Two researchers in neuroethics

December 5, 2016

Our neuroethics group at CRB currently seek two postdoctoral researchers to work in the Human Brain Project (European Commission Future and Emerging Technologies Flagship Project). The positions have different focus.

One research task focuses on the role of contexts and cultural imprinting in understanding the brain’s functional architectures. Read more and apply.

The second research task focuses on philosophical and ethical challenges of modelling cognitive processes in silica. Read more and apply.

Employments are temporary, renewable halftime positions, starting February 1, 2017 (or as otherwise agreed). If you have questions, please contact Kathinka Evers.

Application deadline is January 12, 2017.

Pär Segerdahl

We transgress disciplinary borders - the Ethics Blog

The apparent academy

November 29, 2016

Pär SegerdahlWhat can we believe in? The question acquires new urgency when the IT revolution makes it easier to spread information through channels that obey other laws than those hitherto characterizing journalism and academic publishing.

The free flow of information online requires a critical stance. That critical stance, however, requires a certain division of labor. It requires access to reliable sources: knowledge institutions like the academy and probing institutions like journalism.

But what happens to the trustworthiness of these institutions if they drown in the sea of impressively designed websites? What if IT entrepreneurs start what appear to be academic journals, but publish manuscripts without serious peer review as long as the researchers are paying for the service?

This false (or apparent) academy is already here. In fact, just as I write this, I get by email an offer from one of these new actors. The email begins, “Hello Professor,” and then promises unlikely quick review of manuscripts and friendly, responsive staff.

What can we do? Countermeasures are needed if what we call critical reflection and knowledge should retain their meaning, rather than serve as masks for something utterly different.

One action was taken on The Ethics Blog. Stefan Eriksson and Gert Helgesson published a post where they tried to make researchers more aware of the false academy. Apart from discussing the phenomenon, they listed deceptive academic journals to which unsuspecting bioethicists may submit papers (deceived by appearances). They also listed journals that take academic publishing seriously. The lists will be updated annually.

In an article in Medicine, Health Care and Philosophy (published by Springer), Eriksson and Helgesson deepen their examination of the false academy. Several committed researchers have studied the phenomenon and the article describes and discusses what we know about these questionable activities. It also proposes a list of characteristics of problematic journals, like unspecified editorial board, non-academic advertisement on the website, and spamming researchers with offers to submit manuscripts (like the email I received).

Another worrying trend, discussed in the article, is that even some traditional publishers begin to embrace some of the apparent academy’s practices (for they are profitable). Such as publishing limited editions of very expensive anthologies (which libraries must buy), or issuing journals that appear to be peer reviewed medical journals, but which (secretly) are sponsored by drug companies.

The article concludes with tentative suggestions on countermeasures, ranging from the formation of committees that keep track of these actors to stricter legislation and development of software that quickly identifies questionable publications in researchers’ publication lists.

The Internet is not just a fast information channel, but also a place where digital appearance gets followers and becomes social reality.

Pär Segerdahl

Eriksson, S. & Helgesson, G. 2016. “The false academy: predatory publishing in science and bioethics.” Medicine, Health Care and Philosophy, DOI 10.1007/s11019-016-9740-3

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Approaching future issues - the Ethics Blog

The brain develops in interaction with culture

November 16, 2016

Pär SegerdahlThe brain develops dramatically during childhood. These neural changes occur in the child’s interaction with its environment. The brain becomes a brain that functions in the culture in which it develops. If a child is mistreated, if it is deprived of important forms of interaction, like language and care, the brain is deprived of its opportunities to develop. This can result in permanent damages.

The fact that the brain develops in interaction with culture and becomes a brain that functions in culture, raises the question if we can change the brain by changing the culture it interacts with during childhood. Can we, on the basis of neuroscientific knowledge, plan neural development culturally? Can we shape our own humanity?

