FEB. 2, 2023

MEET THE SCIENTISTS WHO WANT TO MAKE MEDICAL DEVICES WORK FOR EVERYONE, FINALLY In the early months of the pandemic, Ashraf Fawzy, then a pulmonary fellow at Johns Hopkins University, noticed something strange. Black patients he was treating, all hospitalized with Covid-19, had oxygen levels scattered all over the place, often not in sync with their dire respiratory symptoms. “I remember one particular encounter…an African American woman, relatively young with asthma, came in with Covid [and] we were weaning her off supplemental oxygen,” Fawzy, now an assistant professor of medicine at Johns Hopkins, tells Inverse. But the patient’s pulse oximeter — a non-invasive medical device to rapidly measure blood oxygen levels — were giving readings higher than what her actual oxygen levels were on blood tests. “We realized we were under-treating her with oxygen because we were relying on these inaccurate pulse oximeters,” he says. One inaccurate machine could have been an isolated case, but Fawzy wasn’t the only one noticing something off with pulse oximeters. As the Covid-19 pandemic raged on and the simple fingertip device became an increasingly recommended way to monitor drops in oxygen, a December 2020 study in the New England Journal of Medicine captured national attention: Black patients were nearly three times more likely than white patients to have hidden hypoxemia, or dangerously low oxygen levels missed entirely by pulse oximeters.

"WE REALIZED WE WERE UNDER-TREATING HER WITH OXYGEN BECAUSE WE WERE RELYING ON THESE INACCURATE PULSE OXIMETERS."

The study spurred considerable alarm within the medical community, as pulse oximeters are a heavily relied-on medical device. In 2021, patients and lawmakers sent a letter to the Food and Drug Administration (FDA) expressing concerns about potential racial disparities, noting the pulse oximeter disparity as “a matter of life or death.” “The pulse [oximeter] has become the poster child of [health inequity], in part because of the pandemic. It really highlights the need for diversity at all stages of technology development, from the nascent stages of coming up with a design to how these things are tested, vetted, and distributed,” Kimani Toussaint, a professor of engineering at Brown University, tells Inverse. Pulse oximeters are just one example of a persistent, prevalent, and overlooked problem that the Covid-19 pandemic brought to light: Medicine and healthcare have harbored racial bias since their inception. But this long-known problem finally reached the federal level. In November 2022, the FDA discussed plans to both improve pulse oximeter regulation and provide clearer labeling and more testing of these devices. Now, the question becomes, can scientists fix these biases, starting with the ubiquitous pulse oximeter, and prevent them from happening in the future?

THE HISTORY OF THE PULSE OXIMETER

Long before it made its way to hospitals and consumer markets, the pulse oximeter was originally developed for the military by American and German scientists during World War II, according to a 1986 article in the Journal of Clinical Monitoring. The aim was to prevent fighter pilots from losing consciousness due to oxygen deprivation as they flew at high altitudes. The first iteration of the device, according to the report, was more of a clip-on earring pilots wore that warned them to take supplemental oxygen when their oxygen levels dipped below a critical level, making them more likely to lose consciousness.

PULSE OXIMETERS ARE JUST ONE EXAMPLE OF A PERSISTENT, PREVALENT, AND OVERLOOKED PROBLEM THAT THE COVID-19 PANDEMIC BROUGHT TO LIGHT: MEDICINE AND HEALTHCARE HAVE HARBORED RACIAL BIAS SINCE THEIR INCEPTION.

Between the 1960s and 1970s, while collaborating with NASA to develop health devices for astronauts, computer company Hewlett-Packard (HP) took a stab at expanding the ear pulse oximeter for the hospital market. Interestingly enough, this would be the first attempt at an equitable device, although this probably wasn’t purely for the sake of equity. At the time, and still today, pulse oximeters worked like this: A light source shines two wavelengths of light — red light at 600 nanometers and infrared light at 940 nanometers — into a finger, passing through fingernail, skin, tissue, and blood. Hemoglobin, the molecule that carries oxygen throughout the body, absorbs either wavelength depending on whether it’s oxygenated (absorbing more infrared light) or not (absorbing more red light). How much of either wavelength is relayed back to the pulse oximetry is used to provide a blood oxygen level percentage. HP said it wanted something that would work for all skin types; in the October 1976 issue of their journal, called The Hewlett-Packard Journal, the company acknowledged how oxygen level readings were impacted by “skin and blood pigments, and the surface characteristics of the skin.” HP engineers borrowed the ear clip-on design and wired it with fiber optic cables that transmitted eight different wavelengths of light onto the skin — different brightness settings for different skin types. This build allowed the oxygen reader to be specifically adjusted and calibrated to one’s skin color. Indeed, this appeared to work in experimental trials HP conducted involving Black patients. Later studies of HP’s device show that this early pulse oximeter more closely matched the invasive arterial blood gas tests, which takes a blood sample to measure oxygen levels along with carbon dioxide and pH. Despite its early promise, HP’s pulse oximeter didn’t take off and had quite a number of limitations, Philip Bickler, director of the University of California, San Francisco’s Hypoxia Lab, tells Inverse. “It was a clumsy clamp that you put on the ears that didn’t really account for differences in the size and shape of [someone’s] ears,” says Bickler. On top of that, it was quite pricey at $13,000 a pop in 1970 and found mostly in a select few research labs. With the boom of the personal computing market of the 1980s, HP shifted its focus and abandoned plans to miniaturize its pulse oximeter.

