Center for Practical Bioethics

Deep brain stimulation (DBS) has increasingly been pursued as a treatment for obesity over the past couple of decades. This has occurred despite limited scientific justification or a serious ethical analysis of the concerns it raises. These interventions have relied on an “obese brain” model, which treats fatness as a neurological defect that can and should be corrected—reflecting and reinforcing stigmatizing, racialized assumptions about self-control, deviance, and bodily normalcy. To show this, we situate DBS for obesity within the broader and ethically troubling history of psychosurgery. We critique the scientific basis of the obese brain model and argue that its moral justification ultimately collapses. In this narrative framing, we argue that DBS for obesity is not a therapeutic innovation; instead it is a continuation of medicine’s role in pathologizing nonconformity.

Sleep apnea-related intermittent hypoxia and the chronic inflammation of arthritis share oxidative-stress pathways, yet their epidemiologic overlap remains under-described. The prevalence of both conditions increases with age and presents unique challenges for patient management. To quantify the association between clinician-suspected arthritis and self-reported sleep apnea and to explore whether demographic or cognitive factors modify that link. We analyzed 17,013 adults enrolled in the referral-based National Alzheimer Coordinating Center Uniform Data Set, version 3. Complete-case binary logistic regression modeled obstructive sleep apnea (OSA) (yes/no) on arthritis (yes/no) with adjustment for age, sex, race (White vs non-White), years of education, cognitive status (normal, mild cognitive impairment, Alzheimer disease), body mass index, and cardiometabolic comorbidities. A pre-specified interaction term tested whether cognition modified the arthritis-OSA association. Multiple imputation was used to address missing data. Arthritis was associated with 60% higher odds of OSA (adjusted odds ratio = 1.60, 95% confidence interval: 1.46-1.76, P < .001). The effect was attenuated in Alzheimer disease. Male sex, atrial fibrillation, stroke, diabetes, and higher body mass index were additional correlates (all P < .001); age was not independently significant. Imputation yielded similar estimates. Clinician-suspected arthritis was robustly associated with self-reported OSA even after extensive adjustment, although unmeasured confounding and exposure misclassification cannot be excluded. Both OSA and arthritis were ascertained by self-report or single-clinician designation without polysomnography, actigraphy, imaging, or serology, raising non-differential misclassification potential. The cross-sectional design prevents causal interpretation, and the predominantly White, highly educated volunteer cohort limits generalizability. Prospective, objectively phenotyped studies, ideally with arthritis sub-typing, are needed to verify directionality and clarify mechanisms. We used records from more than 17,000 volunteers at U.S. Alzheimer Disease Research Centers to ask whether people who say they have arthritis are also more likely to report OSA. After controlling for age, sex, education, cognitive status, weight, and common medical conditions, arthritis still raised the odds of OSA by about 60%. Joint pain and poor sleep can feed off 1 another, so recognizing both problems may help doctors treat them earlier. Neither arthritis nor OSA was confirmed with X-rays, lab tests, or sleep studies, we relied on what participants or clinicians reported. Furthermore, the study looked at 1 point in time, so we cannot tell which problem came 1st; and most volunteers were White and highly educated, so the findings may not reflect every community. Future research that tracks patients over time and uses overnight sleep tests and detailed arthritis subtypes will be crucial.

How can health care organizations balance physicians’ interests with patient safety in designing programs to ensure that cognitive and physical decline in older physicians doesn’t harm patients?

Biomedical research involving minors or other persons incapable of giving consent raise many complex ethical issues, particularly when the research offers no prospect of direct therapeutic benefit to the participants. To protect such individuals from exploitation and undue risks that compromise their dignity, integrity, rights, and well-being, most ethical and regulatory standards prohibit the enrollment of incompetent subjects in studies that have no therapeutic potential, unless participation involves only minimal risk and burden. This well-established standard has also been adopted by Regulation (EU) No 536/2014 on Clinical Trials on Medicinal Products for Human Use, and Repealing Directive 2001/20/EC, which recently entered into force. However, the provisions of the Regulation defining the minimal risk threshold are so ambiguous and confusing that they can easily be interpreted in ways that are unethical and inconsistent with the overall goals of the legislation. This paper critically analyzes the minimal risk requirement of the Clinical Trials Regulation and offers an ethically and legally sound interpretation of the threshold in “non-therapeutic” clinical trials involving selected categories of vulnerable subjects.

The null variant of the Duffy antigen is a non-pathological mutation that is partially protective against Plasmodium vivax and results in a lower absolute neutrophil count (ANC) in peripheral blood without increasing the risk of infection. Healthcare practices, clinical trials eligibility and medication dosing are often influenced by the definition of neutropenia. In many regions, however, neutropenia has been defined by the ANC distribution of Duffy-positive individuals, which may be unsuitable for decision-making in Duffy null individuals. This review describes the association between Duffy status, Plasmodium vivax exposure, racial or ethnic groupings and ANC. We outline biological and iatrogenic associations between Duffy antigen status and health outcomes and recommend changes to healthcare practices required to ensure equity for Duffy null individuals.