In an article in EMBO reports, Kathinka Evers and Jean-Pierre Changeux discuss this neuro-cultural outlook, where brain and culture are seen as co-existing in continual interplay. They emphasize that our societies shape our brains, while our brains shape our societies. Then they discuss the possibilities this opens up for ethics.

The question in the article is whether knowledge about the dynamic interplay between co-existing brains-and-cultures can be used “proactively” to create environments that shape children’s brains and make them, for example, less violent. Environments in which they become humans with ethical norms and response patterns that better meet today’s challenges.

Similar projects have been implemented in school systems, but here the idea is to plan them on the basis of knowledge about the dynamic brain. But also on the basis of societal decision-making about which ethics that should be supported; about which values that are essential for life on this planet.

Personally I’m attracted by “co-existence thinking” as such, which I believe applies to many phenomena. For not only the brain develops in interaction with culture. So does plant and animal life, as well as climate – which in turn will shape human life.

Maybe it is such thinking we need: an ethics of co-existence. Co-existence thinking gives us responsibilities: through awareness of a mistreated nature; through awareness of our dependence on this nature. But such thinking also transcends what we otherwise could have imagined, by introducing the idea of possibilities emerging from the interplay.

Do not believe preachers of necessity. It could have been different. It can become different.

Pär Segerdahl

Evers, K. & Changeux, J-P. 2016. “Proactive epigenesis and ethical innovation: A neuronal hypothesis for the genesis of ethical rules.” EMBO reports 17: 1361-1364.

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Approaching future issues - the Ethics Blog

What is the risk?

November 2, 2016

Pär SegerdahlTo communicate about genetic risk with patients, we need to know how people think about risk and that experts and people in general often think differently.

A common feature, however, is this: Risk has to do with future adverse events. We talk about the risk of getting sick. But we rarely talk about the risk of getting well. We must then imagine people who value their disease (perhaps to avoid enrollment in an occupation army).

The expert’s concept of risk presupposes the negative value, but does not delve into it. It focuses on the probability that the unwanted event will happen (and how certain/uncertain the probability is).

For patients, however, the value aspect probably is more in focus. A couple learning about a 25% risk of having a child with a certain disability probably considers how bad such impairment would be: for the child and themselves. Maybe it isn’t so bad? Perhaps there is no great “risk” at all! They evaluate the risk scenario rather than calculate the probability.

How can we understand this value aspect, which risk presupposes and patients ponder? Ulrik Kihlbom at CRB asks the question in an article in the Journal of Risk Research.

Kihlbom describes two common ways of understanding value. The first is in terms of preferences. People have different preferences. Most prefer health before sickness, but occasionally someone may prefer disease. Value lies in satisfying these preferences, whatever they are. There is then only one value: preference satisfaction. The problem is that we can object that these preferences are not always reasonable or well informed. Additionally, patients can adapt to their illness and prefer their lives as much as healthy persons prefer their lives. Is it valuable to satisfy even such preferences?

Not surprisingly, the other way of understanding value is more objective. Here one assumes that value depends on how well certain basic human capabilities are supported. Such as being able to use one’s senses, imagine, think, play, be healthy, etc. Here there is a more objective measure of value. The problem is the authority the measure is given. May not a person lack some of these capabilities and still live a full and dignified life? Who decides which capabilities should belong to the measure?

Actually, I would say that both proposals impose a measure of value. Preference satisfaction is, of course, a general measure too.

Kihlbom proposes a third way of understanding value. No measure of value is imposed and value is not separated from that which has value. If someone gets cancer, the negative value lies already in the disease, so to speak. A person who knows what cancer is does not ask: “Why is it bad to get cancer?” And hardly anybody would answer: “Because it frustrates my preferences” or “Because it prevents me from flourishing as a human being.”

Knowing what disease is means knowing that it is bad. It is part of the point of the word. To exclaim, “I’m so sick!” is to complain (not to rejoice). The value lies in the phenomenon itself and in the word. If some people still value their disease (perhaps to avoid military service), the value lies in the situation where the disease can appear as a good thing.

