Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

As algorithms pervade numerous facets of daily life, they are incorporated into systems for increasingly diverse purposes. These systems’ results are often interpreted differently by the designers who created them than by the lay persons who interact with them. This paper offers a proposal for human-centered algorithm design, which incorporates human and social interpretations into the design process for algorithmically based systems. It articulates three specific strategies for doing so: theoretical, participatory, and speculative. Drawing on the author’s work designing and (...) deploying multiple related systems, the paper provides a detailed example of using a theoretical approach. It also discusses findings pertinent to participatory and speculative design approaches. The paper addresses both strengths and challenges for each strategy in helping to center the process of designing algorithmically based systems around humans. (shrink)

This article seeks to shed light on civil commitment in the context of the opioid crisis, to sketch the existing legal landscape surrounding civil commitment, and to illustrate the relevant medical, ethical, and legal concerns that policymakers must take into account as they struggle to find appropriate responses to the crisis.

Our research on non-religion supports the proposed shift toward more interactive models of prejudice. Being nonreligious is easily hideable and, increasingly, of low salience, leading to experiences not easily understood via traditional or contemporary frameworks for studying prejudice and prejudice reduction. This context affords new opportunity to observe reverse forms of interactive prejudice, which can interfere with prejudice reduction.

No detailed description available for "Themes in Linguistics".

We define the notion of a completely determined Borel code in reverse mathematics, and consider the principle $CD - PB$, which states that every completely determined Borel set has the property of Baire. We show that this principle is strictly weaker than $AT{R_0}$. Any ω-model of $CD - PB$ must be closed under hyperarithmetic reduction, but $CD - PB$ is not a theory of hyperarithmetic analysis. We show that whenever $M \subseteq {2^\omega }$ is the second-order part of an ω-model (...) of $CD - PB$, then for every $Z \in M$, there is a $G \in M$ such that G is ${\rm{\Delta }}_1^1$-generic relative to Z. (shrink)

How do ethics show up in the everyday behaviors and conversations of researchers in a scientific laboratory? How does the microcosmic culture of the laboratory shape researchers’ understandings of scientific ethics? We, an interdisciplinary team representing anthropology, computer science, and rhetorical studies, investigated these questions in two university STEM labs. Similar to previous work mapping out the epistemic cultures, we sought to understand the ethical cultures of these research groups. We observed their lab meetings for several months and conducted interviews (...) with members of the research laboratories. Ultimately, we recognized two distinct ethical cultures within the two laboratories: one focused on the relationship between science and social justice, and the other focused on clean data and accuracy as an ethical issue. These two distinct ethical cultures were discernable through ethnography, close reading of laboratory members’ language, as well as broad-scale topic modeling. Our project complements previous studies of ethics in science that have focused on codes of ethics or student curricula as ways in which scientists develop an understanding of scientific ethics. Our project demonstrates that everyday interactions between the members of scientific research labs additionally shape, at a decidedly local level, how scientists understand and ultimately approach ethical decision-making in the scientific research process. (shrink)

This paper reports on the results of a survey of faculty members at California State University, Northridge in Los Angeles, California regarding their understanding of and familiarity with the concept of fake news. With very few studies published on the attitudes of teaching faculty at universities, this study is a unique approach to the issues facing educators, knowledge creators, and information specialists. The paper examines the origins of the term “fake news”, the factors contributing to its current prevalence, and proposes (...) a new definition. It also reports upon the attitudes that teaching faculty hold, and how they define fake news within their specific disciplines. Though nearly all surveyed faculty felt fake news was an important topic that impacted them professionally, the researchers also find that faculty across all disciplines and ranks, ages, and gender, hold widely differing conceptions of fake news. This lack of consensus may have future implications for students in particular and higher education in general and are worth exploring further. (shrink)

