justice

Why I Am Not Your Ally

R. Horton1 Comment

In response to injustice against members of various communities, those affected rise up, thank goodness, against the injustice accompanied by their allies from outside the community. Thus, the black community has white allies, the gay community has straight allies, women have male allies, and so on. I want to join all these communities in the struggle for justice, but I’ve never felt any connection with the word “ally.” Perhaps I over think things (I’ve certainly been told I do), and I can see why some people would see an “alliance” as a good thing, but I really think the idea of an ally preserves the concept of division and otherness.

The source of most oppression comes from this concept of otherness. Simone de Beauvoir told us, “No group ever sets itself up as the One without at once setting up the Other over against itself.” Thus, she says, “In small-town eyes all persons not belonging to the village are ‘strangers’ and suspect; to the native of a country all who inhabit other countries are ‘foreigners’; Jews are ‘different’ for the anti-Semite, Negroes are ‘inferior’ for American racists, aborigines are ‘natives’ for colonists, proletarians are the ‘lower class’ for the privileged.” It is the distinction between One and Other that is the source of the problem. If the One becomes an advocate for the Other, does this change the balance of power? I argue that it does not. The ally speaks from a position of power on behalf of the less fortunate, often with the expectation that the weaker party will feel and exhibit an overflowing gratitude. At least, that is how it feels to me.

All the same, we can’t ignore our differences from others. It is important to preserve cultural distinctions, for example. Only the Deaf community fully understands the special problems faced by deaf people. Only the Native American community can understand injustices against Native Americans. And so on. What unites us in our struggle, though, is that we all are able to understand what injustice is. Those of us who are outraged, disgusted, and revolted by injustice, will react with those feelings every time we see it, regardless of the specific circumstances or characteristics of the victim. At least this is what I hope. When I react to injustice, I don’t do it because I feel someone deserves my sympathy or respect. I do it because I am offended by injustice. The specific qualities of the victim are not the source of my outrage.

This isn’t to say the specific qualities of the victim are not relevant, especially regarding discussions of how to understand and address the injustice. We need to have conversations so that we can understand each other. As Kwame Athony Appiah put it in his book, Cosmopolitanism, “We take seriously the value not just of human life but of particular human lives, which means taking an interest in the practices and beliefs that lend them significance.” We must also understand the experiences of others. Through conversation, stories, art, music and language we can share experiences and enhance our ability to imagine the lives of others. By understanding the experiences of others, we are better able to understand that their experiences are morally inexcusable.

Affirming justice requires us to see the common humanity we have with others. Those who harbor feelings of innate superiority are easily enticed to barbarous behavior. David Hume notes that Europeans had such feelings of superiority over natives in America that it “made us throw off all restraints of justice, and even humanity, in our treatment of them.” He goes on to describe similar treatment of women, owing to the fact that men “have in all countries bodily force sufficient to maintain this severe tyranny.” Those who are able to disregard the humanity of others and have the power to force them in to submission feel entitled to exercise their power. It is my contention that the person who does not carry feelings of entitlement will be sickened by the abuse of others. When we recognize our shared experiences with others, feelings of entitlement dissolve. When we feel an innate superiority, entitlement is cemented in our psyche.

The people who are most able to recognize their common humanity are those who have experienced injustice or at least recognized the possibility that they might. I don’t mean those threatened by the loss of their own power or privilege but those who recognize that we are all inferior in someone else’s eyes. The rage against injustice against other races or citizens in other countries is a rage against injustice that could befall anyone at any time. Often marginalized and oppressed groups recognize the oppression of other groups before the privileged can see. Declaring that someone is privileged, however, has its own hazards. A person’s oppression may not be readily apparent on his or her face or skin or other aspects of personal appearance. Religious, sexual, gender, and cultural differences are not always visible on the skin, but these differences often lead to extreme oppression and violence.

Occasionally, people are unable, flawed as we all are, to recognize their common humanity allieseven with those with whom they have no discernible differences. Consider the bitter conflict between the Hutu and the Tutsi in Rwanda. In a 1996 interview with Charlayne Hunter Gault, Professor George Izangola described the lack of differences between the two groups: “In Rwanda, the Tutsi and the Hutu are the same people. They are all people–large grouping or communities which go from seven regions of Cameroon to Uganda–all the way to South Africa, in the same culture. People used to be Tutsi or Hutu, depending on the proximity to the king. If you were close to the king, you owned wealth, you owned a lot of cattle, you are a Tutsi. If you are far away from the king, you are a cultivator, you don’t own much cattle, you are a Hutu.” (I’ve taken this quote from PBS here.)