This is probably how people approach genetic risk information: What does this mean in my life? How bad is it? They immerse themselves in the value aspect, which the numerical probability presupposes. The 25-percent risk of having a child with a certain disability leads to concerns over what such a life might turn out to be like; how it can be described; how it can be valued.

So what should we keep in mind in genetic risk communication? The novelty about genetic risk information is not only that patients get difficult to interpret percentages of probability. The scenarios are new. These scenarios can involve time perspectives that extend throughout one’s future life, even to future generations. They can be about diseases and treatments that we do not know what it means to live with.

We evaluate risks daily (like the risk of missing the train), but here patients encounter novel risk scenarios that are difficult to evaluate. If I understand Kihlbom right, he thinks that the challenge is not only to explain probabilities to patients. The challenge is not least that of talking with patients about these new risk scenarios: about how they react to them in terms of value, how they describe them as “catastrophic” or “not so bad.”

Patients need support to evaluate genetic risk scenarios reasonably; not only to understand probabilities.

Pär Segerdahl

Kihlbom, U. 2016. “Genetic Risk and Value.” Journal of Risk Research, DOI: 10.1080 / 13669877.2016.1200653

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We like real-life ethics :

How to listen to (the right) patient voices?

October 25, 2016

Ulrik Kihlbom, Academic co-lead of PREFER's methodology work packageWe all think patients’ voices are important. But how do we make sure we listen to the right ones? Patient engagement and patient perspectives have come into focus in health care in recent years. Though this is especially true for the clinical setting, this development can be expected to continue for decision-makers at other levels.

We are just starting to research these questions in a project called PREFER. The aim is to establish which methods to use to bring in patient perspectives into important decisions regarding medical drugs; decisions made by different stakeholders, such as physicians, regulatory and reimbursement authorities, and the industry. In short: how and when should decision makers listen to the patients?

But, how can we make sure that the methods enable decision-makers to listen to the right patient voices?

Now, the expression “the right patient voices” should plausibly be understood as comprising several aspects such as being representative of the actual views patients have, being adequately informed, and as being non-biased. Each of these aspects require thorough consideration and also methodological development. I am myself responsible for one task that will specifically address these questions. One of the many intriguing issues here is when, during the process of falling ill, coming under treatment, and hopefully convalescing, a patient’s voice should be listened to? The patient’s preferences will probably change during the trajectory of illness. Imagine that you fall seriously ill, are treated and recover, and suppose also that your preferences for a risky treatment change during this period of time. Do you know when your preferences are such that your physician should listen to them? And when they merit less attention? I am myself far from sure how to answer this question.

Another set of questions concerns how the (right) patient perspective should be incorporated into the decision making. How, for example should a reimbursement authority weigh the patient perspective against cost-effectiveness when making a decision of subsidising a medical drug? Or how should a regulatory authority, such as EMA in Europe, FDA in the US, and Läkemedelsverket in Sweden, weigh patient effectiveness against safety concerns? It seems fair to say that everybody agrees that the patient perspective should have a weight, but no one has an established scale.

These are some of the very hard and intriguing questions that the PREFER project will address over the coming five years. 33 partners from academic institutions, patient organisations, health technology assessment bodies, small companies and the pharmaceutical industry are putting their heads, competence and resources together. Uppsala University is coordinating the project, with CRB’s director Mats G. Hansson at the helm. Apart from me and Mats, Josepine Fernow, Elisabeth Furberg, Jorien Veldwijk and Karin Schölin Bywall at CRB are involved in PREFER. We are looking forward to interesting research questions, but also to learning by working in, and leading, a public-private partnership of this size.

In the autumn of 2021, the project will issue recommendations. By then we will know better how decision makers may find and listen to the (right) patient voices. And how patients’ voices can make themselves heard in the decisions of regulators, health technology assessment bodies, reimbursement agencies, and pharmaceutical companies.