By using instrumentation initially designed for counting white blood cells, sperm counts have been utilized by clinicians since 1929, particularly to evaluate cases of suspected infertility. Although this basic biological parameter might be assumed to be stable over time, several studies over the past 20 years have suggested a decline in sperm count or density. The most controversial of these analyses was published in 1992. A flood of criticism followed this analysis of 61 studies that found a 50% decline in (...) sperm density between 1938 and 1990. Critics suggested that historical methods (of counting sperm or conducting studies) were variable and unreliable, differing from modern methods both qualitatively and quantitatively. To address this issue we analyzed these studies for trends in counting methods or their variability. We found neither. Alternative analyses produced some differences in trend estimates, but statistical factors alone could not account for the total decline in sperm density. We reviewed study populations to identify trends in population characteristics, such as abstinence time, that might explain the decline. However, controlling analytically for such factors only increased the rate of decline. We conclude that historical data on sperm density, despite large random error, are surprisingly reliable. Nonetheless, understanding causes of temporal and geographic differences in sperm density must await contemporary data. BioEssays 21:614–621, 1999. © 1999 John Wiley & Sons, Inc. (shrink)

In a recent study on the spawn of the common frog surveyed over several breeding sites, a significant linear relationship. An open question exists, as to why such a strong linear relationship is to be found. Using elementary physics, I suggest some factors which may underly the observed linearity and how it may reveal characteristics other than size of a breeding population. A follow-up experiment is outlined to test for these in the field and some ecological implications are discussed.

Although Brouwer is well known for his Intuitionistic philosophy of mathematics, a constructivist philosophy which calls for restricted use of certain logical principles, there is much less awareness of the well-developed metaphysical basis which underlies those restrictions. In the first half of this paper I outline a basic interpretation of Brouwer's metaphysics, and then in the second half consider the compatibility of that metaphysics with Dummett's argument for a principled non-metaphysical approach to intuitionism. I conclude that once the variously misleading (...) accretions of the central concepts - metaphysics and logic - are set aside, Dummett and Brouwer's accounts can be seen to be at the very least compatible, if not complementar. (shrink)

Contemporary Debates in Philosophy of Mind showcases the leading contributors to the field, debating the major questions in philosophy of mind today. Comprises 20 newly commissioned essays on hotly debated issues in the philosophy of mind Written by a cast of leading experts in their fields, essays take opposing views on 10 central contemporary debates A thorough introduction provides a comprehensive background to the issues explored Organized into three sections which explore the ontology of the mental, nature of the mental (...) content, and the nature of consciousness. (shrink)

Intraspecific niche variation can differentially impact community processes and can represent the initial stages of adaptive radiation. Here we test for intraspecific differences in niche use in a keystone species, the alewife (Alosa pseudoharengus). To test whether feedbacks between predator foraging traits and prey communities have led to differences in niche use, we compare the diet composition and trophic position of anadromous and landlocked alewife populations. These populations differ in phenotypic traits related to foraging (gill raker spacing, gape width, and (...) prey selectivity). Trait differences appear to have resulted from eco-evolutionary feedbacks between alewives and their zooplankton prey, and suggest that these two life history forms are exploiting different niches. Direct diets show that anadromous alewives consume a greater biomass of predatory copepods than do landlocked alewives. Anadromous alewives also consume more ostracods—a littoral prey item—as the growing season progresses. These diet differences do not translate into a significant difference in trophic position, as estimated from stable isotopes. However, stable-isotope estimates of diet source show that during early fall, anadromous alewives obtain significantly more of their dietary carbon from the littoral food web. This increased reliance on littoral prey is likely a result of a diet switch that occurs in response to the alewife-driven exhaustion of large-bodied prey items available in the pelagic zone, i.e., alewife niche construction. These findings show the existence of important intraspecific niche differences in the alewife and support the role of eco-evolutionary feedbacks in shaping these niche differences. The initiation of alewife divergence is the result of dam building by humans. Therefore, alewife niche differentiation can be considered to be an eco-evolutionary byproduct of human cultural niche construction. (shrink)

Although Brouwer is well known for his Intuitionistic philosophy of mathematics, a constructivist philosophy which calls for restricted use of certain logical principles, there is much less awareness of the well-developed metaphysical basis which underlies those restrictions. In the first half of this paper I outline a basic interpretation of Brouwer's metaphysics, and then in the second half consider the compatibility of that metaphysics with Dummett's argument for a principled non-metaphysical approach to intuitionism. I conclude that once the variously misleading (...) accretions of the central concepts - metaphysics and logic - are set aside, Dummett and Brouwer's accounts can be seen to be at the very least compatible, if not complementar. (shrink)