If some of us can deny the humanity of those who look almost exactly like us, then “otherness” is a phenomenon that goes beyond race and gender. We either recognize that we are part of humanity or we do not. One way leads to freedom and the other to fascism. In “The Ethics of Ambiguity,” Simone de Beauvoir declares that we are each in a subjective struggle for freedom but that we are defined in our relationship to others. Our struggle for our freedom entails a will for the freedom of others. She says the activist “exists only by transcending himself, and his freedom can be achieved only through the freedom of others. He justifies his existence by a movement which, like freedom, springs from his heart but which leads outside of him.”

For Beauvoir’s activist, the constant push for freedom is a push for humanity. In this sense, an injustice anywhere is, indeed, a threat to justice everywhere, as the saying goes. The existence of injustice itself destroys the condition of freedom. Resistance is, she says, the annihilation of injustice. In an apparent paradox, I struggle alone but alongside and in relation to others. As your struggle is yours alone, my struggle is mine alone. Rather than acting as an ally seeking justice on your behalf, we must work together to secure freedom on our own account, which requires freedom for all.

Your health choked by the invisible hand of the market

R. Horton

Sometimes the invisible hand of the markets is all too apparent as it clutches us by the neck and strangles us slowly and painfully. If you are a typical adult American, you are likely to have at least one prescription for a drug indefinitely, either until you die or another drug is developed to replace it.

In the world of libertarian fantasy, pharmaceutical companies would compete to develop drugs we need to cure diseases that plague us. Hoping to sell us their products, they would race to develop effective and inexpensive drugs that consumers would rush to purchase. Unfortunately, those profits would be short-lived. People would buy the drugs, get well, and go about their business drug-free and non-contagious. Companies can make some money that way for sure, but it is much more lucrative to develop drugs that do not cure anyone but simply maintain their health.

This is why we have so many drugs for cholesterol, blood pressure, acid reflux, and other chronic conditions with fewer drugs aimed at eliminating disease, and even fewer aimed at curing (or even treating) diseases that affect those too poor to pay for expensive remedies. The fact that there is any treatment, even in early experimental drug trials, for Ebola is thanks to government funding of research. Left to markets alone, the diseases that kill the most people in the world would be completely ignored by drug companies.

Some diseases, such as Type II Diabetes, affect poor people, but drug companies spend quite a bit of time developing treatments for them. This, of course, is because enough people receive insurance payments from private insurance or Medicare and Medicaid to make treating them worthwhile. Almost 27 percent of Medicare beneficiaries 65 or older have diabetes, accounting for 32 percent of Medicare spending.  in 2002, Medicaid expenditures for people 20 and over with diabetes were estimated at more than $18 billion.

Of course, diabetes also affects people who are relatively affluent by global standards. In fact, it is considered a disease of babymotherdeathoverconsumption notwithstanding the fact that many who suffer from diabetes in the US are less affluent. Thus, it is extremely profitable for companies to develop products and services for diabetics in the US where their profits are underwritten by taxpayers. Diseases that primarily affect impoverished people in poor countries get much less attention.

It would seem likely that donations from individuals could fund research and development into alleviating disease. Indeed, the ALS ice bucket challenge raised more than $100 million as of this writing for research and treatment of ALS. But this again, leaves the allocation of resources to the mercy of marketing campaigns. ALS is a cruel disease, and it will only be a blessing if a cure can be found, but diseases that affect primarily impoverished individuals (e.g., malaria, antimicrobial resistance, trachoma) in the world are still waiting for a viral marketing campaign to draw attention to the millions that die from them. Market-based approaches drive money to those with the most influence.

In order to reduce the burden of diseases that affect the most people, we must provide research funds that are distributed where they will be most effective, rather than where the market funnels them. We need research centers funded by money offered with no conditions with the charge only to reduce mortality and relieve suffering. Such centers could be funded by government money or by individual contributions, but funding must come with no strings attached other than a demand for transparency from researchers as to how the money is used and what diseases are being treated. Some have offered solutions that would rely on industry to conduct research and develop products to alleviate suffering, but industry cannot be trusted with this task. Industry will always develop products to maximize profits, not minimize suffering.

