Why we should not "help bad choosers:" screening, nudging, and epistemic risk.

One prominent line of support for nudging in screening programs is the claim that nudging can help 'bad choosers' - that is, it can help some patients make choices more in line with their own values and preferences. In this article, I argue that due to the presence of epistemic risk in many screening programs, the argument that nudging can help 'bad choosers' should be revised or rejected. Expanding on the work of Biddle, J. B. 2020. Epistemic risks in cancer screening: Implications for ethics and policy. Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 79: 101200.), I argue that epistemic risk undermines the argument that nudging can help to promote patient autonomy in the context of screening. Specifically, I argue that epistemic risk results in the inclusion of non-patient values and preferences in the screening process, which challenges the claim that nudging can help patients make choices more in line with their own values and preferences. I present four reasons to think epistemic risk undermines the argument in this way: (1) conflicting values; (2) lack of transparency; (3) limited autonomy in opting out; (4) unjustified manipulation. The presence of epistemic risk in screening programs means that nudging may not always be an effective means of promoting patient autonomy and informed consent. As such, epistemic risk poses significant challenges to at least one ethical justification of nudging in screening programs, and raises further questions about the role of nudging in promoting patient decision-making.

Best to possibly not be: A prudential argument for antinatalism.

This article starts by examining the present state of death ethics by attending to the euthanasia debate. Given that voluntary active euthanasia has seen strong support in the academic community, insights on the choiceworthiness of continued existence may be derived. Having derived cases of choiceworthy nonexistence (which I refer to as choiceworthy nonexistence [CNE] cases), I extend these intuitions to lives not worth starting, or choiceworthy nonexistence for potential people (which I refer to as foetal-CNE, or fCNE cases). Although I depart from Benatarian antinatalism by rejecting Benatar's claim that all existence is necessarily a harm, I posit a weaker argument that all existence is likely a harm since we cannot know until later in life if an existence is a harm. If I am right, then we have prudential reasons not to bear children, since they are more likely to suffer in lives not worth living than not.

Exposure to COVID-19 is associated with increased altruism, particularly at the local level.

Theory posits that situations of existential threat will enhance prosociality in general and particularly toward others perceived as belonging to the same group as the individual (parochial altruism). Yet, the global character of the COVID-19 pandemic may blur boundaries between ingroups and outgroups and engage altruism at a broader level. In an online experiment, participants from the U.S. and Italy chose whether to allocate a monetary bonus to a charity active in COVID-19 relief efforts at the local, national, or international level. The purpose was to address two important questions about charitable giving in this context: first, what influences the propensity to give, and second, how is charitable giving distributed across different levels of collective welfare? We found that personal exposure to COVID-19 increased donations relative to those not exposed, even as levels of environmental exposure (numbers of cases locally) had no effect. With respect to targets of giving, we found that donors predominantly benefitted the local level; donations toward country and world levels were half as large. Social identity was found to influence charity choice in both countries, although an experimental manipulation of identity salience did not have any direct effect.

The Case of Billy Best: 25 Years Later.

Billy Best was diagnosed with Hodgkin lymphoma in 1994 at age 16 and became well-known when he ran away from home to avoid receiving further chemotherapy. His story became national news when, with the support of his adopted parents, he returned home and opted to use complementary and alternative medicine (CAM) instead of standard chemotherapy and radiation for his cancer treatment. Now 25 years since Billy Best entered the public eye, his story is one that is frequently referenced in pediatrics, bioethics, and other related fields. Here, the authors examine the evolution of various features of this case, including treatment of Hodgkin lymphoma, the interplay between medicine and the media, the role of CAM in pediatric care, navigating entrenched disagreements and how best to integrate adolescents into health care decision-making, and the role of narrative in medical practice. The authors explore the unique role of each of these facets of Billy Best's case, describing how each has or has not changed in the quarter century since that time amid the changing landscape of pediatric health care. Ultimately, although many advances have occurred since Billy Best's time, significant work remains. Additional effort will be required in the future to optimize communication, improve treatment toxicities from Hodgkin lymphoma without decreasing survival, integrate the voice and perspective of adolescents into their treatment decisions, and navigate the roles of CAM and the media in pediatric health care.

Biomedical career enrichment programs: Exploring women and minority participants' motivators and outcomes.

Limited empirical data exists on why women and minority students enter Biomedical Career Enrichment Programs (BCEPs) and how program variables-such as duration of research-influence their intention to pursue research careers. This exploratory study reports motivators for participation in BCEPs among women and racial/ethnic minority students-historically underrepresented groups-and the influence of program and personal variables on their research-career intent and self-efficacy beliefs. We studied the program variables of research experience, research duration, and mentor influence; and the personal variables of race, gender, family, and peers. Using the conceptual framework of planned behavior theory and social cognitive career theory, we interviewed students from underrepresented groups participating in BCEPs that offered research experience for short duration (Group A), long duration (Group B), and no research experience (Group C). We utilized Atlas Ti, a qualitative methodological software tool, to analyze the interview responses. Students choosing a BCEP with research experience cited "opportunity to gain experience" and "interest or curiosity in research" as motivators. Duration of research experience had a positive relationship with enhancement in research skills and self-efficacy beliefs, but did not change the initial research-career intent of these BCEP participants. The study revealed an interesting and unexpected theme of "perceived deterrents" to a career in research that included stress of competition (e.g. grants), the instability of projects, and the isolation of scientific research. Importantly, the study findings indicate the need to reform program design and science policies that challenge the current biomedical workforce and dissuade interested students from underrepresented groups from entering the field.