LAYERS ON LAYERS OF BIAS Subsequent devices would continue to use light as a means of measuring oxygen levels. Given how versatile light is with its spectrum of wavelengths and intensities, it wouldn’t have been hard for pulse oximeter manufacturers to calibrate their devices for darker skin tones, as HP had done. But at the time, the nascent market was largely dominated by those of lighter skin, such as in Europe, the U.S., and Japan, says Bickler. The bias persisted simply because differences in skin color weren’t considered at all important. “Any additional complexity [like skin color] was met with resistance and a lack of interest,” says Bickler, who in 2005 co-authored one of several other early studies investigating how skin color affected pulse oximeter readings. “[Our study] was largely ignored. It was inconvenient for pulse oximeter manufacturers to accept that the way they had been testing and calibrating their devices [with lighter skin tones] had a flaw.” The indifference speaks to a wider, persisting crisis of bias within medicine, health care, and pharmaceutical or medical device development, Achuta Kadambi, an engineering professor at the University of California, Los Angeles, tells Inverse. “There’s essentially three types of bias: The bias of the physical layer, which is what we’re talking about often with pulse oximeters,” he says. “Then there’s bias at the [artificial intelligence], or computational, layer, and a third layer is interpretation bias, which means that even if the rest of the system is equitable, you might have a human factor adjust the output accordingly.” A prime example of interpretation bias, says Kadambi, is pulmonary function testing, where the results are filtered through equations that compare, or correct, the data against healthy values based on sex, height, age, as well as race. For Blacks and other ethnic minorities, these adjustments tend to assume a lower lung function. That doesn’t necessarily reflect on someone’s actual innate biology. Instead, it normalizes disparities that lead to poor lung health and exacerbate chronic disease, as studies have found.

THE BIAS EXTENDS EVEN BEYOND WHAT’S TYPICALLY USED IN A CLINICAL SETTING TO OUR EVERYDAY WEARABLES RELAYING A CONSTANT STREAM OF DATA WE USE TO MONITOR AND GUIDE OUR OWN HEALTH.

Other medical-grade devices harboring bias include the ubiquitous infrared thermometers, which are as much relied upon as pulse oximeters to make clinical decisions. A 2022 study out of Emory University found these forehead thermometers, which infer body temperature through infrared radiation produced by the body, were as much as 26 percent less accurate at detecting fever in Black patients compared to oral thermometers. The bias extends even beyond what’s typically used in a clinical setting to our everyday wearables relaying a constant stream of data we use to monitor and guide our own health. Devices like Fitbits and Apple Watches operate in a similar fashion to pulse oximeters, using light sensors to capture information such as oxygen levels and heart rate. Most of these wearables use green light (a cheaper option than red and infrared light used in a hospital-grade device), which a number of studies over the years have found may give inaccurate results for those of darker skin and people with obesity. This bias hasn’t gone unnoticed, judging from online complaints and the fact that last month, Apple was hit with a class-action lawsuit for allegedly not warning consumers that its Watch couldn’t accurately gauge blood oxygen levels for those of darker skin. In the case of pulse oximeters, subsequent studies since the December 2020 report in the New England Journal of Medicine have found inaccurate pulse oximeters readings delayed timely Covid-19 treatments for patients with darker skin or not getting appropriate treatment at all, according to Fawzy, in a study he co-authored in 2022, which was published in JAMA. (Important to note pulse oximeters are not solely to blame for the high Covid-19 mortality rate in Black and other ethnic minorities.) And this is problematic not just for anyone of darker skin hospitalized with Covid-19 but for anyone of darker skin with respiratory issues managed by pulse oximeters. “As a pulmonologist, my main research interest is COPD [chronic obstructive pulmonary disease], and in COPD, we prescribe oxygen to patients based on their pulse oximeter readings,” says Fawzy. “We’ve been depending on [pulse oximeters] to say whether someone has sleep apnea for decades. So it’s really problematic that there’s a potential underdiagnosis in lung diseases for prescribing oxygen [and] a potential for under-diagnosing sleep apnea using these devices.”