The so-called “rugged individualists” in our society would argue that each person should have the healthcare he or she can afford, as income is a reliable measure of a person’s worth. Unfortunately, disease doesn’t attack people on the basis of merit. Honest and hard-working individuals can and do fall ill or become injured. Some are surprised by their turn of fortune. It is easier for a wealthy person to become poor than it is for a poor person to become wealthy, and disease and injury are great conveyors to the lower classes. Some, of course, are rich enough to be indifferent to the cost of healthcare or even long-term care. Even without working at all, these individuals will be housed, fed and treated.

People who work for their income, though, even in highly paid professions, are vulnerable to losing everything to healthcare costs. The “excellent” health insurance many people rely on is tied to employment and employment is tied to health. The unlucky ones who become ill lose both in a heartbeat. Bad luck isn’t a matter of bad choices or immorality; it is only a matter of chance. Libertarians argue, basically, that people should be responsible for the choices they’ve made in life, but libertarians also feel the government should protect people from events and circumstances out of their control. Thus, libertarians support the use of government funds to provide courts, police, and standing armies to protect the security of citizens.

The risk of disease and injury threatens us all. The question is whether we, as a society, should take responsibility for protecting all our citizens from this threat. If we don’t do this through government action, we must do it through collective action. Single-payer healthcare, such as all other developed nations have, is the most obvious solution to making citizens secure. Other solutions exist, and can be considered, but no one can prepare for catastrophe alone—collaboration is required.

We must provide funding for both medical research and healthcare. I am not asking you to provide healthcare for someone else. I am asking you to share the burden of providing healthcare for yourself. Sure, there is the chance you will never need it, but your chances are no better than anyone else’s. If we are not all secure, we are all insecure, we are at risk of being choked by the invisible hand. If we are insecure, we are not free.

 

 

 

 

 

Ebola and the ethics of international drug testing

R. Horton

Ebola has been around for nearly 40 years now, and until recently the public was unaware of any available treatments or treatments in development for the disease. In fact, there is no market incentive for pharmaceutical companies to develop treatments as most of its victims are too poor to buy medicines. If and when Ebola spreads to more affluent parts of the world, of course, pharmaceutical companies will adjust their research and development strategies.

As market incentives for development of treatments do not exist, it falls to governments to fund research into possible treatments and vaccines. As Marie-Paule Kieny, assistant director-general of the World Health Organization (WHO), pointed out, “If it hadn’t been for the investment of a few governments in the development of these drugs, we would be nowhere.” Much of the funding for research has come from the United States, not from humanitarian concerns for Africans, but for domestic concerns. According to a Globe and Mail article by Geoffrey York, “most of the research on Ebola treatments has been financed by the U.S. government, often because of fears that the Ebola virus could be used aesculab-stabas a form of bioterrorism.” Be that as it may, it is a relief to know that someone is working on treatment and prevention.

As the disease has occurred in Africa, you might expect that research on it should also occur in Africa with robust drug trials being conducted in an ongoing basis, Bioethicist Arthur Caplan  says it is unreasonable to expect the research to happen in Africa. He wrote, “Privileged humans were always going to be the first ones to try it. ZMapp requires a lot of refrigeration and careful handling, plus close monitoring by experienced doctors and scientists—better to try it at a big urban hospital than in rural West Africa, where no such infrastructure exists.” ZMapp is the drug given to the Americans who contracted Ebola in Africa before being flown back to the US for treatment.

It might be possible for pharmaceutical companies to build such infrastructure, but Caplan encapsulates the real reason research does not happen in Africa nicely: “Drugs based on monoclonal antibodies usually cost a lot—at least tens of thousands of dollars. This is obviously far more than poor people in poor nations can afford to pay; and a tiny company won’t enthusiastically give away its small supply of drug for free.” Enthusiastically give away? No, they won’t even develop the drug in the first place.

Now that an experimental treatment (ZMapp) does exist, should it be tested on Africans? Bioethicist George Annas says, “If the drugs we are currently working on have been shown to be reasonably safe, and if there is realistic and robust African review and individual informed, voluntary consent, use of American-developed drugs in Africa could be justified.” Annas is here emphasizing the protection of possible African research participants rather than explaining why only the privileged should receive the drug, and he has good reason.