A little good is good enough: Ethical consumption, cheap excuses, and moral self-licensing.

This paper explores the role of cheap excuses in product choice. If agents feel that they fulfill one ethical aspect, they may care less about other independent ethical facets within product choice. Choosing a product that fulfills one ethical aspect may then suffice for maintaining a high moral self-image in agents and render it easier to ignore other ethically relevant aspects they would otherwise care about more. The use of such cheap excuses could thus lead to a "static moral self-licensing" effect, and this would extend the logic of the well-known dynamic moral self-licensing. Our experimental study provides empirical evidence that the static counterpart of moral self-licensing exists. Furthermore, effects spill over to unrelated, ethically relevant contexts later in time. Thus, static moral self-licensing and dynamic moral self-licensing can exist next to each other. However, it is critical that agents do not feel that they fulfilled an ethical criterion out of sheer luck, that is, agents need some room so that they can attribute the ethical improvement at least partly to themselves. Outsiders, although monetarily incentivized for correct estimates, are completely oblivious to the effects of moral self-licensing, both static and dynamic.

Removing Harmful Options: The Law and Ethics of International Commercial Surrogacy.

Focusing on the UK as a case study, this article argues that having the choice to enter into an international commercial surrogacy arrangement can be harmful, but that neither legalisation nor punitive restriction offers an adequate way to reduce this risk. Whether or not having certain options can harm individuals is central to current debates about the sale of organs. We assess and apply the arguments from that debate to international commercial surrogacy, showing that simply having the option to enter into a commercial surrogacy arrangement can harm potential vendors individually and collectively, particularly given its sexed dimension. We reject the argument that legalizing commercial surrogacy in the UK could reduce international exploitation. We also find that a punitive approach towards intended parents utilizing commercial rather than altruistic services is inappropriate. Drawing on challenges in the regulation of forced marriage and female genital cutting, we propose that international collaboration towards control of commercial surrogacy is a better strategy for preserving the delicate balancing of surrogate mothers' protection and children's welfare in UK law.

Development and evaluation of decision aids for people considering taking part in a clinical trial: a conceptual framework.

Ethical requirements of informed consent stipulate that patients approached to participate in a clinical trial be provided with written information that must cover key aspects of the trial. For consent to be deemed "informed", potential participants should be provided with a range of information about the trials (e.g., the trial aims, the anticipated benefits and potential risks of the trial, and their right to withdraw consent at any time). However, it is well documented that simple provision of this information does not ensure that participants make truly informed decisions. Decision aids, tools that have been shown in a treatment and screening context to support better-quality decisions, are emerging as a possible vehicle to support decision making about trial participation. However, information on how they should best be developed and evaluated in a clinical trial context is lacking. Therefore, this article, drawing on theoretical and empirical insights, outlines a framework for the development and evaluation of decision aids for people considering taking part in a clinical trial.

The value of diagnostic testing for parents of children with rare genetic diseases.

PURPOSE: Exome sequencing (ES) can rapidly identify disease-causing variants responsible for rare, single-gene diseases, and potentially reduce the duration of the diagnostic odyssey. Our study examines how parents and families value ES. METHODS: We developed a discrete choice experiment (DCE) survey that was administered to parents of children with rare diseases. The DCE included 14 choice tasks with 6 attributes and 3 alternatives. A valuation-space model was used to estimate willingness to pay, willingness to wait for test results, and minimum acceptable chance of a diagnosis for changes in each attribute. RESULTS: There were n = 319 respondents of whom 89% reported their child had genetic testing, and 66% reported their child had a diagnosis. Twenty-six percent reported that their child had been offered ES. Parents were willing to pay CAD$6590 (US$4943), wait 5.2 years to obtain diagnostic test results, and accept a reduction of 3.1% in the chance of a diagnosis for ES compared with operative procedures. CONCLUSION: Timely access to ES could reduce the diagnostic odyssey and associated costs. Before ES is incorporated routinely into care for patients with rare diseases in Canada and more broadly, there must be a clear understanding of its value to patients and families.

Rationalization is rational.