WHAT’S THE SOLUTION? In February 2021, the FDA issued a warning that skin pigmentation and other factors could impact pulse oximeter readings. And this past November, a Medical Devices Advisory committee convened to review the current clinical data on pulse oximeters, recommending the agency update its regulation and put labels that warn of potentially inaccurate readings. The FDA has requested new studies to assess pulse oximeter accuracy in hospital settings for both adults and children. For Black engineers like Valencia Koomson, an associate professor of electrical and computer engineering at Tufts University, the challenge to offsetting the racial bias is not so much overhauling the pulse oximeter entirely but finding ways to improve how it functions. “We’re dealing with very weak optical signals that have to transverse through tissues with lots of [other] elements that absorb and scatter light,” she tells Inverse. “It’s very similar to when you’re riding a car, and you go through a tunnel. You lose signal because of the absorption of the materials in the tunnel, such that the signal being transmitted from the cell phone tower is too weak to be processed by your phone. To remedy this, Koomson and her fellow scientists are working on a pulse oximeter that uses the same light as devices currently on the market but includes a technology that measures a person’s skin tone. So if you’ve got darker skin (i.e., more melanin), the pulse oximeter will emit more light. Skin color, though, isn’t the factor that can give rise to inaccurate pulse oximeter readings. At the Hypoxia Lab, Bickler and his colleagues are seeking to comprehensively understand how these other factors like blood flow and body temperature stacked on top of skin color impact a pulse oximeter reading. In a recent study that’s currently in pre-print, the researchers found that poor perfusion, or blood flow through vessels and body tissues, exacerbated inaccurate pulse oximeter oxygen readings alongside skin color. “Poor perfusion is super common in sick people,” says Bickler, due to a combination of problems such as low blood oxygen levels, being dehydrated, or being on medications that cause blood vessels to constrict. Koomson says while further research and innovation are all great and good, it doesn’t change the fact that devising with equity in mind needs to happen at the federal regulatory level, with how the FDA sets guidelines for pulse oximetry approval, which on the whole are relatively lax. “We know that if you have a [federal] guideline that says that a device has to be tested on a minimum of 10 people and at least 15 percent have to be [of] dark skin pigmentation, that opens the door for a lot of loopholes because ‘dark’ is very subjective,” says Koomson. “That subjectivity is going to affect the kind of product that you put out.” Other Black engineers, like Brown’s Kimani Toussaint, are taking a slightly offbeat tack by investigating how light’s electromagnetic waves interact and behave with matter such as body tissues, the skin pigment melanin, and blood.

“We’re trying to exploit [these] properties to see if we can use that to differentiate between the response from oxygenated hemoglobin versus deoxygenated hemoglobin,” says Toussaint. “Although we strive to get rid of the bias completely, it’s still an open question how effective our approach is… and how reduced is the effect of having the melanin contribution.” Toussaint’s lab also has a prototype that’s undergone some initial trials in healthy volunteers. An upcoming clinical study started earlier this year at the intensive care unit at The Miriam Hospital in Providence, Rhode Island. “We’re trying to vet this [device] right now, compare it to [the] gold standard arterial blood draw that physicians normally use,” he says. Bickler, Fawzy, and Toussaint are optimistic that shining a spotlight on the pulse oximeter will be the clarion call to action within the health community, rousing physicians and other healthcare workers to advocate for a better understanding of the inequities inherent in this devices as well as a hunt for solutions — especially as we don’t have more equitable, non-invasive technologies or alternatives on the foreseeable horizon. “The FDA is working very hard towards improving [pulse oximeters]. We’ve had funding from the FDA to study pulse oximeters in patients in the hospital and in real-world clinic conditions in a very carefully controlled way,” says Bickler. “It’s been almost 20 years since this was really defined as a problem, and here we are 20 years later. Yes, it’s way too late, but at least it’s on the radar.” It may also encourage discourse around bias beyond the borders of the pulse oximeter, firmly entrenched in other medical devices and in health care at large. Part of that need for diversity is essential within a workforce that can inform and guide equity during a technology’s development. According to a 2021 Pew Research Center study, while jobs in science, technology, engineering, and math (STEM) have seen considerable growth in years, Black and Hispanic workers still remain underrepresented. “These are things now where we have to think about how technologies aren’t as agnostic as we may have thought in terms of their impact on communities,” says Toussaint, “It’s part of the human condition to think about how bias can creep in and be perpetuated, whether deliberately or not.”

