.”13 There is a questionable association of mental illness with violence while clear evidence supports the correlation between the availability of guns and mass shootings. From a bioethical perspective, this must manifest in political action. 
 References 
 [1] According to the Associated Aress, Harper-Mercer’s weapons of choice included a Glock pistol, a Smith & Wesson pistol, a Taurus pistol and a Del-Ton assault rifle, according to The Associated Press. Buchanan, L., Keller, J., Oppel, R., & Victor, D. (2015, October 2). How They Got Their Guns. New York Times. Retrieved October 4, 2015. 
 [2] https://www.whitehouse.gov/blog/2015/10/01/watch-president-obamas-statement-shooting-oregon 
 [3] Deaths: Final Data for 2013. National Vital Statistics Report. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf 
 [4]Gun Violence: The Global Crisis. IANSA.http://www.iansa.org/system/files/GlobalCrisis07.pdf 
 [5] Parsons, C. Johnson, A. Young Guns: How Gun Violence is Devastating the Millennial Generation. Center For American Progress. https://cdn.americanprogress.org/wp-content/uploads/2014/02/CAP-Youth-Gun-Violence-report.pdf 
 [6] Gregg Lee Carter, The Gun Control Movement (New York: Twayne Publishers, 1997), p. 3. 
 [7] Walton, A. (2011, October 4). Why More Americans Suffer From Mental Disorders Than Anyone Else. The Atlantic. Retrieved October 4, 2015. 
 [8] Horwitz AV. Creating Mental Illness. Chicago, IL: University of Chicago Press; 2003. 
 [9] Shapiro, I. (1990). JGA Pocock's republicanism and political theory: A critique and reinterpretation. Critical Review, 4(3), 433-471. 
 [10] Breggin P. Reclaiming Our Children: A Healing Plan for a Nation in Crisis. New York, NY: Basic Books; 2000 
 [11] Preview: imminent danger. 60 Minutes. CBS. 2013. Available at: http://www.cbsnews.com/videos/preview- imminent-danger. 
 [12] Lewiecki EM, Miller SA. Suicide, guns, and public policy. Am J Public Health. 2013;103(1):27--31. 
 [13] Brekke JS, Prindle C, Bae SW, Long JD. Risks for individuals with schizophrenia who are living in the community. Psychiatr Serv. 2001;52(10):1358--- 1366. 
 [14] Metzl, J. M., & MacLeish, K. T. (2015). Mental illness, mass shootings, and the politics of American firearms. American journal of public health, 105(2), 240-249. 
 [15] Tankersley, J. Shooting in Oregon: Where unemployment is high and gun rights are precious. The Washington Post. http://www.washingtonpost.com/news/wonkblog/wp/2015/10/02/shooting-in-oregon-where-unemployment-is-high-and-gun-rights-are-precious/ 
 [16] Kennedy-Kollar D, Charles CAD. Hegemonic mas- culinity and mass murderers in the United States. South- west J Crim Justice. 2013;8(2):62--74. 
 [17] Dane L. Why more gun control won’t prevent mass shootings. The Daily Sheeple. December 14, 2013. Available at: http://www.thedailysheeple.com/why-more- gun-control-wont-prevent-mass-shootings_122013. 
 [18] DeFilippis, E. Campus Gun Control Works. Boston Review. http://bostonreview.net/us/evan-defilippis-guns-schools-nra-ucsbgu
  • Reconciling Surrogacy Adversaries Through the Embryo

    Katarina Lee (Columbia University Libraries, 2015-09-01)
    Surrogacy is constantly in the news, with the Supreme Court’s decision in Obergefell,[1] the recent conviction of an owner of an American surrogacy company,[2] and the recent birth of Lucy Liu’s son via a gestational surrogate.[3] Like many bioethical issues, surrogacy divides individuals into three distinct groups: (A) those who believe surrogacy is ethically permissible, (B) those who believe surrogacy is ethically impermissible, and (C) those who are apathetic—meaning they would not engage in surrogacy, but either have no opinion or hold the conviction that individuals should be able to make autonomous choices. In my piece last month, I discussed why surrogacy is a legally problematic enterprise; this month I will present the ethical problems of surrogacy. Much of the literature elucidating the surrogacy debate is prejudiced, incomplete, highly repetitive, and too politically polarizing. Instead of focusing on the typical ethical arguments surrounding surrogacy, commentators need to start looking at surrogacy in the realm of both the physical and mental health of the intended child. 
 Those who oppose surrogacy typically present the following arguments: 
 
 • Surrogacy exploits and commodifies women.[4]
 
 • Surrogacy is especially exploitative in foreign countries in which there is less regulation, language barriers, and typically little or no legal representation.[5] 
 • Domestically, intended parents “prey” on women who are young and desperate for cash.[6] 
 
 
 • Surrogacy exploits and commodifies children (a.k.a. “baby selling”).[7] 
 • Surrogacy is ethically impermissible because it alters nature. 
 • Surrogacy is ethically impermissible because fertility specialists are “playing God.”[8] 
 • The exchange of money and other means of compensation create a myopic lens that prevents surrogates from informed consent. 
 • Through gestating a child, a surrogate bonds with the child and therefore has an important connection to that child. This bond should not be severed.[9] Those who support surrogacy typically present the following arguments: 
 
 
 • Individuals should have the “right” to a family.[10]
 
 • Surrogacy provides an opportunity for individuals struggling with fertility to have the opportunity to be a parent. 
 • Surrogacy provides same-sex individuals and couples (particularly male homosexuals) the opportunity to have a family.[11] 
 