It isn’t as though the lack of infrastructure in Africa has prevented drug trials from taking place there in the past as you might imagine from the debate over Ebola drugs. In fact, testing has raised serious issues of exploitation in the past as drugs were tested on vulnerable populations with no intention of ever providing those same populations with any treatments that might be developed. In 1994, the HIV drug, AZT (zidovudine) was found (in a study known as AIDS Clinical Trials Group 076)  to prevent transmission from HIV-positive mothers to their infants. The study was considered important in the development of drugs to treat AIDS, but there were no plans to provide AZT to the communities where it was tested once the clinical trials concluded. Research subjects in Africa bore the risks associated with taking experimental medications but would not see the benefits of the medications developed.

As there is no market incentive for pharmaceutical companies to develop treatments while protecting research subjects in vulnerable populations, it is up to governments to help promote treatments for unprofitable diseases. This has obviously happened to an extent., but we could, and should, do more. Philosopher Thomas Pogge has initiated a plan to help improve the situation. He has proposed a Health Impact Fund  that would provide a sort of artificial market incentive for companies to develop otherwise unprofitable treatments. Under the plan, governments would contribute to a fund that would then be distributed to pharmaceutical companies based on their ability to develop drugs that would have the greatest health impact. In order to receive payments from the HIF, companies would agree to provide treatments at cost anywhere in the world. I don’t know whether the Health Impact Fund will provide a solution to treating diseases that primarily affect the poor, but it certainly represents the kind of thinking required to address these serious issues.

If we are not motivated by the suffering of others in the world, and it appears many in affluent countries are not, we may do well to recognize that diseases do spread beyond all borders. Diseases that do not affect us today may well affect us tomorrow. The so-called “free” market is obviously not the solution, so we will do well to consider other options.

Our Bodies, Ourselves and the birth of bioethics

R. Horton

The first works of academic bioethics I read were by notables such as Peter Singer, James Rachels, and Bonnie Steinbock, but that is not where my interest in bioethics actually began. In the 1980s, I ran across the book, Our Bodies, Ourselves, and I was immediately captivated by the book and the movement it represented, even if I wasn’t part of the particular movement.

The book began as an outgrowth of the feminist movement when 12 women met in 1969 to discuss their experiences with doctors. They began compiling and disseminating their stories and information to empower women to take charge of their own healthcare decisions. Bioethics as a professional field developed in the 1970s, but the authors of Our Bodies, Ourselves were ahead of professional bioethicists by a few years. In 1970, these authors released a booklet titled “Women and Their Bodies.” While professional bioethicists focused on the role of autonomy in healthcare, these women were creating autonomy by giving women information and the courage to take charge of their own healthcare. You can read more about the history here.

At the time these women met, abortion was illegal and most doctors were male. As the authors explained in the preface to the first edition of the book, “we wanted to do something about those doctors who were condescending, paternalistic, judgmental and noninformative.” To combat the attitudes they found common in doctors, they presented information on birth control, abortion, menstruation, masturbation, and sexuality in frank and shame-free language. As a outcome of the approach, they said, “Our image of ourselves is on a firmer base, we can be better friends and better lovers, better people, more self-confident, more autonomous, stronger and more whole.”

Our Bodies, Ourselves, the book, continues to be published (now in more than two-dozen languages), and the organization, Our Bodies Ourselves (OBOS), continues as a nonprofit organization promulgating information on girls’ and women’s health and sexuality. Their efforts now extend globally through the Our Bodies Ourselves Global Initiative (OBOGI).

These women approached bioethics from the ground up and changed the world.

This is how I feel bioethics should be conducted for the greatest impact. Patients, ideally, should drive the focus of bioethics and inform both ethicists and healthcare providers of what issues are important. The only way for this to happen is for patients to tell their stories of how they experienced healthcare, medicine, illness, and even death.

To that end, I am inviting patients to submit their own stories of illness and medicine to Ethics Beyond Compliance. If you would like to submit a story related to your experience of illness (either as a patient or as a caregiver) or grief, please send it to me. I will have a story coming up in the next few days, but I hope to make it a regular feature of the blog.

