Where Do We Go From Here?

Where Do We Go From Here?

In the field of bioethics, truth is often sought but rarely found. Impassioned debate encourages a progress toward greater understanding and a greater agreement of what constitutes certainty, but few moments in history have shown fundamental truth to be an achievable goal in the study of how we humans ought to interact with the universe around us. Nevertheless, it would seem we at the Virginia Journal of Bioethics find ourselves in a uniquely rare position to offer a simple and profound truth: Donald Trump will be the President of the United States of America.

President-elect Trump has tapped into the fears and anxieties of an American people facing increasingly important yet complex questions. These questions pertained to global climate change, immigration, healthcare, security, and much more. He ran on a platform of change, one centered on a deviation from the status quo and standard operating procedures that many saw as hidebound and annoyingly stagnant. He promised reforms to long-standing institutions that have been created to codify and embody the collective American morality.

Poignantly, this intersection of morality in the face of change was one of the major impetuses for the genesis of the field of bioethics. In a world of constant technological and ideological change, bioethics asks whether there are fundamental truths of humanity and life that should inform or even proscribe certain actions.

Bioethics is often associated with the ivory tower, academics who champion a belief in morality through pen and paper. However, we at the Virginia Journal of Bioethics are taking a stand to ask readers to do something different, to reflect on the current state of the field, to introspect on why readers are involved in the field, and importantly, to act in the name of this belief.

We believe that it is prudent to outline the probable future of Bioethics and recommendations on how to take action now, regardless of your philosophical tradition.

Trump’s presidency means that issues wherein significant change was made and thought to have been resolved will now likely reemerge. Topics which were important during the early days of bioethics such as abortion and sexuality will now likely return to the centerfold of debate. It also means that ethical discussion regarding research oversight and public health will be viewed as controversial. Trump’s largely disproven claims about climate change and science will likely stir discussions regarding environmental and medical research. 1, 2, 3

While we cannot predict the exact outcome of a Trump presidency, we can hypothesize likely outcomes and discussion points based on his past statements.

 

Healthcare Policy and Law

Trump has made many statements regarding his healthcare plan, which will most likely include some alteration of the ACA (Affordable Care Act). Trump first stated that he would repeal the law during “Day One” of his time in office but it is clear that most of what he desires will require action by Congress. The Congress – composed of a Republican majority – has demonstrated significant support in repealing portions of the ACA. There is strong willingness to repeal the insurance tax subsidies and Medicaid expansion portions of the ACA, along with the law which requires all Americans to hold medical insurance. Democratic filibuster, which might prevent repeal, could not happen due to a fast-track legislative measure known as “reconciliation” which was passed last year. A budget reconciliation bill can be passed by a simple majority and cannot be stopped by a filibuster. Reconciliation in the Senate must include provisions that affect revenues of the United States and cannot contain “extraneous provisions.” This means that this measure cannot be passed on day one of Trump’s presidency. Regardless, the Congressional Budget Office has predicted that if passed, these measures could leave 20 million people, who were uninsured before the ACA, once again without health insurance. Repealing the requirement for all Americans to purchase health insurance could lead to a costly outcome wherein many are buying health insurance when sick. This is especially true because insurers can no longer refuse to cover a person based on preexisting conditions. Recently Trump has stated that he might amend, rather than repeal, the ACA which makes it more difficult to hypothesize what may occur.

Trump has also said that he agrees with the portion of the ACA which allows young adults to remain on their parents' policy until the age of 26; House republicans also agree with this provision. In terms of specific benefits such as access to birth control, Trump may be able to redefine what elements of healthcare are covered by working with the Department of Health & Human Services. It is also unclear how new legislation will affect prices of health coverage and benefits, as Trump has not commented on whether subsidies would be available to patients under the his healthcare reforms. Finally, Trump has proposed expanding tax-free health services accounts and allowing insurers to sell plans across state lines, presumably increasing market competition.

What it means for ethics:

This all means that access to healthcare is likely up to debate and will return to the foray of medical ethics discussion in the United States. Utilitarianism and commonly-cited libertarian principles regarding the allocation of health resources will likely inform any amendments the new administration will aim to implement with regards to the Affordable Care Act.

