Jesse Gray

Some public health authorities are calling on health systems to reevaluate the clinical division of labor, and where epistemically or normatively justified, to shift medical tasks onto less-experienced health care personnel. Mobile health technologies are often seen as the vehicle to achieve this aim. Two technology-driven task shifting approaches stand out. In Europe, task-preserving policies are the norm. These policies aim to integrate medical devices with regulatory approval into clinical care. In contrast, the U.S. is experimenting with task-expanding programs, which encourage unregulated general wellness products to be assimilated into medical practice and other informal healthcare delivering networks. Absent regulatory oversight of these products, some health systems are turning to digital navigators—entry-level health care personnel—and asking them to evaluate and recommend “empowering” devices to patients. This paper argues that these task expanding initiatives are weakly justified, self-defeating, or pose unacceptable risks to patients and consumers.

Mobile health tools often claim to empower their users by giving them the knowledge they need to take control of their health. However, this notion of empowerment, what we refer to as the knowledge-control paradigm, only superficially engages with the concept and leaves out the different ways in which people come to be empowered. We first identify two distinct elements of empowerment: psychological empowerment, which pertains to beliefs about one’s power and control over their health, and relational empowerment, which is connected with one’s actual power to control their health, as well as the ability to hold those in positions of power (the empowered) accountable. The knowledge-control paradigm is incapable of creating empowered individuals in the relational sense, and it is only when knowledge is coupled with both the means and the motivations to control health and/or hold the empowered to account, that one can be considered empowered. Mobile health tools that overemphasize knowledge as the empowering mechanism often misempower their users, that is, they create a belief in users about their power to control their health that does not align with their actual capacity to do so. This mismatch between beliefs and reality can have far reaching consequences as with knowledge, ability, control, and power comes responsibility. We worry not only that the misempowered will be viewed as more responsible for their health than the circumstances permit, but also, that these individuals will lose the ability to hold those in positions of power accountable..

© 2014 American Society of Plant Biologists. All rights reserved.A key unanswered question in plant biology is how a plant regulates metabolism to maximize performance across an array of biotic and abiotic environmental stresses. In this study, we addressed the potential breadth of transcriptional regulation that can alter accumulation of the defensive glucosinolate metabolites in Arabidopsis. A systematic yeast one-hybrid study was used to identify hundreds of unique potential regulatory interactions with a nearly complete complement of 21 promoters for the aliphatic glucosinolate pathway. Conducting high-throughput phenotypic validation, we showed that.75% of tested transcription factor mutants significantly altered the accumulation of the defensive glucosinolates. These glucosinolate phenotypes were conditional upon the environment and tissue type, suggesting that these TFs may allow the plant to tune its defenses to the local environment. Furthermore, the pattern of TF/promoter interactions could partially explain mutant phenotypes. This work shows that defense chemistry within Arabidopsis has a highly intricate transcriptional regulatory system that may allow for the optimization of defense metabolite accumulation across a broad array of environments.

Purpose Prescription stimulant use as “cognitive enhancers” has been described among undergraduate college students. However, the use of prescription stimulants among future health care professionals is not well characterized. This study was designed to determine the prevalence of prescription stimulant misuse among students at an academic health sciences center. Method Electronic surveys were e-mailed to 621 medical, pharmacy, and respiratory therapy students at East Tennessee State University for four consecutive weeks in fall 2011. Completing the survey was voluntary and anonymous. Surveys asked about reasons for, frequency of, and side effects of nonprescription misuse of prescription stimulants. Given the sensitive material, an opportunity to win one of ten $50 gift cards was used as an incentive. Results Three hundred seventy-two (59.9%) students completed the survey from three disciplines (47.6% medical, 70.5% pharmacy, and 57.6% respiratory therapy). Overall, 11.3% of responders admitted to misusing prescription stimulants. There was more misuse by respiratory therapy students, although this was not statistically significant (10.9% medicine, 9.7% pharmacy, 26.3% respiratory therapy; P =.087). Reasons for prescription stimulant misuse included to enhance alertness/ energy (65.9%), to improve academic performance (56.7%), to experiment (18.2%), and to use recreationally/get high (4.5%). Conclusions Prescription stimulant misuse was prevalent among participating students, but further research is needed to describe prevalence among future health care workers more generally. The implications and consequences of such misuse require further study across professions with emphasis on investigating issues of academic dishonesty (e.g., “cognitive enhancement”), educational quality, and patient safety or health care quality.

Mobile health tools are often said to empower users by providing them with the information they need to exercise control over their health. We aim to bring clarity to this claim, and in doing so explore the relationship between empowerment and autonomy. We have identified three distinct models embedded in the empowerment rhetoric: empowerment as information, empowerment as control, and empowerment as values. Each distinct model of empowerment gives rise to an associated problem. These problems, the Problem of Interpretation, the Value Alignment Problem, and the Priority Problem, show that mobile health tools in their current form are either insufficient for empowerment or are self‐defeating. These digital health technologies encourage users to adopt an individualized conception of autonomy, one that may weaken the doctor–patient relationship and undermine practices in shared decision making, and ultimately may not deliver on improving the health outcomes for those that need it the most.

Dr Gray leaves us with a question at the conclusion of his article--how should we choose priorities? He says that the debate so far has been mainly on what we should choose, but perhaps we should consider how to choose even more. Under the various subheadings of Criteria, Principles and Persons Dr Gray sets out the pros and cons of the arguments in the priority debates and tries to offer some more specific guidelines to offset the criticism that the government's priority discussions have been too generalised. Yet this is a difficult task when everyone's priorities are so different

Nicholas Agar, Jeff McMahan and Allen Buchanan have all expressed concerns about enhancing humans far outside the species-typical range. They argue radically enhanced beings will be entitled to greater and more beneficial treatment through an enhanced moral status, or a stronger claim to basic rights. I challenge these claims by first arguing that emerging technologies will likely give the enhanced direct control over their mental states. The lack of control we currently exhibit over our mental lives greatly contributes to our sense of vulnerability. I then argue moral status should be viewed in terms of vulnerability. The enhanced will slowly gain the ability to command their mental states, reducing their vulnerability. These radically enhanced beings will have greater capacities, and possibly an inner life more valuable than our own. They will also be less vulnerable, and as a result, their moral status will be subordinate to our own.