This has been HORIZONS, a newsletter that explores the innovations of today shaping the world of tomorrow. Do you think it can be improved? Have a story idea? Send your tips and all other musings to horizons@inverse.com

SHARE HORIZONS Enjoy reading this newsletter? Share it with a friend.

Humans TV Series Reviews on IEEG

I noticed two reviews on the Institute for Ethics & Emerging Technology on the new TV Series "Humans".

Spoiler alert in effect, but here is the review by Adrian Cull.
Here is the review by Nicole Sallak Anderson.

I have not seen the TV series but I think the ideas for this kind of science fiction were mined from the film directed by Steven Spielberg in 2001 called  "AI".

As one reviewer for the Humans TV series says, it is good that the public is starting to think about the ethics of this technology.

Coursera - Peter Singer "Practical Ethics" from Princeton - Writing Assignments

I finished my first Coursera MOOC course this week. It was also the first MOOC I ever started and completed.  It was called "Practical Ethics" by Dr. Peter Singer, from Princeton University. The course was recorded at an actual Princeton classroom in Fall 2013. I enjoyed taking the course. I completed 4 writing assignments that were supposed to be between 700 and 850 words. There is no certificate for taking the course. Writing assignments were peer evaluated and I have to grade 5 other students. I had good grades as well as a few low ones and some critical comments.  I had started several other MOOCs, from other famous universities, but didn't manage to stay in beyond the first lecture or so.

There is not much here of relevance to eHealth, and there was not a lot that had direct relevance to bioethics. I found that kind of intriguing, the idea of how philosophical theories can be applied to such things as biodiversity, specieism, affirmative action, altruism, without too much concentration on philosophical theories, save for the utilitarian ethos which runs through all the presentations that Singer makes. Only one series of lectures on brain death, comatose states, or when the medical professions need to call the time of death, and how that is changing, bore some relevance to the field of "indefinite life extension".

The content of the course was excellent. There were interesting guest lecturers. The video format for "office hours" and student question and answer seminars with Dr. Singer were engaging. I spent more time watching the videos for the lectures than I did doing the background reading. The latter was much too difficult for me to do time wise, but for each writing assignment I did try to dip into it more. I think I will try and take another Coursera course later, but I am not sure which or when. I don't like the idea of signing up and dropping out. Apparently 25,000 signed up for this one, but MOOC's generally have a high drop out rate. I decided to post my writing assignments here, not that I am overly proud of what I wrote, but because I respect the questions that we were asked. These are thought provoking ethical questions that deserve attention.

Many people taking this course where not the fresh faced college students you saw in the Princeton lecture room where Peter Singers lectures and guest talks where videotaped, but retired academics, other career professionals, veterans, the whole gamut. Based on what I read in the copius number of discussion forums, there are some extremely clever people participating in these courses. Some are indeed Coursera veterans. Several, are even PhD academics doing research on MOOC. This latter idea is a relevant one, because MOOCs are still finding their way in higher education as a strategy or mission statement for the university.

The course content was excellent as Singer waded into the many different fields to apply ideas about "practical ethics". Highlights for me were the folks from Give Well, who are using evidence based data to find out the most effective way to give cash to help the poor, and which charities save the most less and accrue the less waste in terms of administrative overhead. Giving cash directly is saving lives in the developing world. Related to the idea of moral responsibilities for the poor in the so called "developing world" were the philosophical ideas of Thomas Pogge:"that international financial and trade institutions perpetuate poverty and therefore contribute to human rights violations". I hadn't ready anything by him before, and still have not read as much as I would like. His ideas are that the rich nations have ethical responsibility and in many cases are responsible for the poverty of other nations. Another eye opener for me were the guest lectures and discussion on Geoengineering to reverse the effects of climate change. Dale Jamieson was fascinating in that department. Another major highlight was guest lecturer Zell Kravinsky, who not only gave a kidney to a deserving person who was dying on the organ donor list, but most of the money he made in real estate deals - about $45,000,000. Not bad for a man who has two PhDs (in Rhetoric and English Literature).

Anyway, the course concentrated on the "practical" or the applied side of ethics, and not so much it's philosophical or metaphysical underpinnings. I have copied in here my answers to the writing assignments. I did my best to answer, but I think I ended up writing more from my experience than from arguing with the course content and the reading assignments. My experience working for NGO's, charities, human rights, the developing world, and spirituality, came through a bit.