See also: O is for Our Bodies, Ourselves

Why men don’t speak out against sexism and misogyny

R. Horton3 Comments

When we feel ashamed or judged, we have several possible ways of responding. One IMG_0516method of dealing with shame is to defend yourself vigorously, to deny anything is wrong, and to attack those who might think differently. We can imagine the loud protests of Hamlet’s mother, though perhaps Hamlet’s attack on his mother is equally revealing. A second method, which is my preferred method, is to try to suppress it, hide it, and pretend it does not exist, and I think I have plenty of company with millions of people struggling with feelings of inadequacy, guilt, and a myriad of shortcomings. This kind of shame destroys you from the inside out. The third and most difficult method of dealing with shame is to acknowledge it, confront it, and try to resolve it in some way. When we meet individuals who can do this, we admire them, praise them, and exalt them, which is as it should be. Think of a former member of the KKK who becomes a civil rights leader, for example.

In the aftermath of Elliot Rodgers’ mass killing, pundits, analysts, feminists, psychologists, and just about everyone else has jumped to understand and explain what may cause someone to want to kill with such intensity and drive. It appears that Rodgers dealt with feelings of deep shame and inadequacy because he felt he failed as a man because he couldn’t convince women to have sex with him. Many men, even those who have had their share of sexual encounters, share his shame, but fewer question the assumptions that create that shame. Men are expected to be on a constant mission to prove themselves through sexual conquests, and most men internalize this to one degree or another in the same way that women internalize attitudes toward body image.

It isn’t surprising, then, that many men reacted defensively to discussions of sexist attitudes and their dire consequences. Who is going to say, “I see now that I’ve bought into a dangerous belief system. I see that my way of thinking leads to mass murder.”? Not many, which might explain the emotional and unrelated defenses of Glenn Beck, Seth Rogen, and all the men who reacted negatively to #yesallwomen. Beck went on a long tirade against the idea that sexual assault and harassment is prevalent and suggested that people are calling normal, consensual sex rape. Rogen responded to Ann Hornaday’s critique of media that depicts women as trophies by tweeting, ““How dare you imply that me getting girls in movies caused a lunatic to go on a rampage.”

These men want to make clear that they are not part of the problem. They recognize that their attitudes and maybe even their actions are now being criticized as part of the problem, and they are saying, “Hey, don’t point the finger at me.” They may also realize they have internalized the values that oppress and torture men. We may want to respond to #yesallwomen with #notallmen, but the fact is that all men, at least in my culture, are familiar with the beliefs and attitudes that shame men for “purity” and women for “sexual prowess.” We feel it deep in our bones, and it makes us uncomfortable.

In the next wave, many women wonder why more “enlightened” men don’t speak up and stand with them. To be fair, many men have shown the courage to do this, but doing so requires us all to look inside and examine what we may prefer to hide and suppress. You don’t have to be a rapist or a murderer to recognize common feelings or assumptions you may have or may have once had, and it can create a kind of soul-burning shame.

Few tasks in life are as difficult as confronting our own shame. The attitudes and beliefs that define us as men and women touch us at the core of our being. A thoughtful, honest, complex, and courageous discussion of how to liberate and protect men and women will be lengthy and arduous, but a better world is possible.

PS: And let’s have a discussion about access to guns as well.

For more on shame, see the work of Brené Brown.

 

Horton’s Taxonomy of Racial Prejudice

R. Horton1 Comment

It seems we keep having people make racist remarks and then proclaim, defensively, that they are not racists. Some people are so hostile that their claims of innocence are both laughable and infuriating, but others seem genuinely bemused by the accusation that they are racist. It doesn’t seem possible that anyone could be so clueless, their critics think, that their attitudes would not be obvious to them. In other cases, people strive with everything they have against being racist, only to find to their dismay and horror that they have unconscious racial biases.

In order to sort things out, I think we need to recognize a few categories of racism:

1. Overt racial hostility. In this category we have white supremacists (or other kinds of supremacists, even, depending on your location and circumstances). People in this category believe other races are inferior and will not apologize for saying so. We can renounce them, but we aren’t likely to shame them, as they are quite self-righteous in their belief in their own superiority (leaving their latent fears and anxieties aside for the moment).

2. Racial Prejudice. Some people say they don’t hate anyone or want anyone harmed, but they just happen to believe it is a brute fact that people from different races are different and have different abilities and preferences. People in this category can be the most confounding, as they might say things that are outlandish to the rest of us and then become extremely offended that anyone could possibly accuse them of racism. “I don’t hate such and such people, but they sure hate hard work. God love ‘em.”

