Fifty Years of U.S. Mass Incarceration and What It Means for Bioethics.

A growing body of literature has engaged with mass incarceration as a public health problem. This article reviews some of that literature, illustrating why and how bioethicists can and should engage with the problem of mass incarceration as a remediable cause of health inequities. "Mass incarceration" refers to a phenomenon that emerged in the United States fifty years ago: imprisoning a vastly larger proportion of the population than peer countries do, with a greatly disproportionate number of incarcerated people being members of marginalized racial and ethnic groups. Bioethicists have long engaged with questions of health justice for incarcerated people, including consent issues for those participating in research and access to health care. This article provides an overview of the individual and public health impacts of mass incarceration. The article argues that mass incarceration is a bioethics issue that should be addressed in medical education, identifies opportunities for bioethicists to guide hospitals' interactions with law enforcement officials, and calls on bioethicists to be in conversation with medical and nursing students and health care professionals about these groups' advocacy efforts concerning structural racism, police violence, and mass incarceration.

White Privilege, White Poverty: Reckoning with Class and Race in America.

This essay argues that a failure to think and talk critically and candidly about White privilege and White poverty is a key threat to the United States of America's precarious democracy. Whiteness frames one of America's most pressing collective challenges-the poor state of the nation's health, which lags behind other wealthy nations and is marred by deep and entrenched class- and race-based inequities. The broadscale remedies experts recommend demand what is in short supply: trust in evidence, experts, government, and one another. The authors' prescription is threefold, beginning with a call for intersectional health studies and reports that avoid one-dimensional misrepresentations of widespread health problems as simply Black or White problems. Second, there is the need for a "critical consciousness" about race and class. Lastly, the essay calls for widescale opportunities for Americans to engage in cross-racial and cross-class democratic conversations about their struggles and aspirations in search of common ground.

The challenges of choosing and explaining a phenomenon in epidemiological research on the "Hispanic Paradox".

According to public health data, the US Hispanic population is far healthier than would be expected for a population with low socioeconomic status. Ever since Kyriakos Markides and Jeannine Coreil highlighted this in a seminal 1986 article, public health researchers have sought to explain the so-called "Hispanic paradox." Several candidate explanations have been offered over the years, but the debate goes on. This article offers a philosophical analysis that clarifies how two sets of obstacles make it particularly difficult to explain the Hispanic paradox. First, different research projects define the Hispanic paradox phenomenon in substantially different ways. Moreover, using Bas van Fraassen's pragmatic theory of explanation and Sean Valles's extension of it with the concept of "phenomenon choice," it also becomes clear that there are also multiple ways of explaining each individual definition of the phenomenon. A second set of philosophical and methodological challenges arises during any attempt to study "Hispanic" phenomena, with one key challenge being that the "Hispanic" panethnic concept was intentionally made vague as it was developed and popularized during the 1960s-1970s. After comparing this case with similar cases in the philosophical literature, the article concludes with observations on what makes this problem unique, particularly its ethical features.

How a network of conservationists and population control activists created the contemporary US anti-immigration movement.

Continuing historical narratives of the early twentieth century nexus of conservationism, eugenics, and nativism (exemplified by Madison Grant), this paper traces the history of the contemporary US anti-immigration movement's roots in environmentalism and global population control activism, through an exploration of the thoughts and activities of the activist, John Tanton, who has been called "the most influential unknown man in America." We explore the "neo-Malthusian" ideas that sparked a seminal moment for population control advocacy in the late 1960s and early 1970s, leading to the creation of Zero Population Growth (ZPG). After rising to the presidency of ZPG, Tanton, and ZPG spun off the Federation for American Immigration Reform. After leaving ZPG's leadership, Tanton created additional anti-immigration advocacy groups and built up connections with existing organizations such as the Pioneer Fund. We trace Tanton's increasingly radical conservative network of anti-immigration advocates, conservationists, and population control activists to the present day. Tanton's archived papers illustrate, among other things, his interactions with collaborators such as ecologist Garrett Hardin (author of the famous "Tragedy of the Commons") and his documented interest in reviving eugenics. We contend that this history of Tanton's network provides key insights into understanding how there came to be an overlap between the ideologies and activist communities of immigration restrictionism, population control, conservationism and eugenics.

Coupled Ethical-Epistemic Analysis of Public Health Research and Practice: Categorizing Variables to Improve Population Health and Equity.