1. Describe and evaluate one argument against subjectivism in ethics.
2. How can reason tell us what we ought to do?
3. Evaluate one argument for the view that ethics is independent of religion. 
4. State one objection to utilitarianism. Is it a sufficient ground for rejecting utilitarianism?
5. Do any moral rules hold without exception, no matter what the circumstances?
6. How persuasive is the argument for a revised definition of death provided in the Report of the Ad Hoc Committee of the Harvard Medical School to examine the Definition of Brain Death? (NB: You can only choose this topic if you have been able to locate the Ad Hoc Committee report. Readers of your work may not have read the report, so be sure to summarize it for them.).

6. Brain Death

I think the "Report of the Ad Hoc Committee of the Harvard Medical School to examine the Definition of Brian Death" is a very persuasive argument and a necessary one. It was published in 1968 when things like kidney and heart transplants were novel technologies, and other forms of medical technology were helping to keep people alive, even though they were in a comatose state. The report defines four ways a medical professional could determine whether or not a person was dead, such as being unreceptive and unresponsive, having no movements or breathing, no reflexes, and a flat electroencelphalogram (1). "Irreversible coma" was the descriptor for persons increasingly being seen in medical cases, where it was medically, legally, and ethical difficult to call the time of death. It is important to distinguish that the "person" or consciousness of a living individual can be gone before the living bodily functions of the person cease. As Dr. Singer says, if you ignore quality of life, a living organism can be kept alive even if the person is never coming back. Human bodies on ventilators etc. can be kept alive because the brain stem continues to maintain bodily functions, even though the higher cortical functions may be irreversibly damaged (2). The centuries old previous standard definitions of death were basically about the heart ceasing to beat and, as Dr. Singer quotes Boyle as saying, "decomposition" setting in (2). 

The standard medical and legal definitions of death that existed before this revision can no longer ethically, legally, religiously or medically apply to new cases. A revised "standard of care" was needed to help clinicians make qualified decisions about life and death. The 1968 report could be said to have flaws because in a way it appeared to unintentionally try to justify the opportunity at which a medical decision could be made to take someone off a ventilator, partially in order to save the living heart for a transplant. Other organs can be removed after death, but not a heart. The report to its credit, recognized the inherent conflict of interest of a physician making the decision to remove life support as not being the physician who was also involved with the healthcare of the transplant patient. (1) In such a case as this, when it is not clear whether or not the patient is totally irreversibly brain dead, the concept of removing them from life support can almost be construed as murder. Persons in comatose conditions can be kept alive in this condition for years. The toll on hospitals, families, is horrendous and the idea of the physician assisting the patients' right to die in dignity here is very hard.

I would argue that as technologies continue to develop that a revised definition of death will often have to be made as in 1968. For example, scientists now know that even so called comatose patients still possess consciousness and there are novel technologies that can even communicate with these persons. There is a condition known as locked-in syndrome, and fMRI type technology developed by neuroscientists such as Dr. Adrian Owen (3), have enabled these patients to communicate. Further on the horizon are the claims of transhumanists and futurists that the exponential growth of technology will allow us to live forever. A recent article by "ethical technology" writer Dick Pelletier quotes a leading transhumanist, Aubrey de Grey, that a human being born today will have the chance to live to be 1,000 years old. (4) Add as well current advances in brain research, it is clear to see that the brain is still a whole new undiscovered world, which is now receiving massive amounts of research funding, such as the Brain Project, mentioned in the Pelletier article. (4) The question of when the brain is dead will continue to challenge legal, medical, and ethical definitions of death. There is a 2012 article cited by a poster in the Practical Ethics Coursera discussion group which shows that in fact there have been many revisions to the definition of brain death since 1968, as recent as 2009. (6)

Let's consider the ethical dilemma of a patient who was in a car accident and who winds up in a persistent vegetative state or locked-in syndrome. The patient has signed a Do Not Resuscitate order or an advance directive not to be kept on life support. Through technology like Dr. Adrian Owens' fMRI mind reader (3) it is possible to communicate with the patient. What would the patient communicate? Here presents the persistent ethical dilemma of rights for euthanasia or patient assisted suicide. In a book by veteran physician Sherwin Nuland, (5) he mentions how in their true mind some physicians think it is wrong to prolong the life of a conscious, extremely suffering living person. Then what about a person rendered a mere living organism, who by all standard definitions of brain death has no known brain function and unknown amounts of suffering? Not all of us will die at peace at home in our beds. 