Rationalization occurs when a person has performed an action and then concocts the beliefs and desires that would have made it rational. Then, people often adjust their own beliefs and desires to match the concocted ones. While many studies demonstrate rationalization, and a few theories describe its underlying cognitive mechanisms, we have little understanding of its function. Why is the mind designed to construct post hoc rationalizations of its behavior, and then to adopt them? This may accomplish an important task: transferring information between the different kinds of processes and representations that influence our behavior. Human decision making does not rely on a single process; it is influenced by reason, habit, instinct, norms, and so on. Several of these influences are not organized according to rational choice (i.e., computing and maximizing expected value). Rationalization extracts implicit information - true beliefs and useful desires - from the influence of these non-rational systems on behavior. This is a useful fiction - fiction, because it imputes reason to non-rational psychological processes; useful, because it can improve subsequent reasoning. More generally, rationalization belongs to the broader class of representational exchange mechanisms, which transfer information between many different kinds of psychological representations that guide our behavior. Representational exchange enables us to represent any information in the manner best suited to the particular tasks that require it, balancing accuracy, efficiency, and flexibility in thought. The theory of representational exchange reveals connections between rationalization and theory of mind, inverse reinforcement learning, thought experiments, and reflective equilibrium.

Ethical Criteria for Health-Promoting Nudges: A Case-by-Case Analysis.

Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google's rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most-but not all-nudges in most-but not all-circumstances.

Contextual influence on confidence judgments in human reinforcement learning.

The ability to correctly estimate the probability of one's choices being correct is fundamental to optimally re-evaluate previous choices or to arbitrate between different decision strategies. Experimental evidence nonetheless suggests that this metacognitive process-confidence judgment- is susceptible to numerous biases. Here, we investigate the effect of outcome valence (gains or losses) on confidence while participants learned stimulus-outcome associations by trial-and-error. In two experiments, participants were more confident in their choices when learning to seek gains compared to avoiding losses, despite equal difficulty and performance between those two contexts. Computational modelling revealed that this bias is driven by the context-value, a dynamically updated estimate of the average expected-value of choice options, necessary to explain equal performance in the gain and loss domain. The biasing effect of context-value on confidence, revealed here for the first time in a reinforcement-learning context, is therefore domain-general, with likely important functional consequences. We show that one such consequence emerges in volatile environments, where the (in)flexibility of individuals' learning strategies differs when outcomes are framed as gains or losses. Despite apparent similar behavior- profound asymmetries might therefore exist between learning to avoid losses and learning to seek gains.

Ethical and religious dilemmas of modern reproductive choices and the Islamic perspective.

Advances in the field of Assisted Reproductive Technologies (ART) are constantly evolving, starting from Artificial Insemination (AI) and in-vitro fertilization (IVF), to the current state of the art technologies that enable embryo biopsy for Pre-implantation Genetic Testing (PGT). The future includes gene mapping and DNA replacement technologies with the potential for the so-called "designer babies." In other words, shortly, a modern couple may be in a position to decide how to procreate and with whom; which pregnancy to keep and which one to terminate depending on their prior knowledge about the pregnancy and the available choices. This article addresses the moral, ethical, legal and religious dilemmas as a result of these technological advances in the field of ART and how these new challenges are addressed theologically in the Islamic world where the state law is strongly influenced by religion. This article sets out to discuss relevant issues and dilemmas but does not seek to prioritize or promote any opinion or view over any other religion/sect, ethical or legal opinion or view.

An ethical appraisal of the choice of vaccines against Poliomyelitis.

Medical ethics is invoked for immunisation of children as it involves an interaction between a healthcare professional and the child. Immunisation under the national immunisation programme is a public health intervention and the common belief is that ethics is not relevant. Two vaccines with contrasting safety and efficacy profiles were available against polio before the national immunisation programme was launched: the inactivated poliovirus vaccine (IPV) and the live attenuated oral poliovirus vaccine (OPV). India chose OPV and excluded IPV. We carried out an ethical appraisal of that choice. Principles of medical ethics comprising four elements-non-maleficence, beneficence, autonomy and justice-was already in vogue at the time. Applying each of them, a head-to-head comparison between IPV and OPV is made. The results clearly show that the choice of vaccine was made without using ethical principles, resulting in serious adverse effects in hundreds of thousands of children. We recommend that medical ethics must be applied to all choices of public health interventions.

Chimpanzees' understanding of social leverage.

Social primates can influence others through the control of resources. For instance, dominant male chimpanzees might allow subordinates access to mate with females in exchange for social support. However, little is known about how chimpanzees strategically use a position of leverage to maximize their own benefits. We address this question by presenting dyads of captive chimpanzee (N = 6) with a task resulting in an unequal reward distribution. To gain the higher reward each individual should wait for their partner to act. In addition, one participant had leverage: access to an alternative secure reward. By varying the presence and value of the leverage we tested whether individuals used it strategically (e.g. by waiting longer for partners to act when they had leverage in the form of alternatives). Additionally, non-social controls served to show if chimpanzees understood the social dilemma. We measured the likelihood to choose the leverage and their latencies to act. The final decision made by the chimpanzees did not differ as a function of condition (test versus non-social control) or the value of the leverage, but they did wait longer to act when the leverage was smaller-particularly in test (versus non-social control) trials suggesting that they understood the conflict of interest involved. The chimpanzees thus recognized the existence of social leverage, but did not use it strategically to maximize their rewards.