Nir Eyal

Sissela Bok's1 and Torbjörn Tännsjö's2 writings on trust and informed consent were sources of inspiration for my article.3 It is gratifying to have a chance to respond to their thoughtful comments.Bok concurs with my scepticism that the ‘trust-promotion argument for informed consent’ can successfully generate commonsense morality's full set of informed consent norms. But she finds that argument even more wanting, perhaps so wanting as to be unworthy of critical attention. What she seems to find particularly objectionable is the fact that the argument treats all social trust as valuable. For Bok, misplaced trust in health practitioners who are deceitful or violate patients’ other rights lacks any value whatsoever. There isn't even a pro tanto duty in favour of promoting it.My own inclination is to say that nearly all trust has some social value, if only thanks to its tendency to promote social stability or its tendency to promote medical adherence . But often, trust also tends to generate bad outcomes, and in many cases of misplaced trust, that tendency will make its value negative on balance. Still, in my view, …

Commentators on the ethics of translational research find it morally problematic. Types of translational research are said to involve questionable benefits, special risks, additional barriers to informed consent, and severe conflicts of interest. Translational research conducted on the global poor is thought to exploit them and increase international disparities. Some commentators support especially stringent ethical review. However, such concerns are grounded only in pre-approval translational research (now called T1 ). Whether or not T1 has these features, translational research beyond approval ( T2 : phase IV, health services, and implementation research) is unlikely to and, when conducted on the global poor, may support development. Therefore, insofar as T1 is morally problematic, and no independent objections to T2 exist, the ethics of translational research is diverse: while some translational research is problematic, some is not. Funding and oversight should reflect this diversity, and T2 should be encouraged, particularly when conducted among the global poor

Next SectionAccess to medicines, vaccination and care in resource-poor settings is threatened by the emigration of physicians and other health workers. In entire regions of the developing world, low physician density exacerbates child and maternal mortality and hinders treatment of HIV/AIDS. This article invites philosophers to help identify ethical and effective responses to medical brain drain. It reviews existing proposals and their limitations. It makes a case that, in resource-poor countries, ’locally relevant medical training’—teaching primarily locally endemic diseases and practice in scarcity conditions, training in rural communities and admitting rural students preferentially—could help improve retention. Locally relevant training would arguably diminish medical brain drain in five ways. It would (i) make graduates less attractive for Western employers, (ii) align graduates’ expectations with actual practice, diminishing ‘burn-out’, (iii) enhance the professional prestige of local practice, (iv) hold rotations in, and recruit applicants from, rural areas, which is known to improve retention there, and (v) create local career development options that attract practitioners to stay. Such educational reform may raise worries about poor-quality care, breach of the freedom of education and occupation, breach of the freedom of movement, unequal distribution of opportunities among students, hypocrisy and resistance from influential actors. We address these worries

Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. This account is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested

The article begins by reconstructing the just distribution of the social bases of self-respect, a principle of justice that is covert in Rawls’s writing. I argue that, for Rawls, justice mandates that each social basis for self-respect be equalized. Curiously, for Rawls, that principle ranks higher than Rawls’s two more famous principles of justice - equal liberty and the difference principle. I then recall Rawls’s well-known confusion between self-respect and another form of self-appraisal, namely, confidence in one’s determinate plans and capacities. Correcting that confusion forces Rawls to accept objectionable and illiberal politics. Surprisingly, a consistent Rawls must endorse absolute economic equality, deny liberty any priority whatsoever, or sponsor still other illiberal political views - evidence of a flaw in the ethical basis of Rawls’s politics.

In political philosophy and in economics, unfair inequality is usually assessed between individuals, nowadays often on luck-egalitarian grounds. You have more than I do and that's unfair. By contrast, in epidemiology and sociology, unfair inequality is traditionally assessed between groups. More is concentrated among people of your class or race than among people of mine, and that's unfair. I shall call this difference the egalitarian ‘divorce’. Epidemiologists, and their ‘divorce lawyers’ Paula Braveman, Norman Daniels, and Iris Marion Young, explain that not every inequality between individuals is an inequity. Only inequality between social status groups is unfair. Only such inequality stems from problems like partiality, discrimination, oppression, inequality-related population health problems, and unfair distribution of prospects. And it alone is actionable. By contrast, inequality between individuals, e.g. in longevity, is natural, inevitable, less important, or otherwise less informative — not unjust. In ‘divorce trial’ mode, I respond to epidemiologists that group inequalities lack the intrinsic disvalue that they ascribe them. They may be instrumentally or contingently bad or wrong, not essentially so. I then shift to ‘remarriage’: although group inequalities lack intrinsic badness or wrongness, for multiple reasons they remain useful to measure.

Most books on ethics are boring. Against Autonomy 1 is fun to read because its helpful and profound points are made without a fuss. Author Sarah Conly is right that “when individuals engage in behavior that undercuts their own chances of happiness, state interference may be justified”. In what follows I argue that Conly misinterprets that thesis in three ways. First, she says that her paternalism seeks to “help people get where they want to go... live the lives they truly want to live”. That's a different idea from the one I quoted earlier. Why? Because people do not always (truly) want to live in the way that (in fact) would give them the highest chance of happiness. Conly is surely right that when we “habitually choose the large fries”, that's not always because large fries is what we want truly. Such choice can also reflect ignorance and miscalculation on our parts—when we simply “choose ineffective means to our ends”. But Conly fails to recognise another potential source. Sometimes self-harming choice reflects what we truly want at the time. Many young people do not care much about health problems in their older years. They habitually choose large fries not because they …

Several contributions in this book tell of doctors' increasing emigration from developing countries where they are in critical shortage, especially from the underserved rural and public sectors of countries in sub-Saharan Africa (SSA) and South Asia. They point out the severe harm from that migration to some of the world's poorest and sickest populations who have no other doctors to turn to, and gain little from their emigration. Since significant harm to the badly off is bad, decline in that migration is usually a good development. But how to strive to achieve it?

In many countries worldwide, especially in Sub-Saharan Africa, a shortage of physicians limits the provision of lifesaving interventions. One existing strategy to increase the number of physicians in areas of critical shortage is conditioning medical school scholarships on a precommitment to work in medically underserved areas later. Current practice is usually to demand only one year of service for each year of funded studies. We show the effectiveness of scholarships conditional on such precommitment for increasing physician supplies in underserved areas. Then we defend these scholarships against ethical worries that they constitute slavery contracts; rely on involuntary, biased, or unauthorized early consent by a young signatory; put excessive strains on signed commitments; give rise to domination; and raise suspicion of slavery contracts. Importantly, we find that scholarships involving far longer commitment than current practice allows would also withstand these worries. Policymakers should consider introducing conditional scholarships, including long-term versions, as a means to increasing the supply of physicians to medically underserved areas

The majority of deaths due to tobacco in the twenty-first century will occur in the developing world, where over 80% of current tobacco users live. In November 2010 guidelines were adopted for implementing Article 14 of the World Health Organization’s Framework Convention on Tobacco Control (FCTC). The guidelines call on all countries to promote tobacco treatment programs. Nevertheless, some experts argue for a strict focus, at least in developing countries, on population-based measures such as taxes and indoor air laws, which they consider more cost-effective than individual treatment. In this article we defend tobacco dependence treatment in developing countries. First, these experts understate the comparative cost-effectiveness of individual treatment programs. Second, they overlook numerous ethical considerations beyond cost-effectiveness that support individual tobacco treatment in developing countries. We conclude that the strict population-based focus in developing country tobacco control advocated by some experts is misplaced. In general, developing nations should combine population-based measures and individual tobacco treatment programs.