1. Beecher, H., "A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death", JAMA, Aug 5, 1968. Vol 205, No 6
2. Singer, P., Coursera Practical Ethics, 2014.
3. Cyranoski, D. "Neuroscience, the Mind Reader" http://www.nature.com/news/neuroscience-the-mind-reader-1.10816
4. Pelletier, D., "Living for a 1,000 years: an 'out of this world future" awaits us", http://ieet.org/index.php/IEET/more/pelletier20140317
5. Nuland, S., "How We Die", New Chapter Edition, 1993
6. Smith, M. "Brain death: time for an international consensus", Br. J. Anaesth. (2012) 108 (suppl 1): i6-i9.doi: 10.1093/bja/aer355

1. Is it possible to defend the moral permissibility of abortion without deciding on the moral status of the human fetus?
2. What moral status should human embryos and fetuses have?
3. Consider these two questions. Would you answer both these questions in the same way? Why, or why not?
   1. Is a physician ever justified in withdrawing life-support, including a respirator, from an infant so premature that it cannot breathe on its own?
   2. Is a physician ever justified in giving a lethal injection to a severely disabled infant?
4. Should we legalize physician-assisted suicide, along the lines of Oregon’s Dying With Dignity Act? Would you give the same answer if the question were about legalizing voluntary euthanasia, along the lines of legislation in The Netherlands?
5. What obligations, if any, do people with money to spare have to assist people in extreme poverty?
6. Assume that you have decided to give $1000 to the best cause you can find. How should you decide which cause that is?

1. Assume that you have decided to give $1000 to the best cause you can find. How should you decide which cause that is?

If I had $1000 and had to find the best cause I could find, how should I decide which cause that is? I might now go to the Give Well website and see their recommendations after taking this course and learning about them. I might even think about giving to Giving Direct, as I think the evidence for cash transfers has some merit. In fact, I used to give cash direct to Tibetan refugees in Nepal and India for many years.  I used to think micro loans were the best idea, but now I need to re-examine the evidence for direct cash gifts. Although this is well and good, for many years as I have supported various causes in the developing world my first inclination would be to go to these sources because I know and trust them well and I know directly how the money will benefit. I don't consider myself naive in regards to charities, having been one myself almost. I have been to developing countries more than several times and from experience living there, have seen the hands held outstretched. 

So, in essence, I can't think of too many philosophical arguments in support of my decision to decide to support the causes which I have supported in the past.  In fact I don't quite understand the question at all unless i was totally naive about charities (or causes) and had to make a decision. If that were the case I might well use Give Well because it represents some pretty solid "evidence-based" methodologies. It is a kind of "value investment" of the Benjamin Graham variety for philanthropy.The question has nothing to do with the nature of altruism, whether it is biological or socio-biological or anything like that. The argument could even be construed around whether or not we have moral obligations to others. Many religious and spiritual traditions espouse the virtues of giving to others. Utilitarian philosophies are based on maximizing the good for the many. It is almost self-evident, from a biological, spiritual and philosophical basis, that humans are made essentially to behave in non-selfish ways for survival.  

Speaking about philanthropy, $1000 is a drop in the bucket compared to the kind of global largesse we see from the likes of Bill Gates. I have been following Bill on his twitter feed and his vision of global health and giving to causes around the world is staggering. In fact, there is even another Dr. Peter Singer who is an ethicist at the University of Toronto who received a grant from the Bill Gates Foundation to study the ethics of the Grand Challenges for Health.   Human nature has within it the virtues for giving to others, but it also the potential to be caught in an endless cycle of greed, lust, and aggression.

It might be interesting to take some of the current popular culture trends like reality TV shows and create one for choosing the best charity to give to. There are already TV shows similar to that, but they often just revel and glorify in the dream of suddenly having a big house, or having this or that. And nobody really wants to see another hungry child's face on a TV commercial. I would not include the Coursera and Peter Singer's "Giving Game" in this category. It is more an ethical economics experiment. What would be problematic is winning a lottery or a huge money windfall. We all know that people who instantly win huge wealth can quickly spend or lose all of it. What thoughts did they have about giving to charities? What if there was a huge lottery, but the winner had to do what we are asked to do in this course, decide on a way to distribute the money to charities?

Creating a habit of giving, as Holden Karnofsky referred to his Harvard Alumni, isn't a bad policy to keep in the public face. Even if a Harvard grad only gives $10, what is that to the billions in trust that are given there? Well as Holden says, they keep asking because eventually the habit of giving will pay dividends sometime down the road. Children in elementary schools are already taking courses in how to choose careers and have success in them. We could also be teaching them about ethical economics.