 

Research Ethics

The NIH had a fiscal budget of $32 billion in 2016.4 Trump has stated many times that he plans to cut federal funding for research. While he has not yet outlined a proposal for funding, the President elect has made statements which are oppositional to an increase in NIH funding.5 This also means funding for President Obama’s BRAIN Initiative, Precision Medicine Initiative, and Cancer Moonshot will all remain on shaky ground. The United States has had a long history of formulating healthcare policies driven by quality research data. If this trend continues, it will be difficult to reconcile policy with fallacious claims, such as vaccines causing autism.6 The NIH also maintains a registry of funding-eligible human embryonic stem cell lines, which President Obama had initiated as one of his first executive orders. Trump’s promise to overturn all executive orders issued by President Obama may, in turn, limit the feasibility of embryonic research in the United States.

Other scientists worry that the President-elect’s stance on immigration may negatively impact research within the United States. Skilled labor has been growing recently, especially in Science, Technology, Engineering, and Mathematics (STEM).  According to the National Science Foundation, graduate students enrolled in programs within STEM fields are up, rising by 5.5 percent from 2013 to 2014. Meanwhile, the number of graduate students with temporary visas has also been growing.7 Hard-line immigration policies could bring the influx of high-skilled scientists entering the United States to a halt. If the United States is less competitive when it comes to research, it is likely that we’ll see these highly skilled researchers taking their knowledge sets to other countries instead – countries which allow for experimentation in areas that the United States has agreed are morally off limits.8, 9

What it means for ethics:

This likely means that debate regarding the permissibility of embryonic research, the administration appealing to metaphysical and religious claims of personhood, while opponents drawing arguments from the biological necessity of stem cell research for the advancement of medicine. Additionally, it is likely that debate will center around value theory, and discussions of the allocation of research funds will arise. Finally, international ethical guidelines will more pertinent than ever as tighter immigration regulations will lead researchers to other countries with murkier research regulations.

 

Reproductive Ethics

With one seat in the Supreme Court up for nomination, it is likely that the court will become strongly conservative. We may see a reversal of Roe. v. Wade, especially considering Vice-President elect Mike Pence’s strongly socially conservative views. We may also see Congress making abortion illegal altogether, or possibly declaring that “personhood” is established during the embryonic stage of human development, limiting abortions past the first trimester. A move like this would likely limit access to abortion for many women. Many Republicans have come out against organizations which support abortion access. Additionally, both Trump and newly re-elected House Speaker Paul Ryan have dedicated to defund Planned Parenthood due to its abortion provision. Moreover, Ryan has endorsed making the Hyde Amendment – which bars the use of certain federal funds to protect taxpayers from having to pay for abortions – permanent law.

What it means for ethics:

In essence, access to abortion and the definition of personhood will return as important discussions, along with debates on women’s access to healthcare. Much of the evidence to be cited by the new administration will likely appeal to religious principles, while opposition may actively rebuke these claims as grounds for disqualification of their arguments and instead opt for secular justifications for their ethical claims.

 

Environmental Ethics

Although Trump has pledged to “cancel billions in payments to U.N. climate change programs and use the money to fix America's water and environmental infrastructure,” this move is not only unlikely but impossible, as the U.S. does not give billions of dollars to the United Nations for “climate change programs.” The U.S. government does give about $10 million a year to the United Nations Framework Convention on Climate Change (UNFCCC), which was instituted by George H. W. Bush.

Trump has also declared wind farms to be “disgusting looking” and “bad for health.” He has also made claims that “new environmentally friendly light bulbs cause cancer” and that “fracking poses zero health risks.”10 Trump’s views on science are surprisingly misinformed and this is likely to impact his environmental positions. He has also pledged to cut funding to the Environmental Protection Agency and tapped a climate change skeptic to oversee the new transition.11

What it means for ethics:

These positions will likely encourage debate regarding environmental justice and the scope of a nation’s duties in preventing global climate change and promoting adherence to widely-accepted but still factionally-contentious scientific thought.

