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Monthly Archives: September 2013

Narrative versus Principle-Based Bioethics

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The field of bioethics addresses moral questions in the areas of medical practice and policy, as well the life sciences. Although there are many different methods of approaching bioethical issues, two in particular are currently very influential and often thought to be in tension.  The first, often called principlism, looks to certain basic principles as its central guide.  These principles of autonomy, non-maleficence, beneficence, and justice are held to be objective and universal, the set of norms that all morally serious persons share.  A course of action is morally justified if it is consistent with the principles.  The work of ethical decision-making consists in bringing these principles to bear on the particular situation at hand.   The principles are weighed, tested, and revised in response to the specific context involved.

 

While principlism has long dominated the bioethical landscape, in the last twenty years, an increasing number of theorists have turned their attention to alternative approaches.  One such alternative approach is narrative ethics, which incorporates narrative concepts and methodologies drawn from literary criticism and philosophy.  According to bioethicist Joan McCarthy, narrative ethics holds that “every moral situation is unique and unrepeatable and its meaning cannot be fully captured by appealing to universal principles.  In any given health care situation, any decision or course of action is justified in terms of its fit with the individual life story of the patient,” not with how closely it follows universal moral principles.  The objective of narrative ethics is “not necessarily to unify moral beliefs and commitments, but to open up dialogue, challenge received views and norms, and explore tensions between individual and shared meanings.”

 

McCarthy sees principlism and narrative ethics as each having their own respective strengths.  Principlism “provides a clear method and vocabulary for identifying ethical concerns in health care situations and for negotiating moral ideas and arguments.” It is also a “particularly useful means of drawing the parameters of moral relationships between strangers.” Since “the four principles are considered to be binding on all moral persons irrespective of culture or creed,” principlism is “a particularly important tool for legislators and public policy makers, whose task is to regulate the conduct of various individuals, groups, and institutions with different backgrounds and agendas.” “The strength of narrative ethics, on the other hand, is that it provides a method and vocabulary for interpreting and respecting the unique and personal stories of individuals.”

 

In considering McCarthy’s descriptions and analysis of principlism and narrative ethics, it seems to me that the two theories function as complementary partners in the process of ethical decision-making.  Narrative ethics acts as a check on the tendency of principlism to lose sight of the particularities of the stories involved in a moral situation.  In applying moral principles to a situation it is crucial that we have an accurate portrayal of the stories that constitute that situation.  We must have a correct diagnosis (the story) before we can apply the cure (the moral principles).  Arriving at such an accurate portrayal is more challenging, painstaking work than some ethicists applying principles to a situation might at first appreciate.  Rather than a god’s-eyed view of the situation, a tapestry of narratives is sometimes the most we can expect to obtain. 

 

But the stories that make up a moral situation do not themselves supply the values and principles that guide moral action.  For example, McCarthy describes how a narrative approach has “contributed to discussion and debate in relation to end of life decisions.” The U.S. Council on Ethical and Judicial Affairs suggests when making decisions for an incompetent patients, one the decision-maker’s tasks is to consider “how the patient constructed his or her identity or life-story.” In this way, the surrogate decision-maker can act in a way that continues the patient’s life-story “in a manner that is meaningful and consistent with the patient’s self-conception.” Here it seems to me the principle of autonomy is being implicitly applied.  That a person constructed a certain identify or life-story does not bind the surrogate decision-maker to make a decision in continuity with that life-story.  The surrogate decision-maker’s values might conflict with the patient’s, leading to a decision that is contrary to the patient’s will.  For example, a surrogate decision-maker who values the continuation of life at all costs might disagree with the living will of a patient who opposes any “heroic measures.”  It is principle of autonomy—respecting the patient’s agency—that instructs the surrogate decision –maker to nevertheless act in continuity with the patient’s life-story.

 

Narrative ethicists might respond that we do not need values or principles to guide moral decision-making.  Even without reference to any moral principles, sharing and hearing the stories that constitute a moral situation enriches our understanding and generates a better appreciation of the courses of action we might take.  But what is the use of arriving at a better understanding of our moral options unless there is some real moral standard to which we want our choices to conform?    While “opening up dialogue, challenging received views and norms, and exploring tensions between individual and shared meanings” are intrinsically valuable activities, aren’t they ultimately driven by question, “what is the truly right thing to do?”  To answer that question, we need criteria or principles for what constitutes right action.  Positing, as some narrative ethicists seem to do, that “right action is what best fits the story” is smuggling in such a moral principle.

Even as I don’t see narrative ethics as supplanting the principle-based approach to bioethics, it nonetheless is making important contributions to the field and to health care in general.  Here is an interesting article about the movement.

 

 
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Posted by on September 5, 2013 in Uncategorized

 

The Complex Problem of Obesity

mid section view of a man sitting on a bench in a park

Obesity and the struggle to lose weight are among the most challenging issues I encounter in my medical practice.  At first glance, the problem and solution seem rather straightforward.  As New York mayor Michael Bloomberg recently put it, “If you want to lose weight, don’t eat.  This is not medicine, it’s thermodynamics.  If you take in more than you use, you store it.”

