Care or Complicity? Medical Personnel in Prisons

Imprisonment may sometimes be a justified form of punishment. Yet the U.S. carceral system suffers from appalling problems of justice-in who is put into prisons, in how imprisoned people are treated, and in downstream personal and community health impacts. Medical personnel working in prisons and jails take on risky work for highly vulnerable and underserved patients. They are to be lauded for their professional commitments. Yet at the same time, prison care undercuts the ability of medical personnel to uphold their own professional standards and sometimes fails in even basic health protection. Doctors in prisons are stuck between their commitment to vulnerable patients and complicity in a system that requires their participation to uphold its constitutionality. Medical ethics is frayed in prisons, and the problem deserves our attention.

The real cause of our complicity: The preoccupation with human weakness

Chater & Loewenstein offer an incisive criticism of how behavioral sciences and public policy have become complicit with corporations in blaming public health and societal problems on individual weaknesses, thus deflecting support away from systemic reforms. However, their analysis stops short of holding the field to account in one important respect: its preoccupation with human irrationality and weakness.

Epithelial and stromal co-evolution and complicity in pancreatic cancer

Pancreatic ductal adenocarcinomas are distinguished by their robust desmoplasia, or fibroinflammatory response. Dominated by non-malignant cells, the mutated epithelium must therefore combat, cooperate with or co-opt the surrounding cells and signalling processes in its microenvironment. It is proposed that an invasive pancreatic ductal adenocarcinoma represents the coordinated evolution of malignant and non-malignant cells and mechanisms that subvert and repurpose normal tissue composition, architecture and physiology to foster tumorigenesis. The complex kinetics and stepwise development of pancreatic cancer suggests that it is governed by a discrete set of organizing rules and principles, and repeated attempts to target specific components within the microenvironment reveal self-regulating mechanisms of resistance. The histopathological and genetic progression models of the transforming ductal epithelium must therefore be considered together with a programme of stromal progression to create a comprehensive picture of pancreatic cancer evolution. Understanding the underlying organizational logic of the tumour to anticipate and pre-empt the almost inevitable compensatory mechanisms will be essential to eradicate the disease.

Researching the health and social inequalities experienced by European Roma populations: Complicity, oppression and resistance

This paper draws on the experience of two Romani and three non-Romani scholars in knowledge production on the health and social inequalities experienced by European Roma populations. Together, we explore how we might better account for, and work against, the complex web of dynamic oppressions embedded within processes of academic knowledge production. Our aim is to encourage careful scrutiny through which sociologists of health and illness might better recognise our own complicity with oppression and identify concrete actions towards transforming our research practices. Drawing on a well-known domains of racism typology (Annual Review of Public Health, 40, 2019, 105), we use examples from our own work to illustrate three interconnected domains of oppression in which we have found ourselves entangled (structural, cultural and interpersonal). A new conceptual framework is proposed as an aid to understanding the spectrum of different "types" of complicity (voluntary-involuntary, conscious-unconscious) that one might reproduce across all three domains. We conclude by exploring how sociologists of health and illness might promote a more actively anti-racist research agenda, identifying and challenging subtle, hidden and embedded negative ideologies and practices as well as more obviously oppressive ones. We hope these reflections will help revitalise important conversations.

Complicity in sociology and community-based participatory research with Marshallese

Complicity with colonialism can be reflected in a particular approach to research, whose interests it serves, and who has power or ownership over the research process. It can also be reflected in neglect, inaction or methodological erasure of groups historically subjected to domination by colonial empires. Social scientists have often failed to account for colonialism's role or the complicit role they have played. We provide a brief historical overview of colonialism in the Marshall Islands and the role social scientists-and their methodological and epistemological approaches-played in the US empire's expansion into the region. We discuss the tenets of Community Based Participatory Research (CBPR), setting the research agenda, co-direction of the research process, research team membership, collaboration challenges, and the action and outputs which have come from our team's health disparities research among the largest Marshallese population in the continental US. We argue CBPR is a promising but imperfect approach to guarding against complicity within medical sociology and situate our methodological approach within ongoing debates regarding objectivity and advocacy within sociology. We reflect on successes and shortcomings of our CBPR efforts to address health disparities among Marshallese, as well as how those successes and shortcomings overlap with questions of complicity.