The categorization of variables can stigmatize populations, which is ethically problematic and threatens the central purpose of public health: to improve population health and reduce health inequities. How social variables (e.g., behavioral risks for HIV) are categorized can reinforce stigma and cause unintended harms to the populations practitioners and researchers strive to serve. Although debates about the validity or ethical consequences of epidemiological variables are familiar for specific variables (e.g., ethnicity), these issues apply more widely. We argue that these tensions and debates regarding epidemiological variables should be analyzed simultaneously as ethical and epistemic challenges. We describe a framework derived from the philosophy of science that may be usefully applied to public health, and we illustrate its application.

Bioethics and the Framing of Climate Change's Health Risks.

Cheryl Cox Macpherson recently argued, in an article for this journal, that 'Climate Change is a Bioethics Problem'. This article elaborates on that position, particularly highlighting bioethicists' potential ability to help reframe the current climate change discourse to give more attention to its health risks. This reframing process is especially important because of the looming problem of climate change skepticism. Recent empirical evidence from science framing experiments indicates that the public reacts especially positively to climate change messages framed in public health terms, and bioethicists are particularly well positioned to contribute their expertise to the process of carefully developing and communicating such messages. Additionally, as climate framing research and practice continue, it will be important for bioethicists to contribute to the creation of that project's nascent ethical standards. The discourse surrounding antibiotic resistance is posited as an example that can lend insight into how communicating a public health-framed message, including the participation of bioethicists, can help to override public skepticism about the findings of politically contentious scientific fields.

Heterogeneity of risk within racial groups, a challenge for public health programs.

Targeting high-risk populations for public health interventions is a classic tool of public health promotion programs. This practice becomes thornier when racial groups are identified as the at-risk populations. I present the particular ethical and epistemic challenges that arise when there are low-risk subpopulations within racial groups that have been identified as high-risk for a particular health concern. I focus on two examples. The black immigrant population does not have the same hypertension risk as US-born African Americans. Similarly, Finnish descendants have a far lower rate of cystic fibrosis than other Caucasians. In both cases the exceptional nature of these subpopulations has been largely ignored by the designers of important public health efforts, including the recent US government dietary recommendations. I argue that amending the publicly-disseminated risk information to acknowledge these exceptions would be desirable for several reasons. First, recognizing low-risk subpopulations would allow more efficient use of limited resources. Communicating this valuable information to the subpopulations would also promote truth-telling. Finally, presenting a more nuanced empirically-supported representation of which groups are at known risk of diseases (not focusing on mere racial categories) would combat harmful biological race essentialist views held by the public.

Should direct-to-consumer personalized genomic medicine remain unregulated?: a rebuttal of the defenses.

Direct-to-consumer personalized genomic medicine has recently grown into a small industry that sells mail-order DNA sample kits and then provides disease risk assessments, typically based upon results from genome-trait association studies. The companies selling these services have been largely exempted from FDA regulation in the United States. Testing kit companies and their supporters have defended the industry's unregulated status using two arguments. First, defenders have argued that mere absence of harm is all that must be proved for mail-order tests to be acceptable. Second, defenders of mail-order testing have argued that there is an individual right to the tests' information. This article rebuts these arguments. The article demonstrates that the direct-to-consumer market has resulted in the sidelining of clinical utility (medical value to patients), leading to the development of certain mail-order tests that do not promote customers' interests and to defenders' downplaying of a potentially damaging empirical study of mail-order genomic testing's effects on consumers. The article also shows that the notion of an individual right to these tests rests on a flawed reading of the key service provided by mail-order companies, which is the provision of medical interpretations, not simply genetic information. Absent these two justifications, there is no reason to exempt direct-to-consumer personalized genomic medicine from stringent federal oversight.

Lionel Penrose and the concept of normal variation in human intelligence.

Lionel Penrose (1898-1972) was an important leader during the mid-20th century decline of eugenics and the development of modern medical genetics. However, historians have paid little attention to his radical theoretical challenges to mainline eugenic concepts of mental disease. Working from a classification system developed with his colleague, E. O. Lewis, Penrose developed a statistically sophisticated and clinically grounded refutation of the popular position that low intelligence is inherently a disease state. In the early 1930s, Penrose advocated dividing "mental defect" (low intelligence) into two categories: "pathological mental defect," which is a disease state that can be traced to a distinct genetic or environmental cause, and "subcultural mental defect," which is not an inherent disease state, but rather a statistically necessary manifestation of human variation in intelligence. I explore the historical context and theoretical import of this contribution, discussing its rejection of typological thinking and noting that it preceded Theodosius Dobzhansky's better-known defense of human diversity. I illustrate the importance of Penrose's contribution with a discussion of an analogous situation in contemporary medicine, the controversial practice of using human growth hormone injections to treat "idiopathic short stature" (mere diminutive height, with no distinct cause). I show how Penrose's contributions to understanding human variation make such treatments appear quite misguided.