3. Racial insensitivity. Sometimes people genuinely don’t mean any harm at all but have no idea how their comments may hurt others. Assuming a person of a particular race enjoys a certain kind of music, dance, food, or whatever may seem completely reasonable to you while it reduces that person to a broad stereotype. Even if the person does happen to like that music or food, he or she may resent you making any assumptions about their taste based merely on race or ethnicity.

4. Racial privilege. A member of my family once said he couldn’t understand why certain groups were always complaining about police harassment. He mentioned that he had many experiences with the police and he had always been treated with respect and courtesy. It didn’t occur to him that his skin color, sexual orientation, and socioeconomic class had anything to do with his treatment. That certain groups are targeted for mistreatment seemed inconceivable to him because he never had to experience what others endure regularly. This is the nature of racial privilege. (Yes, many kinds of privilege exist, but they aren’t relevant to this discussion.)

5. Unconscious and undesired racial bias. Finally, we all have biases without realizing it. When people take psychological tests (you can take one here) to see what biases they have, they may be chagrined to find they are biased against others without wanting to, but some of us are even surprised to find we hold implicit biases against our own social groups. Even those who are aware of no bias whatsoever find that some biases are so deeply entrenched that they are difficult to detect. Ironically, those with the least ill feelings toward other races are, in my experience, more aware of implicit bias. Confront an obvious racist about overt racial attitudes, and he or she will often declare, loudly, that he or she is completely indifferent to race. In my experience, those who are most committed to ending racial prejudice are the ones who are also most willing to examine their own implicit biases. Such is life.

Gender Disparity: Paycheck Fairness Act is not enough

R. Horton

Before I start, let me say that I support any effort to address wage inequality and I believe strongly in the right to equal pay for equal work. If the Paycheck Fairness Act helps to bring more equity to the workplace, I’m all for it, but it will not eliminate wage disparities between men and women on its own.

Republicans are wont to point out that women make less than men not because of discrimination but because of lifestyle choices. (Read a fuller discussion of this in The Guardian.) Their argument centers on the fact that it is possible to pay every woman in any given job the same wage as every man in a similar job and still end up with wage disparity because more women are in lower-paying jobs. To Republicans, this means sexual discrimination is not a problem (everyone should just choose to be a petroleum engineer or investment banker, right?), but for the rest of us it means that sexism is a pernicious problem that will not easily be solved with a piece of legislation.

First, we might ask why the jobs more women choose pay less than the jobs more men choose. One proposed answer is that men choose jobs that are riskier and require a more “masculine” personality. Women, it is assumed, will choose safer and less demanding jobs. Another answer is that women gravitate toward jobs that require fewer hours (they need to get home to the kids, you know?). And another is that women choose jobs that require less training.

According to the 2013 Physician Compensation Report, male doctors earn 30 percent more than female doctors. The report explains the disparity thus: “There are fewer women in some of the higher-paying specialties. For example, in orthopedics, only 9 percent of the survey respondents were women, whereas in pediatrics, 53 percent of survey respondents were women.”

Interestingly, the lowest paid specialty in medicine is now HIV/Infectious Diseases, which also happens to be the specialty with the second highest rate of overall satisfaction (just behind dermatology). The other low-paying specialties are family medicine, diabetes/endocrinology, and internal medicine. Other high-paying specialties, after orthopedics, are cardiology, radiology, gastroenterology, and urology.

While I can’t see that the risk of treating infectious diseases is lower than the risk of practicing urology, I do see that the lower-paid specialties focus more on care and concern and require human interaction. (It still may be true that women are more risk-averse, which may be why they are safer doctors.) It seems to me that we value technical expertise over human and care and concern in most fields. At least we are more willing to pay for technical expertise and less willing to pay for the care and concern that we will all need.

Teachers work hard and take many risks but will never earn as much as petroleum engineers. Ah, but petroleum engineers fatten the bottom line for their employers, you say. Let them try to survive without teachers to get them there. Let all the hard-working risk takers make it through life without the people who cared for them and helped them become successful. And men have always said this, haven’t they? We have clichés such as “Behind every successful man is a woman.” And women have done their work, largely, for free—because they had no other choice. So the work women have done is devalued (though prized in way) and undercompensated. If fewer people were willing to do “women’s work,” the price of such work may indeed rise, but I don’t see this happening any time soon.