The challenge of institutionalised complicity: Researching the pharmaceutical industry in the era of impact and engagement

The pharmaceutical industry plays a central role in the production of the drugs we use to treat most illnesses. It is immensely powerful and has received sustained attention from sociologists of health and illness, who have provided a critique of its influence and sometimes unethical behaviour. However, in recent years, funders are increasingly expecting researchers to engage and collaborate with stakeholders, including industry. This raises important questions about the institutionalisation of complicity and the different forms this might take. This article asks: How can sociologists engage with the pharmaceutical industry in a positive and constructive manner, whilst remaining independent, principled and critical? It will draw on my experience of establishing a major project on high-priced drugs for rare diseases and the literature on collaboration, stakeholder engagement and responsible research to propose a methodological framework to address this challenge. This is based on six PRIMES: (normative) Principles, Reflection and Independence, (field) Mapping, (careful) Engagement and Strategic intervention that have broad applications to many other areas of contemporary social science research.

Dealing with complicity in fieldwork: Reflections on studying genetic research in Pakistan

Health-related ethnography undertaken in a context marked by social inequalities and colonial legacies requires critical attention to power imbalances in the fieldwork. In this paper, I draw on my own experiences from studying genetic research in Pakistan. As a Danish-born female researcher with roots in Pakistan, I have followed genetic researchers and families dealing with genetic conditions in Pakistan. Through examples I unearth how encounters in the field were shaped by complicities of being in-between the Danish and the Pakistani, of studying and doing international research at the same time, and of my inaction towards suffering families. I base my analysis on the notion that complicity manifests in a generative, and unavoidable, engagement with both complex structures of inequality and interlocutors. We can never fully understand the specificities or consequences of complicity-whether moral or epistemic-when entering, engaging with or representing our fields. However, by staying constructively with the tensions, instead of attempting to move beyond the discomfort that they might create, we can learn how to deal with the consequences and in that, build further the value of ethnographic activity.

The practice of participatory action research: Complicity, power and prestige in dialogue with the 'racialised mad'

Mental health service users in the UK have become increasingly involved in research over the last 2 decades partly as a consequence of research governance. Ethnic minority service users, however, point to power imbalances stemming from marginalisation and discrimination creating barriers to knowledge co-production (Kalathil, J. (2013). Hard to reach? Racialised groups and mental health service user involvement.). Heavily influenced by Freire's liberatory education, participatory action research (PAR) repoliticises participation where those most affected by injustice are central in both producing knowledge about injustice and implementing solutions. Ethnic minority people with lived experience of 'severe mental illness' ('the racialised mad') were appointed as coresearchers to work with academic researchers on a qualitative study exploring ethnic inequalities in 'severe mental illness'. Drawing on Foucault's notion of power as relational, we focus on three key aspects of productive power: (1) relational engagement and reciprocity, (2) positioning coresearchers as authentic researchers and (3) adopting an ethic of care, to explore complicity and resistance in reproducing hierarchies of knowledge and power when attempting to create and sustain a PAR process for collective analysis, action and solidarity. We utilise retrospective and recorded reflections over the course of the project. Finally, we discuss the ethical and methodological implications for contemporary sociological research into health and illness.

Complicity: Methodologies of power, politics and the ethics of knowledge production

In this collection we develop the concept of "complicity" as a means to understand how medical sociologists might be allied in unexpected or uncomfortable ways with dominant structures of power. After giving examples of complicity from our own research, we introduce existing scholarship on complicity, describing it as a concept that comes coupled with a sense of responsibility and that is related to, yet distinct from, a range of other terms including reflexivity, collusion, guilt, and shame. We also discuss how complicity has been described to occur at the level of the institution, within theoretical frameworks, and during mundane moments that we face on a day-to-day basis. Building on this review, we hypothesise that medical sociology - where access to fieldsites is often hard won, where "researching up" in medical and scientific institutions is common, and where our own work frequently concerns matters central to medical institutions themselves - is a discipline wherein mundane complicity is likely. Following this gathering exercise, we introduce the interventions that comprise this collection: interventions from a diversity of sociologists of health and illness who, perhaps for the first time in written form, account for how complicities of various kinds came to shape their work and how, with varying levels of success, they have sought redress. We close by offering some insight into the process of developing this collection, celebrating its successes while also acknowledging that many gaps and complicities remain.

The impossibility of engaged research: Complicity and accountability between researchers, 'publics' and institutions

Over the past decade, U.K. universities have increasingly sought to involve publics in research as active participants in the construction of academic knowledge. Sociologists of health have largely welcomed this enthusiasm for engaged and participatory ways of working, including methodologies long in use in the field such as patient-led research and co-creation. Despite the strong interest in engaged research, however, we argue that funding patterns, bureaucratic structures and an overreliance on people employed on casual contracts make it extremely difficult, often impossible, to do engaged research in British universities. Drawing on our own experiences, we show how our attempts to practise and deepen accountability to variously situated publics were constrained by the way our institution imagined and materially supported engagement. We argue that it falls to individual researchers to mitigate or work around structural barriers to engagement, and that this process creates dilemmas of complicity. If engaged research is to fulfil its remit for inclusion and its radical potential, researchers need to think carefully about how the U.K. engagement agenda entwines with processes of casualisation, acceleration and projectification, and how institutional recuperations of engagement can undermine its political and epistemic objectives.