 
 • Individuals should have the “right” to make individual choices.[12] 
 • Surrogacy, especially for surrogates in lesser socioeconomic situations, provides an opportunity for women to sustain themselves and their families.[13] 
 • The medical risks to surrogate pregnancies are minimally greater than typical pregnancies. 
 • Surrogacy laws regulate the practice; therefore, there is minimal risk of exploitation.[14] 
 • Regarding altruistic surrogacy: other “donations” such as kidneys are permissible, so how is surrogacy any different?
 The problem with these arguments is that no one is going to capitulate. For example, the argument that surrogacy is impermissible because of its manipulation of nature or “playing God” will never reconcile with the conviction that individuals should be able to make choices for themselves. Similarly, those who believe that monetary exchange provides a good financial opportunity to surrogates are never going to reach the same conclusion of those who oppose surrogacy based on the “baby selling” argument. As a result, the debate surrounding surrogacy involves ethicists, politicians, journalists, and advocates talking past each other ad nauseam. 
 A possible bridge between opponents and supporters of surrogacy is that most individuals will agree that if there are negative health repercussions to surrogates then surrogacy may be impermissible. Those who oppose surrogacy argue that women should be prohibited from consenting to surrogacy, as it increases a woman’s physical and mental health risks.[15] Surrogacy supporters argue that women should be able to make autonomous informed choices and that the medical risks are not too severe as to prohibit the practice. 
 Where this argument breaks down for those who support autonomous choices is that the intended child cannot consent. Arguably, the most important party in third party reproduction cannot consent to its creation. For those who oppose surrogacy (especially from a pro-life ethic), it is almost impossible to argue that an embryo is better off not born than born, nor is it feasible to argue that there are ideal situations in which children should be procreated. What is possible to argue is that individuals have a duty not to create situations that may harm the physical and mental health of an intended child. 
 Those who disagree with this premise will typically argue that a living person’s ability to choose how he/she wants to procreate supersedes the interest of the embryos; that the embryos are this person’s property and/or genetic material and therefore the intended parent can beget these children in whatever way he/she deems permissible. What opponents fail to account for is that having a child through surrogacy increases the health risks to that child. First, we have seen increasing rates of negative health effects to children created through IVF[16] and second, we have noticed cell transfer between surrogates and the children they gestate.[17] Moreover, studies suggest there are possible negative psychological impacts on children born through surrogacy.[18] The potential impacts of these concerns will only become apparent with time. 
 Those who disagree with this may also argue that embryos are not persons and therefore do not have the right to consent; moreover, abortion is legal. First, even if one wishes to argue that embryos are not persons, at the very least, embryos are intended persons. The parties involved in third-party reproduction hope that an embryo will implant and that the intended child will result. Second, abortion is primarily legal because it allows women the ability to make autonomous choices regarding their bodies. Embryos in third-party reproduction are created outside of a woman’s body and then placed in a woman’s body. They are a completely separate entity in which a woman’s autonomous choice is not relevant. Therefore, instead of individuals arguing over the problems associated with the surrogate and the intended parents, it is more fruitful if we start examining the impact of third-party reproduction on children. 
 References: 
 
 
 [1] http://www.latimes.com/opinion/op-ed/la-oe-nejaime-gay-marriage-decision-does-not-solve-everything-20150628-story.html 
 [2] http://mynewsla.com/crime/2015/09/28/glendora-surrogacy-agency-owner-gets-prison-for-cheating-would-be-parents/ 
 [3] http://www.inquisitr.com/2451158/lucy-liu-role-model-for-non-traditional-families-and-gestational-surrogacy/ 
 [4] http://www.nytimes.com/roomfordebate/2014/09/22/hiring-a-woman-for-her-womb/paid-surrogacy-is-exploitative 
 [5] http://www.nytimes.com/roomfordebate/2014/09/22/hiring-a-woman-for-her-womb/the-role-of-international-law-for-surrogacy-must-be-expanded 
 [6] https://erlc.com/article/issue-analysis-surrogacy 
 [7] http://www.lifenews.com/2015/04/01/surrogacy-firms-are-selling-extra-babies-on-the-black-market-to-the-highest-bidder/ 
 [8] http://www.cnn.com/2013/03/04/health/surrogacy-kelley-legal-battle/ 
 [9] http://www.thepublicdiscourse.com/2015/05/15037/ 
 [10] https://www.psychologytoday.com/blog/genetic-crossroads/201507/is-family-equality-right-surrogacy 
 [11] http://www.thepublicdiscourse.com/2015/07/15362/ 
 [12] https://web.stanford.edu/group/womenscourage/Surrogacy/moralethical.html; https://www.washingtonpost.com/opinions/surrogacy-should-be-regulated-not-banned/2013/05/29/2198c134-c7db-11e2-9cd9-3b9a22a4000a_story.html 
 [13] http://theweek.com/articles/544253/how-made-60000-surrogate-mother 
 [14] http://www.psmag.com/politics-and-law/the-messy-complicated-nature-of-assisted-reproductive-technology 
 [15] http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.Nsf/pages/Surrogacy_the_issues?open 
 [16] http://www.dailymail.co.uk/health/article-180379/Child-health-problems-linked-IVF.html; http://www.cbc-network.org/pdfs/What’s%20Wrong%20with%20Third%20Party%20Assisted%20Reproduction%20Center%20for%20Bioethics%20and%20Culture.pdf 
 [17] http://philpapers.org/rec/FISMCT 
 [18] http://www.dailymail.co.uk/health/article-2344362/Surrogate-born-children-likely-suffer-depression-carried-real-mother.html; http://ncbcenter.org/document.doc?id=897

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