 

Looking Forward

So what can be done?

We hope to provide recommendations which encourage taking a step back and reorienting your thought process to, “How can I be most effective now?” We recommend the Principles of Effectuation.

  1. Means (Bird in Hand): What resources do you have available to you now? What are your strengths and weaknesses, and how do they play into solving problems with other people? Are you aligning your ideals, talents, and goals with a clear understanding of the problem at hand? How can you leverage your talents, however seemingly disconnected they may be?

  2. Affordable Loss (Focus on the Downside): What are you willing to give up? What are you willing to lose? At what point will you decide that it’s time to choose another fight?

  3. Co-Creation (Partnership) - This is about understanding the power of diversity. Instead of fighting for cohesion, what happens when you allow things to proceed with everyone contributing their unique talents?

  4. Leverage Contingencies (Lemonade) - When life gives you lemons, what will you make? How do you convert potential surprises into valuable turning points?

  5. Worldview (Control v. Prediction) - Understand the importance of both creating your destiny and rolling with the punches. What is within your control, and what should be left up to chance? What can you predict for the near future, and how will that inform your decision-making for the better?

Bioethics has always been an area of study which celebrates reflection, discourse, and action. Now more than ever, we believe it is extremely important to engage in each of these notions to focus on meaning-making rather than partisan-based acrimony. Fear paralyzes, curiosity empowers, and we believe it is important to maintain a strong philosophically motivated curiosity and ethically inspired action.

 

References:

  1. Peterson, Thomas C., and M. O. Baringer. "State of the climate in 2008." Bulletin of the American Meteorological Society 90, no. 8 (2009): S1-S196.

  2. Allison, Ian, N. L. Bindoff, R. A. Bindschadler, P. M. Cox, Nathalie de Noblet, M. H. England, J. E. Francis et al. The Copenhagen Diagnosis: Updating the world on the latest climate science. Elsevier, 2011.

  3. "Climate Change: How Do We Know?" NASA. November 22, 2016. Accessed November 23, 2016. http://climate.nasa.gov/evidence/.

  4. "Budget | National Institutes of Health (NIH)." U.S National Library of Medicine. April 4, 2016. Accessed November 17, 2016. https://www.nih.gov/about-nih/what-we-do/budget.

  5. “Shock Jock Who Wants to Be Trump's Top Medical Researcher Once Told a Caller to "Get AIDS and Die.” Mother Jones. October 8, 2015. Accessed November 17, 2016. http://www.motherjones.com/politics/2015/10/donald-trump-michael-savage-aids-nih

  6. Taylor, Luke E., Amy L. Swerdfeger, and Guy D. Eslick. "Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies." Vaccine 32, no. 29 (2014): 3623-3629.

  7. Margetta, Rob, and Kelly H. Kang. "National Science Foundation - Where Discoveries Begin." Number of Science and Engineering Graduate Students up in 2014 | NSF - National Science Foundation. March 30, 2016. Accessed November 20, 2016. https://www.nsf.gov/news/news_summ.jsp?cntn_id=138155.

  8. Craven, Lindsay; et al. (29 September 2015). "Research into Policy: A Brief History of Mitochondrial Donation". Stem Cells. 34 (2): 265–267. doi:10.1002/stem.2221.

  9. Callaway, Ewen. "Second Chinese Team Reports Gene Editing in Human Embryos." Nature.com. April 8, 2016. Accessed November 20, 2016. http://www.nature.com/news/second-chinese-team-reports-gene-editing-in-human-embryos-1.19718.

  10. Trump, Donald J. "Not Only Are Wind Farms Disgusting Looking, but Even Worse They Are Bad for People's Health Http://t.co/2G8YrOUZ (cont) Http://t.co/NujHgnXU." Twitter. April 23, 2012. Accessed November 21, 2016. https://twitter.com/realDonaldTrump/status/194493341302394880.

  11. Fountain, Henry (November 11, 2016). "Trump's Climate Contrarian: Myron Ebell Takes On the E.P.A.". New York Times. Retrieved November 11, 2016.

 

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