Confronting the Medical Community's Complicity in Marginalizing Abortion Care

This Viewpoint discusses the exclusion of abortion care from many established medical sources (such as hospitals) and from coverage by many major payers and how the health care system should legitimize and ensure clinician training in safe abortion care.

Is the international regulation of medical complicity with torture largely window dressing? The case of Israel and the lessons of a 12-year medical ethical appeal

This is the account of an ongoing appeal initiated in 2009 by 725 doctors from 43 countries concerning medical complicity with torture in Israel. It has been underpinned by a voluminous and still accumulating evidence base from reputable international and regional human rights organisations, quoted below, and has spanned the terms of office of four World Medical Association (WMA) presidencies and two UN special rapporteurs on torture. This campaign has been a litmus test of whether international medical codes regarding doctors and torture actually matter, and are applied rigorously and even-handededly, particularly when compelling evidence incriminates a WMA member association. Our findings in the case of Israel suggest that this is not true, and that impunity largely operates. The WMA seems in partisan violation of its mandate to be the official international watchdog on the ethical behaviour of doctors. And as the IMA case demonstrates, by their inaction national medical associations or other regulatory bodies appear to function at base as buttresses and shields of the state.

How Should Students Learn About Contemporary Implications of Health Professionals' Roles in the Holocaust?

Foundational documents of modern biomedical ethics, such as the Nuremberg Code, the World Medical Association's declarations of Geneva and Helsinki, and the Belmont Report, trace their origins to health care professionals' complicity in the Holocaust. Rituals of contemporary medical education, such as white coat ceremonies and oath swearing at graduations, are practices that express professional resolve to never again be complicit in genocide or human exploitation. This article considers a historical approach to teaching the Holocaust's contemporary ethical implications for clinicians and their practices.

Weight(s) of complicity

International non-governmental organisations (INGO) face a dilemma when deciding whether to intervene in crisis situations where their efforts can be exploited or co-opted by others: intervene and risk becoming complicit with wrongdoing or sit on the sidelines and consign vulnerable people to the ravages of neglect or oppression. In "'He who helps the guilty, shares the crime'? INGOs, moral narcissism and complicity in wrongdoing," Buth et al argue that concerns about complicity often stifle ethical debate and encourage moral narcissism. We argue that neglecting concerns about complicity can foster a different form of moral narcissism and that where worries of complicity are present, aid efforts face three types of risk: risks to others created by contributing to wrongful acts or bad outcomes; risks to the moral integrity of the INGO and its personnel; and risks to social trust in the INGO. In the end, we challenge the assumption that there is a unique, ethically best way to reconcile these values. We suggest that the causes of justice and humanity might be better served by a diverse community of INGOs who each gives different weight to these concerns, than if each INGO adopts the same framework for reconciling these competing demands.

'He who helps the guilty, shares the crime'? INGOs, moral narcissism and complicity in wrongdoing

Humanitarian organisations often work alongside those responsible for serious wrongdoing. In these circumstances, accusations of moral complicity are sometimes levelled at decision makers. These accusations can carry a strong if unfocused moral charge and are frequently the source of significant moral unease. In this paper, we explore the meaning and usefulness of complicity and its relation to moral accountability. We also examine the impact of concerns about complicity on the motivation of humanitarian staff and the risk that complicity may lead to a retreat into moral narcissism. Moral narcissism is the possibility that where humanitarian actors inadvertently become implicated in wrongdoing, they may focus more on their image as self-consciously good actors than on the interests of potential beneficiaries. Moral narcissism can be triggered where accusations of complicity are made and can slew decision making. We look at three interventions by Médecins Sans Frontières that gave rise to questions of complicity. We question its decision-guiding usefulness. Drawing on recent thought, we suggest that complicity can helpfully draw attention to the presence of moral conflict and to the way International Non-Governmental Organisations (INGOs) can be drawn into unintentional wrongdoing. We acknowledge the moral challenge that complicity presents to humanitarian staff but argue that complicity does not help INGOs make tough decisions in morally compromising situations as to whether they should continue with an intervention or pull out.