But as somebody who regularly works with people battling obesity, I can attest that Bloomberg’s words do not come close to capturing the complex realities overweight individuals face. For example, I sometimes see patients with severe autoimmune or psychiatric conditions who must take medications like corticosteroids and antipsychotics that stimulate  their appetite and cause significant weight gain.  Even more often I work with people whose life situations do not permit regular exercise or a consistently healthy diet.  Think of the single mother working long hours who must get her children out to school in the morning and cook and care for them at night.  For her to find the time to regularly exercise and make nutritious meals is a real challenge.  And this does not even take into account factors like how well she is sleeping or what is going on in her life.  As David Berreby points out,

“sleeplessness and stress have been linked to disturbances in the effects of leptin, the hormone that tells the brain that the body has had enough to eat.”

Berreby’s fascinating piece The Obesity Era considers the

“troublesome fact , reported in 2010 by the biostatistician David B Allison and his co-authors at the University of Alabama in Birmingham: over the past 20 years or more, as the American people were getting fatter, so were America’s marmosets. As were laboratory macaques, chimpanzees, vervet monkeys and mice, as well as domestic dogs, domestic cats, and domestic and feral rats from both rural and urban areas. In fact, the researchers examined records on those eight species and found that average weight for every one had increased. The marmosets gained an average of nine per cent per decade. Lab mice gained about 11 per cent per decade. Chimps, for some reason, are doing especially badly: their average body weight had risen 35 per cent per decade. Allison, who had been hearing about an unexplained rise in the average weight of lab animals, was nonetheless surprised by the consistency across so many species.

How do we explain the increase in obesity across species?  Berreby writes that

it isn’t hard to imagine that people who are eating more themselves are giving more to their spoiled pets, or leaving sweeter, fattier garbage for street cats and rodents. But such results don’t explain why the weight gain is also occurring in species that human beings don’t pamper, such as animals in labs, whose diets are strictly controlled. In fact, lab animals’ lives are so precisely watched and measured that the researchers can rule out accidental human influence: records show those creatures gained weight over decades without any significant change in their diet or activities. Obviously, if animals are getting heavier along with us, it can’t just be that they’re eating more Snickers bars and driving to work most days. On the contrary, the trend suggests some widely shared cause, beyond the control of individuals, which is contributing to obesity across many species.

Some proposed causes for the obesity epidemic include changes in the bacteria in our gut, viruses, industrial chemicals, heating and air conditioning, and light exposure.  Regarding our gut bacteria,

a study in humans by Ruchi Mathur and colleagues at the Cedars-Sinai Medical Center in Los Angeles, published in the Journal of Clinical Endocrinology and Metabolism earlier this year, found that those who were overweight were more likely than others to have elevated populations of a gut microorganisms called Methanobrevibacter smithii. The researchers speculated that these organisms might in fact be especially good at digesting food, yielding up more nutrients and thus contributing to weight gain.

Evidence for a possible viral culprit is suggested by the fact that

a virus called Ad-36, known for causing eye and respiratory infections in people, also has the curious property of causing weight gain in chickens, rats, mice and monkeys. Of course, it would be unethical to test for this effect on humans, but it is now known that antibodies to the virus are found in a much higher percentage of obese people than in people of normal weight. A research review by Tomohide Yamada and colleagues at the University of Tokyo in Japan, published last year in the journal PLoS One, found that people who had been infected with Ad-36 had significantly higher BMI than those who hadn’t.

I find the possible role of air conditioning and heaters in our obesity epidemic to be especially interesting. Berreby writes that

there is a ‘thermoneutral zone’ in which a human body can maintain its normal internal temperature without expending energy. Outside this zone, when it’s hot enough to make you sweat or cold enough to make you shiver, the body has to expend energy to maintain homeostasis. Temperatures above and below the neutral zone have been shown to cause both humans and animals to burn fat, and hotter conditions also have an indirect effect: they make people eat less. A restaurant on a warm day whose air conditioning breaks down will see a sharp decline in sales (yes, someone did a study). Perhaps we are getting fatter in part because our heaters and air conditioners are keeping us in the thermoneutral zone.

Our increased exposure to light is another interesting potential factor in why we’re getting bigger. Berreby points to a 2010 in the Proceedings of the National Academy of Sciences reporting that mice exposed to extra light put on nearly 50 per cent more weight than mice fed the same diet who lived on a normal night-day cycle of alternating light and dark.  Some scientists theorize that this effect occurs by light at night robbing mice (and humans) of natural cues about when they are supposed (and not supposed) to eat.  

I recommend Berreby’s entire piece.  It resonates with my experience that treating obesity is tremendously challenging and complex work.

 
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Posted by on September 2, 2013 in Uncategorized

 

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I’ll Be Back

I’m on vacation for a few days in a cabin without WiFi, so there will be no new posts until Monday night

 
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Posted by on September 1, 2013 in Uncategorized

 
 
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