Anne Barnhill

What It Takes to Defend Deceptive Placebo Use

A complete defense of deceptive placebo use must address this ethical objection: deceptive placebo use violates patient autonomy, because deceiving a patient about the placebo nature of a proposed treatment prevents her from giving informed consent to the treatment. Unfortunately, this objection isn’t always recognized and clearly disambiguated from other ethical concerns. I consider how well several bioethicists who write about placebo use have responded to, or evaded, this objection. I conclude that defenders of deceptive placebo use should, following the lead of Onora O’Neill, argue that deceptive placebo use is compatible with informed consent.

Ethical Agreement and Disagreement about Obesity Prevention Policy in the United States.

An active area of public health policy in the United States is policy meant to promote healthy eating, reduce overconsumption of food, and prevent overweight/obesity. Public discussion of such obesity prevention policies includes intense ethical disagreement. We suggest that some ethical disagreements about obesity prevention policies can be seen as rooted in a common concern with equality or with autonomy, but there are disagreements about which dimensions of equality or autonomy have priority, and about whether it is justifiable for policies to diminish equality or autonomy along one dimension in order to increase it along another dimension. We illustrate this point by discussing ethical disagreements about two obesity prevention policies.

Good and bad ideas in obesity prevention.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

Clinical Use of Placebos: Still the Physician's Prerogative?

The American Medical Associations Code of Ethics holds that if a physician believes a treatment to be a placebo, then the patient should be informed of that belief, and the treatment should not be prescribed unless the patient agrees to its use. But this is not clearly the best way either to protect patients or to benefit them. The physicians own beliefs should not be decisive.

I’d Like to Teach the World to Think: Commercial Advertising and Manipulation

This commentary on Cass Sunstein’s “Fifty Shades of Manipulation†queries Sunstein’s account of manipulation as influence that does not sufficiently engage or appeal to someone’s capacity for reflection and deliberation. Manipulation sometimes undermines the target’s reflection and deliberation; but it is also possible to manipulate someone by providing “bad inputs†to a properly nondeliberative response. This kind of manipulation does not consist of a failure to sufficiently engage reflection and deliberation. While good practical reasoning and good practical engagement with the world requires some reflection and deliberation, it does not require reflection and deliberation at every turn. Sometimes we just like something without reflecting on its virtues. For example, we just like a beverage because it tastes good and feels good, and it comes in a pretty bottle. Building on Sunstein’s discussion of commercial advertising, I consider some ways in which commercial advertising might manipulate these “likings,†as well as other ways in which commercial advertising and marketing potentially manipulate consumers, focusing in particular of food advertising and marketing.

The ethics of placebo treatments in clinical practice: a reply to Glackin

In ‘Placebo treatments, informed consent, and “the grip of a false picture”’ Shane Nicholas Glackin argues that if a physician offers a patient an inert placebo with the following disclosure, this is compatible with informed consent and is not deceptive: ‘I would like to offer you a pill which I believe can help lessen your suffering. I do not know exactly how it works. I have other pills to offer whose mechanism is clearer, but I am not sure that they will work better for you, and they may also entail more serious side effects’. According to Glackin, telling patients that the recommended treatment is an inert placebo is providing incidental information, analogous to telling a patient the chemical details of an active drug. He argues that this information would influence a patients decision only if she was ‘in the grip of a false picture’ that inert drugs do not have physical effects on patients’ bodies. We contend that this disclosure typically is incompatible with informed consent and typically is deceptive. We give an example of a transparent placebo disclosure, that is, a disclosure that is compatible with informed consent and is not deceptive.

Ethical Considerations for Nutrition Counseling About Processed Food

Ethical Considerations for Nutrition Counseling About Processed Food To the Editor We read with great interest the article “Processed Food: An Experiment that Failed.”1 We applaud efforts to bring attention to the public health effects of processed food. However, we are concerned that it misses the mark on 2 important issues related to families’ efforts to eat more healthfully. First, we were troubled by the following sentence: “Onethird of American mothers today don’t even know what real food is or how to cook,” a situation that renders them and their children “hostages to the processed food industry.”1 Such framing is concerning because it reinforces a problematic norm that mothers bear the primary responsibility for childhood obesity.2 Emphasizing the role of mothers in addressing childhood obesity makes sense from one perspective because US women are both more likely to shop for and prepare meals and to take children to the pediatrician than their male counterparts.3,4 Nevertheless, focusing solely on mothers represents a missed opportunity to enlist fathers and the broader society in promoting childhood nutrition and well-being.4 Relatedly, we must acknowledge the growing diversity of American families. In the 1960s, nearly three-quarters of American children lived in a family with 2 married parents in their first marriage. Today, less than half do so, one-quarter live with a single parent, and a growing number are in same-sex couple households. Recommendations and interventions for healthy eating should acknowledge and address changing household arrangements and their implications for children’s health. Second, when recommending dietary changes and designing interventions, we should recognize that families’ efforts to eat more healthfully can have economic, social, and psychological costs. Grocery shopping, meal planning, and cooking is time-consuming work. Some parents have unpredictable and inflexible work schedules, compromising their ability to plan ahead or find time to shop for and prepare healthy meals.5 Switching to healthier dietary practices can also have psychological and social costs because efforts to change dietary patterns can cause tension within families or can be difficult in unsupportive home and work environments.5 While these experiences are not universal, they are real. We must acknowledge the realities of families’ lived experiences if we are to develop effective and ethical approaches to encouraging children’s healthier eating. Simply reducing access to processed food does not address the real costs of healthier eating. We owe it to families to recognize these costs, develop interventions that minimize them, and foster broader responsibility for children’s healthy eating.

The most plausible pro-coercion view: requiring informed agreement while penalizing non-participation in research

In ‘(Why) should we require consent to research?’ Alan Wertheimer probes whether it is legitimate for the government to ‘coerce’ people into participating in biomedical research, including interventional biomedical research. In debating the rules that ought to govern participation in interventional biomedical research, we should distinguish two separate moral claims. First, interventional research should proceed only when the subject has given her informed agreement. Second, it is legitimate for the state to set a requirement that people participate in interventional biomedical research, and to penalize or punish those who refuse to participate. The most plausible ‘pro-coercion’ view accepts both of these claims. Though I stop short of endorsing this view, it captures important ‘pro-coercion’ and ‘anti-coercion’ intuitions.

Fairness and Respect in Obesity Prevention Policies: A Response to David Buchanan

In his response to our article, David Buchanan introduces some useful and important distinctions in the concepts of equality and autonomy. He highlights, for example, the distinction between inequality and inequity, which captures the insight that not all differences between people are unjust. Unjust inequalities are a subset of differences between people, and theories of justice can be defined by how they determine which of these differences are unjust. In addition, he points out that autonomy is not simply a matter of negative liberty, but also about a positive capacity to act. This understanding of autonomy is consistent with the account we offered in the paper, which underlines the importance of both the capacity to understand available options, and the capacity to act on the choices that one makes.