Generally speaking I think the time is ripe to focus on "bottom of the pyramid" economics. As Hans Roslin has discovered in United Nations, world health, GDP, population census data, etc., the so called "developing" world has slowly been rising from the bottom and millions more are rising out of poverty every year. Goodwill of any sort in this direction, and not just giving economic currency, is a gesture that will plant seeds in the conscience of humanity.

1. Rosling, H., "The Best Stats You've Ever Seen" http://www.ted.com/talks/hans_rosling_shows_the_best_stats_you_ve_ever_seen
2. Wikiepedia, "Bottom of the Pyramid" http://en.wikipedia.org/wiki/Bottom_of_the_pyramid

1. Could a career in finance or banking be the most ethical career choice?
2. Are citizens of affluent nations violating the human rights of people living in poverty in developing countries?
3. Are developing countries justified in demanding that developed countries take responsibility for their historical contributions to climate change, and therefore reduce their greenhouse gas emissions before the developing countries do?
4. Could it be ethical intentionally to modify the climate of the planet?
5. Can speciesism be defended?

1. Could a career in finance or banking be the most ethical career choice?

I would have to argue mostly in the negative to this question because you could substitute many other career choices and it would be difficult to empirically determine which is the "most" ethical. If the rule for measuring "the most ethical" is the number of lives saved, and if the numbers of lives saved can be achieved through direct donations of cash, then it is possible that a person who becomes successful at donating money through a career in finance or banking, from a utilitarian point of view, is a person who had made the most ethical career choice. Doctors save lives, so why can't making money help to save lives? A student guest lecturer in the course who gives a large percentage of the income he makes in his finance job mentioned Norman Borlaug, the scientist who's invention of hardier types of wheat triggered a green revolution that saved millions of lives. So being a scientist like that might be a competing ethical career choice, just if you look at the numbers of lives saved. 

In reality, most people tend to "end up" in careers or jobs and the idea of making ethical decisions in their nine to five lives is one of constant paradox and dilemma. At the end of the day, taxes have to be paid and almost no lives are saved, your concern being just trying to survive yourself. Many people who choose a career in finance are doing that as well. Not all of them are George Soros, a philanthropist of plutocratic stature who made a vast fortune in international currency trading, and who now spends his time, like Bill Gates, thinking of ways of giving it away to the best cause. 

It is admirable that young people are making choices to go into careers which might seem soulless and at odds to doing the good, out of the compassionate goal of giving a fair percentage of their income to the poor. There are also people in any career who's intent is to make "enough" money in order to volunteer their time for various causes that are more in line with their conscience. From a utilitarian perspective, they might not be saving as many lives, but who could argue that the consequence of their actions are not doing the most good for themselves? There are other so called "dirty" careers that involve corruption, soul killing, environment killing etc., but young people have to make choices to do these jobs so society doesn't totally run amuck. Going into politics would be another example like that. 

If someone became very wealthy in finance but was trying to give a lot of that money away to save lives in poor countries, just by the numbers of lives saved you could argue that this was most ethical decision to have been made. Maybe they can save more lives than a physician. However, if you look at how that money was actually made, a strong argument against the financial practices of companies where the money was invested might reveal that more lives might have been damaged or lost by those investments. For example, I once heard a Native American activist say that we need to look at the actual companies that we own in our mutual funds. Many people don't look at the details in a balance sheet to see the hundreds of companies that share a financial pool in a mutual fund. Some of those companies are companies that are pushing Native Americans off the land. As a Native American, would that be an ethical mutual fund to own? 

There are consequences to not living an unexamined life, and the typical scenario is the "guilt money" donated by philanthropists to universities and hospitals to have buildings or surgery wards in their names. This same Native American activist mentioned above also said that she knew a billionaire who after making a billion dollar's, that his only goal was to make the next billion.  It is difficult to set out with the intent of working in finance to help the less fortunate and not get caught up in the adrenalin rush and addiction of the game of making money for the sake of making money alone.

In order to help save other lives, we might need to sacrifice not only some of our own ethical sense, but a portion of our lives as well. This is an altruistic motivation and a choice some people consciously make in their career decisions. Many people make decisions to live as ethical a life as possible and their career decisions are based on that, so subjectively speaking, there is no argument that almost any career, including finance, could be the most ethical career choice. Objectively speaking, some might argue, that being an ethicist, or a buddhist monk, or billionaire philanthropist, would be the most ethical career choice, in terms of ethical conduct of behaviour.