And men sometimes choose work that may be seen as “feminized.” When they do, men also earn less because their work is undervalued, too. If the work were not undervalued, I aver that more men would choose different careers. After successful careers in industry, some men choose to leave their jobs for more “meaningful” work after middle age. The work people describe as “meaningful” or “rewarding” is almost always related to either caring relationships or creative enterprises; these are the activities that make life seem worthwhile.

Because these activities bring so much personal satisfaction, people are willing to do them for less pay. If petroleum engineering did not pay so well, I’m sure some people would still choose it as a profession, but many people choose it now only because it pays well and not because it enriches their lives in any other way. Many men are starting to reject the idea that they must choose careers based on how well they pay. Some men in the men’s movement reject being treated as “success objects.” Nonetheless, I think women are more likely than men to feel free to choose careers based on satisfaction rather than remuneration, and men are more likely than women to feel they must choose a career that pays well. There are many, many exceptions, of course, but not enough to close the pay gap between men and women.

So, what should we do to address the problem of wage disparity? First, stop devaluing “feminine” work. Recognize the true value of education and care. Second,  stop treating men as “success objects.” Remove the stigma from rejecting a high-powered career for a more rewarding and meaningful life. Finally, make it possible to find a balance between a career that pays well and a meaningful life. Some women may pass up high-paying professions because they do not want to neglect their family relationships or similar concerns. At the same time, some men neglect relationships and personally rewarding work because they feel obligated to earn as much as possible. Men and women would both behave differently if it were possible to enter any career without having to sacrifice family relationships, volunteer opportunities, and creative outlets. Another world truly is possible.

What Obamacare has done for me

R. Horton2 Comments

When I first met my wife in 2007, she told me she was about to quit her job of 27 years in the oil and gas industry to pursue a career in family therapy. Quitting her job meant giving up her employer-provided insurance, so she went on COBRA for 18 months. By that time, she was in graduate school and was able to get student insurance. When she graduated, however, she was unable to get insurance on her own as she had pre-existing conditions that precluded purchasing insurance on the open market.

I was following a similar path. When we first met, I was working on my PhD while also teaching full time. In 2011, I was beginning my dissertation and my college, facing budget cuts, was offering a payoff to anyone willing to resign. By this time, my wife was on my insurance, and I hesitated to give up my benefits, but we eventually decided I would resign and take student insurance for both of us.

From there, I was playing a delicate balancing act. I knew the healthcare exchanges mandated by the Affordable Care Act (Obamacare) were supposed to become available in January 2014. I pressed forward with my dissertation without wanting to graduate before the exchanges were available. I found that I could stay on the student insurance for six months past my graduation date. I defended my dissertation in March 2013, but did not turn in final paperwork in time for spring graduation, meaning that I would have to enroll in the summer. I graduated in August and was able to keep the student insurance for my wife and myself until February 2014.

Thankfully, the exchanges did go into effect by the beginning of 2014, and we were both able to purchase insurance for ourselves. The cost of the insurance was about the same as the price for the student insurance, but it is a much better insurance plan. I am extremely grateful for the Affordable Care Act (ACA), which made this possible.

But the ACA is even better than I realized. I now teach part time for two colleges. Under the ACA, I can join rejoin the Teacher Retirement System of Texas and purchase health insurance along with disability insurance, accidental death and dismemberment insurance, and life insurance for myself and my wife. Further, the teaching I am now doing applies to my years of service in the Teacher Retirement Service, which means my retirement account is growing and will become available to me sooner.

I am not happy with all of President Obama’s policies by any means, and ultimately I would like to see the US adopt a single-payer model for healthcare, but Obamacare is a step in the right direction. Without Obamacare, my wife and I would have joined the millions of working Americans who have no health insurance or access to affordable healthcare.

So, thanks, Obama.

Will industry-funded research kill you?

R. Horton

Last week, I wrote a blog about the effects of financial conflicts of interest (FCOI) on treatment decisions of doctors and whether disclosure alone will have any effect on eliminating bias and corruption. As a result, I received some comments and information on FCOI in published research.

Before I say more, I would like to clarify that someone who is conducting research funded by industry is not technically, in my studied opinion, involved in a FCOI, because such a person has the single interest of generating products that will result in profit for industry. It is possible that research undertaken with the aim of commercial success will benefit humanity, but if profit is not possible, humanity be damned. (I am making an assumption, which may be naive, that most of us think medical research should be aimed at making life better for humanity.)