Ulrik Kihlbom

About PREFER: The Patient Preferences in Benefit-Risk Assessments during the Drug Life Cycle (PREFER) project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 115966. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. The contents of this text reflects the author’s view and not the view of IMI, the European Union or EFPIA.

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The Ethics Blog - Exploring preferences

Did medicine save the life of ethics?

October 18, 2016

Pär SegerdahlAbout thirty-five years ago, Stephen Toulmin wrote an article on the topic: How medicine saved the life of ethics. I think it is still worth reading.

Toulmin argued roughly as follows:

During the first six decades of the 1900s, ethics wasn’t feeling well at all. One might say that it suffered from moral aphasia: it couldn’t talk sensibly about real ethical problems.

While moral philosophers were preoccupied with formally specifying what distinguishes moral questions and judgements in general, without taking sides on specific ethical issues, ethics debaters outside of academic philosophy were trapped in the opposition between dogmatism and relativism.

Dogmatists referred respectfully to universal principles and authoritative religious systems, while relativists and subjectivists dismissed the absolute claims with reference to anthropological and psychological findings about differences in people’s attitudes.

In short, while philosophers analyzed what characterizes morality in general and left living ethical issues to their fate, dogmatists and relativists fought fruitlessly about whether these issues have absolute answers, based on universal principles, or if the answers are relative to cultural and individual factors.

In this near-death state, medicine came to the rescue. Medical practices gave rise to very definite ethical questions that insisted on answers and guidance. When philosophers in the 1960s began to pay attention to these issues, ethics was rescued from the life-threatening condition in which it found itself.

Toulmin suggests that medical ethics saved the life of ethics through four resuscitation efforts:

By focusing on situations, needs and interests, which are more objectively given than the attitudes, feelings and desires that anthropology and psychology were interested in. Whether a person’s actions threaten another’s health can be discussed in objective terms, as opposed to questions about habits and tastes.

(Here I think of the emergence of empirical ethics, where more objective aspects of ethical problems are explored in various kinds of studies.)

By analyzing concrete cases, instead of striving towards the universal principles to which dogmatists referred. Toulmin compares medical ethics to medical practice. Diseases described only in general terms become abstract and without specific relevance: they acquire practical relevance only for health professionals who learned the art of identifying real-life cases of the diseases. The same applies to ethics, which requires an art of identifying real-life cases of, for example, “disrespect”; otherwise ethical concepts become abstract and without practical significance.

(Here I think, among other things, of the emergence of ethics rounds in the ethics training of healthcare staff.)

By focusing on professional activities, giving rise to definite responsibilities and duties. To understand our duties to each other, we cannot assume an abstract image of humans as individuals. We live in communities and act in forms of life that shape our obligations. Issues in medical ethics are often about obligations shaped by professional roles and contexts.

(Here I think of the previous blog post, about boundaries between public health and healthcare, which sometimes might be transgressed. Practices such as research, healthcare and industry shape different types of obligation and responsibility, which it sometimes can be difficult to keep separate or balance.)

By reintroducing assessments of equity and personal relationships in ethics, assessments of how the circumstances alter the cases. What, in a doctor-patient relationship, is a routine examination, can outside of this context give us reason to speak of an assault. Circumstances alter the cases, and Toulmin compares medical ethics with how courts make assessments of what is just and reasonable between people, given what we know about them.

(Here I think of how medical ethics increasingly is done in dialogue with patients, health professionals and researchers, to better understand the circumstances.)

– Why do I find Toulmin’s article worth reading today?

Among other things, because it provides a broad and realistic description of ethics as a practice and art, in time and in particular contexts, partly comparable to the doctor’s or the lawyer’s practice and art. The article also makes the development of bioethics understandable, such as the emergence of empirical ethics, of ethics rounds, and of the endeavor to work in dialogue with stakeholders and with the professions.