Unit 731 and moral repair

Unit 731, a biological warfare research organisation that operated under the authority of the Imperial Japanese Army in the 1930s and 1940s, conducted brutal experiments on thousands of unconsenting subjects. Because of the US interest in the data from these experiments, the perpetrators were not prosecuted and the atrocities are still relatively undiscussed. What counts as meaningful moral repair in this case-what should perpetrators and collaborator communities do decades later? We argue for three non-ideal but realistic forms of moral repair: (1) a national policy in Japan against human experimentation without appropriate informed and voluntary consent; (2) the establishment of a memorial to the victims of Unit 731; and (3) US disclosure about its use of Unit 731 data and an apology for failing to hold the perpetrators accountable.

Complicity and torture

One of the great merits of On Complicity and Compromise is that it wades into specific swamps where ordinary theorists fear to slog. It is persuasive that in general it can be right sometimes to be complicit in wrongdoing by others through causally contributing to the wrongdoing, but not sharing its purpose, if by being involved one can reasonably expect to lessen the extent of the wrong that would otherwise be suffered by the victims. I focus on whether the book's general thesis is applicable to torture, which depends on what torture and the torture situation are in fact like. I focus on the case to which the chapter several times refers: the innovative CIA paradigm of torture. First, to the extent that the paradigm, which is predominantly mental, or psychological, torture succeeds in its goal of producing regression to a compliant state, the physician would be unable to rely on the torture victim's expressions of preferences or interests as authentically his own. Second, since disorientation plays such a large role in the CIA's style of torture (adopted at Guantanamo by the military), the authorities would refuse to allow a stable relationship to be built up with any one doctor by any victim, making comprehension of the victim's preferences difficult. Third, even if the doctor could somehow judge what the victim's genuine interests were, the control of the situation is much too totalistic to allow the physician any action independent of what the torture regime requires.

The morality of risks in research: reflections on Kumar

Reflecting on the contribution by Rahul Kumar to the symposium, I consider the following topics in relation to risks in research: (1) treating someone as a mere means; (2) aggregation; (3) different conceptions of contractualism; (4) uncertainty; (5) paternalism and complicity.

The ethics of sexual reorientation: what should clinicians and researchers do?

Technological measures meant to change sexual orientation are, we have argued elsewhere, deeply alarming, even and indeed especially if they are safe and effective. Here we point out that this in part because they produce a distinctive kind of 'clinical collective action problem', a sort of dilemma for individual clinicians and researchers: a treatment which evidently relieves the suffering of particular patients, but in the process contributes to a practice that substantially worsens the conditions that produce this suffering in the first place. We argue that the role obligations of clinicians to relieve the suffering of their patients put them in a poor position to solve this problem, though they can take measures to avoid complicity in the harms that would result from widespread use of individually safe and effective reorientation biotechnology. But in the end the medical community as a whole still seems obligated to provide these measures, if they become technologically feasible. Medical researchers are in a better position to prevent the harms that would result if reorientation techniques were safe, effective and widely available. We argue that the harms attendant on the development of safe and effective re-orientation techniques give researchers reason to avoid 'applied' research aimed at developing these techniques, and to be careful in the conduct of basic orientation research which might be applied in this way.

Physicians and alternative medicines in "The Barber of Seville" by Gioachino Rossini: A bicentennial debate

BACKGROUND

The year 2016 marks the bicentennial anniversary of the premiere of "The Barber of Seville" by Gioachino Rossini (1792-1868). This opera buffa, one of the most renowned in the world, puts on stage a sharp criticism against the physicians of that time in favour of empiric healers, respectively represented by the doctor Bartolo and the barber Figaro.

METHODS

The paper analysed both the opera by Rossini and the French comedy "Le Barbier de Séville" (1775) by Pierre Beaumarchais (1732-1799), on which the Italian composer based his own play.

RESULTS

The unlearned barber Figaro is portrayed as a poor but wise guy, while his rival, the graduated doctor Bartolo, is defined as an arrogant and opulent old physician. Dr. Bartolo's incompetence, lack of skill and ignorance are evident in the works by Rossini and Beaumarchais. Both plays show empiric and unskilled medicine triumphs over academic medicine, which appears weak in its scientific concepts and corrupted by money.

CONCLUSIONS

Arrogance, presumption and carelessness among physicians are a danger nowadays as they have been for a couple of hundred years, since they may not only lead to misjudgement and errors, but also to an increase of alternative medicines and strange healing remedies.