To help combat the problem of bias in research, John Henry Noble suggests prison time for those found guilty of scientific fraud. In my opinion, he makes two strong claims: 1. “The false claims of the perpetrators rise to the status of crime against society, insofar as they endanger public health by sullying and misdirecting the physician’s ‘standard of care.’” 2. “The due process of law is likely to uncover and judge the evidence of guilt or innocence more reliably and fairly than will the institutions of science and the professions that historically have resisted taking decisive action against the perpetrators.”

I agree that jail time is appropriate for egregious cases of scientific fraud, but I’m not sure it eliminates the problem of industry-driven research. Another person told me industry-funded research should be published for two reasons: 1. Some people are biased without the benefit of industry funding. 2. Some industry-funded research proves to be quite beneficial. Perhaps surprisingly, I agree with both of these statements as well–as far as they go. Certainly, many people carry any number of biases that do not result from corporate funding, and the history of scientific fraud is littered with examples. Further, corporate labs frequently create products I enjoy immensely.

Oddly enough, the person defending industry-funded research sent me a link to a paper to support the contention that FCOIs are not a strong predictor of bias. I say it is odd because the paper didn’t seem to support that position. The paper analyzed the associate between industry funding and the likelihood that the researchers would find an association between sweetened beverages and obesity. The authors of the paper found that “Those reviews with conflicts of interest were five times more likely to present a conclusion of no positive association than those without them.” It is perhaps the conclusion of the paper that gives hope to those advocating for industry funding:

They [results of the study] do not imply that industry sponsorship of nutrition research should be avoided entirely. Rather, as in other research areas, clear guidelines and principles (for example, sponsors should sign contracts that state that they will not be involved in the interpretation of results) need to be established to avoid dangerous conflicts of interest.

In other words, it would reduce bias if sponsored researchers were limited to collecting data without analyzing it. This is hardly a ringing endorsement of industry-funded research, but so be it.

So, I do not think all industry-funded research should be banned. Rather, I think we (as a society) need to ensure that we have ample researchers who are free of FCOIs. In other words, we need substantial funding for independent research centers where researchers can work for the advancement of knowledge without a constant concern for the production of profit. Forcing our public universities and research labs to turn to corporations for funding corrupts our pursuit of knowledge and the advancement of society. We must restore public funding to education and research.

For more on the possible risks of funded research, read about Dan Markingson here. Or read about Jesse Gelsinger here.

Sunshine disinfects nothing

R. Horton5 Comments

I seem to remember Jon Stewart once playing a clip of a politician declaring that sunshine is the best disinfectant. After the clip, Stewart warned viewers that using sunshine as a disinfectant could lead to a nasty infection. In response to the Sunshine (Open Payments) Act, bioethicist Mark Wilson sounds a similar alarm in a recent paper.

For years, many people, including myself, have argued that industry payments to physicians should be disclosed to the public, so that we will all be aware of possible financial conflicts of interest (FCOI). My hope was that disclosing conflicts of interest might help actually reduce corruption or even simple bias in medical practice, but Wilson points to our experience of Wall Street before and after the 2008 financial collapse to show that knowledge of conflicts of interest does not prevent them. Rather, disclosure only shifts the burden for reducing FCOI to patients, who are least empowered to eliminate them. Rather than fixing the problem, Wilson claims the Sunshine Act only “mythologizes transparency.”

Wilson pointed me to a paper (“Tripartite Conflicts of Interest and High Stakes Patent Extensions in the DSM-5”) in Psychotherapy and Psychosomatics that illustrates the problem. If you want the details, you can read the paper yourself, but I will skip right to the conclusion, which I admit is how I read most papers anyway:

[I]t is critical that the APA recognize that transparency alone is an insufficient response for mitigating implicit bias in diagnostic and treatment decision-making. Specifically, and in keeping with the Institute of Medicine’s most recent standards, we recommend that DSM panel members be free of FCOI.

Telling people about FCOI does not reduce bias and corruption; it only offers an opportunity for people to be aware that bias and corruption exist. I think it is valuable that the Sunshine Act is making people aware of FCOI. In response, though, I hope we will take steps to reduce FCOI. Unfortunately, the burden is indeed shifted to voters and consumers. The most disturbing and obviously true statement Wilson makes in his paper is this: “Until politicians end their own commercial COIs, the Sunshine Act will likely remain the governance order of the day.”

We can’t hope the experts will solve this problem. We must demand that FCOI are eliminated.