The article also nuances a simplified understanding of how ethical questions are answered. We are inclined to think that empirical studies give us the facts. Then we add general moral principles and derive the ethical conclusions. This could resemble a relapse into dogmatism, where religious principles have been replaced by secular philosophical principles.

Finally, I want to mention that the article sheds light on a problem that we encountered in some empirical studies lately. Colleagues have made ethical education interventions in different healthcare professions. The participants appreciated the practical exercises and found them instructive. But no clear effect of the exercises could be measured by comparing results of knowledge tests before and after the interventions.

Toulmin’s description of how medicine saved the life of ethics may suggest an explanation. The exercises were practical and concerned cases with which the participants were familiar. But the knowledge tests were formulated roughly in those general terms which constituted such a large part of the illness of ethics. The interventions might have been vitalizing, but not the method of measurement.

Pär Segerdahl

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We think about bioethics :

Public health campaigns in healthcare: mothers should breastfeed!

October 3, 2016

Pär SegerdahlPublic health campaigns do to some extent infringe upon our lives. Maybe we are prepared to allow some of these intrusions. We protest a little, just for show, but still adopt the message and begin to think that we probably ought to eat a little more X and a little less Y.

Some campaigns, however, encroach on sensitive areas of life, in more vulnerable situations, and in places where one would expect more personal respect.

Campaigns to encourage mothers to breastfeed, instead of giving infant formula, provide an example. These campaigns occur not least in healthcare, in contacts with new mothers who for various reasons may have difficulties with breastfeeding, or who don’t want to breastfeed.

Earlier this year, Jessica Nihlén Fahlquist had an article published in Nursing Ethics about such mothers’ experiences. It’s about mothers who don’t breastfeed and about their experiences of contacts with healthcare and being met with campaigning.

The survey responses described in the article suggest that these mothers can feel like bad mothers. They are told that breastfeeding is the best and safest option for the child, that all mothers can breastfeed if they just try, and that “artificial” formula feeding increases the risk of malnutrition and various diseases in the child.

The mothers feel that they don’t get opportunity to talk about their problems or desires to find a way of feeding their child that works for them. Might not bottle feeding be the better option for some mothers and children? The information seems, to a great extent, to be about communicating the norm that a real mother should breastfeed. That’s at least how the mothers in the study appear to experience the situation, and they may feel guilty not only because they don’t breastfeed, but also because they don’t enjoy it.

Nihlén Fahlquist points out that information about feeding infants in essence is a form of risk communication where parents are informed about the risks and benefits of breastfeeding and bottle feeding. She suggests that breastfeeding campaigns tend to be deficient in three ethical respects, which need to be addressed:

Parents are informed about risks and benefits on a collective level, without regard to individual problems, needs and circumstances. The public health perspective overshadows the unique situations of these mothers, even though the question how to feed one’s child is intimate. Risks and benefits should be weighed individually.

Campaigning collides with respect for autonomy, which is important in healthcare. The risk communication is one-way; questions and doubts are not taken seriously. It’s about informing parents about “the best option.” One-way communication should be replaced by dialogue.

The effects of breastfeeding campaigns should be evaluated not only statistically, in terms of how many mothers are breastfeeding. They should also be evaluated ethically, in terms of good care. The mothers who responded to the survey don’t seem to experience good care, sensitive to their individual needs.

For me, the article shows how public health campaigns conducted in healthcare need to be adapted to the type of meetings that we need and expect there. Otherwise, risk communication might be perceived as an unwarranted intrusion. Additional sensitivity is required when campaigns revolve around strong norms that easily give rise to feelings of guilt, such as norms of motherhood.

Pär Segerdahl

Nihlén Fahlquist, J. 2016. Experience of non-breastfeeding mothers: Norms and ethically responsible risk communication. Nursing Ethics 23: 231-241

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In dialogue with patients

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