Complicity and Japan's Wartime Medical Atrocities: Time for a Response

Shortly before and during the Second World War, Japanese doctors and medical researchers conducted large-scale human experiments in occupied China that were at least as gruesome as those conducted by Nazi doctors. Japan never officially acknowledged the occurrence of the experiments, never tried any of the perpetrators, and never provided compensation to the victims or issued an apology. Building on work by Jing-Bao Nie, this article argues that the U.S. government is heavily complicit in this grave injustice, and should respond in an appropriate way in order to reduce this complicity, as well as to avoid complicity in future unethical medical experiments. It also calls on other U.S. institutions, in particular the Presidential Commission for the Study of Bioethical Issues, to urge the government to respond, or to at least inform the public and initiate a debate about this dark page of American and Japanese history.

A brief report on rape myth acceptance: differences between police officers, law students, and psychology students in the United Kingdom

A common perception is that police officers hold very negative attitudes about rape victims. Therefore, the purpose of this article is to establish whether police officers do accept stereotypical rape myths at a higher level compared to members of other populations. There were 3 comparison samples, composed of police officers, law students, and psychology students, that completed the Illinois Rape Myth Acceptance scale. Male and female police officers accepted "she lied" myths at a higher level than the student samples. Student samples were found to accept 2 types of rape myths ("she asked for it" and "he didn't meant to") at a higher level compared to police officers. No significant differences were found in the other 4 subfactors. Therefore, the pattern of results suggests that police officers do not adhere to stereotypical myths about rape victims more than do other populations.

The new military medical ethics: legacies of the Gulf Wars and the War on Terror

United States military medical ethics evolved during its involvement in two recent wars, Gulf War I (1990-1991) and the War on Terror (2001-). Norms of conduct for military clinicians with regard to the treatment of prisoners of war and the administration of non-therapeutic bioactive agents to soldiers were set aside because of the sense of being in a 'new kind of war'. Concurrently, the use of radioactive metal in weaponry and the ability to measure the health consequences of trade embargos on vulnerable civilians occasioned new concerns about the health effects of war on soldiers, their offspring, and civilians living on battlefields. Civilian medical societies and medical ethicists fitfully engaged the evolving nature of the medical ethics issues and policy changes during these wars. Medical codes of professionalism have not been substantively updated and procedures for accountability for new kinds of abuses of medical ethics are not established. Looking to the future, medicine and medical ethics have not articulated a vision for an ongoing military-civilian dialogue to ensure that standards of medical ethics do not evolve simply in accord with military exigency.

No ethical bypass of moral status in stem cell research

Recent advances in reprogramming technology do not bypass the ethical challenge of embryo sacrifice. Induced pluripotent stem cell (iPS) research has been and almost certainly will continue to be conducted within the context of embryo sacrifice. If human embryos have moral status as human beings, then participation in iPS research renders one morally complicit in their destruction; if human embryos have moral status as mere precursors of human beings, then advocacy of iPS research policy that is inhibited by embryo sacrifice concerns renders one morally complicit in avoidable harms to persons. Steps may be taken to address these complicity concerns, but in the final analysis there is no alternative to achieving clarity with respect to the moral status of the human embryo.

The right to practice medicine without repercussions: ethical issues in times of political strife

This commentary examines the incursion on the neutrality of medical personnel now taking place as part of the human rights crises in Bahrain and Syria, and the ethical dilemmas which these incursions place not only in front of physicians practicing in those nations, but in front of the international community as a whole.In Bahrain, physicians have recently received harsh prison terms, apparently for treating demonstrators who clashed with government forces. In Syria, physicians are under the same political pressure to avoid treating political demonstrators or to act as informants against their own patients, turning them in to government authorities. This pressure has been severe, to the point that some physicians have become complicit in the abuse of patients who were also political demonstrators.This paper posits that physicians in certain countries in the Middle East during the "Arab Spring," specifically Syria and Bahrain, are being used as both political pawns and political weapons in clear violation of Geneva Convention and World Medical Association guidelines, and that this puts them into the most extreme sort of "dual loyalty" dilemma. They are being forced to choose between their own safety and well-being and that of their patients - a negative sum scenario wherein there is no optimal choice. As such, an international call for a United Nations inquiry must be made in order to protect the neutrality of medical care and personnel during times of armed conflict.

A long shadow: Nazi doctors, moral vulnerability and contemporary medical culture

More than 7% of all German physicians became members of the Nazi SS during World War II, compared with less than 1% of the general population. In so doing, these doctors willingly participated in genocide, something that should have been antithetical to the values of their chosen profession. The participation of physicians in torture and murder both before and after World War II is a disturbing legacy seldom discussed in medical school, and underrecognised in contemporary medicine. Is there something inherent in being a physician that promotes a transition from healer to murderer? With this historical background in mind, the author, a medical student, defines and reflects upon moral vulnerabilities still endemic to contemporary medical culture.