1. Do animal or plant species have intrinsic ethical value? Discuss either with reference to Aldo Leopold’s “land ethic” or to Holmes Rolston’s “respect for life”.
2. Should we kill feral animals in order to preserve endangered plants?
3. What reasons are there for and against seeking to increase the numbers of endangered predators like the Siberian tiger? Assess the reasons and indicate which you think are stronger.
4. Assess the case for greater diversity in higher education made in the Report of the Princeton University Ad Hoc Committee, On Diversity.
5. Do we need reasons for acting ethically? If so, are there such reasons?

 Do we need reasons for acting ethically? If so, are there such reasons?

Life in the world is fraught with decisions and dilemmas. As a thinking species humans are programmed to take actions based on constructs in the processes of their reasoning. Most of this reasoning is culturally appropriated by lived experience and some is filtered through an individual will to personally own one's social inventory in a way that pragmatically makes sense to each. An ethical decision is an outcome of the trusted standard norms of behaviour, those mostly socially sanctioned and those individuated through the canons of social acceptability, that have gotten one that far through the endless cycle of karmic cause and effect. And in fact, there are certain universal rules or reasons that have high programming redundancy, in all world cultures and religions. One such ethical universal rule is often called "the golden rule", or "do unto others as you would have them do unto you". There are manifestations of this in all major religions and no doubt in cultures that don't have those religions. It even emerges in sociobiological discussions of what is altruism. The "golden rule" is just one example of an "overriding ethical principle" (1) that guides our social interactions. There is a certain inexplicable innateness to acting morally and making rational decisions. Animals and plant species too have their own right way to do things, and many respect the ways of others to act the way they do - a kind of territorial imperative(4) for surviving the vagrancies of existence.

One preforms ethical actions mostly for reasons of self-interest. Some might called this egoism, or in extreme cases, even called narcissism. Maybe saints preform ethical actions because of love, out of compassion or a sense of rendering service to others for the sake of service itself. Love might be a great explanation why people behave ethically and or altruistically, and I don't think any philosopher is going to be able to tell why we need reasons for love. Love just seems to be a force in it's own right and one can take or make ethical actions out of love without even thinking.

In the world of careers and professional codes of ethics there are entrenched rules or reasons for acting ethical. Doctors and nurses for example must follow certain rules or reasons for behaving the way they do. This applies across the board in many contexts. These ethical reasons are constructs of human realities long since past and established but they only continue to exist because they are followed, and they work as standards.  Society would run amuck otherwise, and quite quickly. Similarly, professional ethicists are trained in philosophical traditions to think in the logic of utilitarianism and consequentialism. Through a process of social osmosis commonly called the education system, the rules and laws of ethical philosophers are inculcated in the common herd of humanity. 

So if there is no purpose or meaning in this existential vortex we find ourselves confused in, how do we attribute any rhyme or reason for ethical thinking? Well, the sages of all times have more or less said that in spite of the existence of vast eternal emptiness we must nevertheless attribute meaning to our thoughts, words and deeds. In terms of ethics, the task taken up by many is to affirm the sacredness of all life. From this presupposition we find the words of Albert Schweizter, as echoed by Peter Singer in this course, that we should have "reverence for all life". The Jain religion which had is origins at the same time as Buddhism in ancient India to this day has adherents who go out of their way not to harm or kill any sentient being. That is, some of them even carry small brooms with them anywhere they go so they can sweep away the small insects they might inadvertently step on and harm or even kill. The realm of sacred duty demands from it's devotees such ethical codes, and this in spite of all reasons to the contrary that the purpose or meaning for such duty is empty of inherent meaning, in the vast existential vortex we inhabit.

In the normal world that most of us dwell in, for example the nine to five type of lives we live, living in terms of practicing ethical behaviour has a lot going for it. Peter Singer's book "Practical Ethics" spells out quite well the pragmatic and self-interested nature of making decisions by using ethical reasoning(1). Of course these have their basis in the great philosophical traditions all the way back to the virtue ethics of Aristotle. As the Dalai Lama and others have said, one need not have a strong religious faith or background to live an ethical life(2). Peter Singer I read on Wikipedia is an atheist(3) while the Dalai Lama, a buddhist, doesn't have a belief in a theocratic type of God. Still, I don't think anyone would want to debate that these two eminent individuals are not ethical beings. So, what, if not reasoning power, makes them that way?

1. Singer, Peter, "Practical Ethics"
2. Dalai Lama, "Ethics for the New Millennium"
3. Wikipedia, Peter Singer http://en.wikipedia.org/wiki/Peter_Singer
4. Robert Ardrey, "The Territorial Imperative" http://www.amazon.ca/The-Territorial-Imperative-Personal-Property/dp/1568361440