Hello, and welcome to the She research podcast. I'm your host, Kate MacKay.
No wait. I'm your host Diego Silva. That's right. We switch things up at Sydney health ethics. So I'll be your host for this wonderful podcast series. I'm super excited. And before that, I want to thank Kate for her amazing work over the last three years getting the ball rolling on this series, and I hope I can come close to meeting her amazing standards and hosting skills. Before introducing our guests. I want to acknowledge that we're recording on the unceded Country of the Gadigal people of the Eora Nation. This is and will continue to be Aboriginal land, and to pay my respects to those who have and continue to care for Country.
Today I'm joined by Hoji Soofi, who is a lecturer at Sydney health ethics here at the University of Sydney to discuss his paper nonclinical uses of anti-psychotics and resource constrained long term care facilities ethically justifiable as lesser of two evils, question mark, in the Journal of Medical Ethics, Hoji thank you so much for joining us.
Thanks, Diego.
So let's get started. How would you summarise your paper?
Yeah, so I think it might be useful to start with some background into why I chose this topic. So my PhD thesis was on the ethics of using antipsychotics in long term care facilities. And I looked at different justifications that healthcare professionals provide for the practice, it's a very controversial practice, there is not that much evidence base for the use of antipsychotics, but they are commonly used. And one justification in the empirical literature is that it can be a lesser of two evils. And that means, on the one hand, we know that it is ethically undesirable because of the side effects because of the risk of social marginalisation of people with dementia, etc. On the other hand, we know that resources in many long term care facilities are limited. And the use of antipsychotics can be one way to manage the high workload of caregivers. Again, it's acknowledged that this is ethically undesirable. But the argument or at least the purportal argument is that it is a lesser of two evils.
Or it is less ethically undesirable than the collapse of the whole care environment. Yeah. So this was the background. And in terms of the summary, the summary is that I think this is a very, this is not a robust justification for non clinical uses of antipsychotics and one non clinical, I mean, there is no clinical indication that medications are used for other reasons like managing the high workload of caregivers, or making the care easier or manageable for caregivers. And I think this is not less than, let's say evil justification is not robust. And we shouldn't routinely invoke that in those clinical contexts.
So actually want to go there. So you invoke the lesser evil justification. I'm wondering if you can briefly describe what that is for listeners, I know that you go into depth in that in the paper, and then give us a little bit of about your perspective, because in the paper, again, you're you remain a bit more agnostic about it. So I just wanted to know what your thoughts were on on it.
Yeah. So there are different versions of lesser evil justifications. But the one that I focus in this paper is the one that has appeared in the current philosophical literature. So the let's say, evil justification of the kind discussed in the philosophical literature. And the basic idea here is this, that there are situations where moral agents have only two options. Both options are morally undesirable. And they are, for some reason, need to make a decision between these two, otherwise morally undesirable choices. And in those cases, it is morally permissible for moral agents to take the course of action that brings about less overall harm. So that's probably a very brief summary of lesser evil justification of the kind that I focus on.
Right, right. Right. And so do you buy these types of arguments? So I know that you, you, you try to use it for the case that that you have a sort of non clinical use of antipsychotics. But generally speaking, what are your thoughts on this type of argument?
Yeah. So I think it would be also useful to make a clarification here. When we talk about lesser evil justification, we can make these justification in two ways. Sometimes we just say that it is morally permissible for moral agents to take a course of action that brings about less overall harm, but sometimes we make lesser evil justification to say that it's morally required for agents, right. So this is a stronger version of lesser evil, stronger use of lesser evil justification. So I am opposed to the strong version. So I don't think we we have more or we are morally required to take the course of action that brings about the overall harm. I am still opposed to the less strong version of lesser evil justifications. For a couple of reasons, I think I alluded to some of those reasons in paper. But for me, the main reason is that we have to find a common moral denominator in most lesser evil situations, in lesser evil situations. And I think in most lesser evil situations, it's very hard conceptually, it's very hard to find and settle on a common moral denominator. And I think absent that common moral denominator, then we cannot say that this course of action is overall, less harmful than the other.
And so kind of coming back to the subject matter, which is the sort of the non clinical use of the antipsychotics, how would this this common denominator or the lack thereof, or the challenge of trying to find that common denominator, what would that look like? Or what does that look like in this particular case?
Yeah, I think actually, it's much more complicated than the common lesser evil situations that philosophers have focused on. So philosophers have focused on situations like the trolley problem. And, in the paper, I argue that there are some nuances in the, in the case that I'm focusing on, which is the use of which is the non clinical use of anti psychotic. And those nuances are absent in the trolley problem. One of them is that in the trolley, so maybe we should talk a bit about the trolley problem, maybe?
Yeah, I mean, I think it's a classic example. But the the trolley problem is, you are at a railroad, you can correct me if I'm wrong, but you're at a railroad, and there's a train moving to the direction of where there's one person who won't be able to move out of the way. Sorry, there's five people. And there's another railroad that has one person. And so the dilemma is do you pull a lever to derail the train towards the one person who can't move out of the way, thus killing the person? So that's sort of the classic example. Is it? Philippa Foot who started I can't remember who? Yeah, so very sort of very classic example.
So yeah. So in that case, I mean, lesser evil justifications have discussed extensively in relation and with regard to the trolley problem. And in the trolley problem, the argument that many philosophers buy, is that the agent, the person who, who can direct the trolley, is morally permissible to do that, to direct the trolley and killed one person to save the five. And I think so I remain agnostic on that. But I think that doesn't apply to the non clinical uses of antipsychotics. Because in the trolley problem, the person who is in the position to direct the the trolley doesn't have any connection to the people who are on the track. Right? And this isn't this is not the this is not the case with the non clinical use of anti psychotics, caregivers, if they have a lesser evil justification, then they have to explain how, how can they account for the duty of care that they have, and that duty of care will will be violated by the non clinical uses of antipsychotics? Because basically, it amounts to putting people with dementia at unnecessary from a clinical perspective, risk of harm.
What I found really interesting about reading your paper is I think that there's a growing number of individuals within bioethics kind of questioning the sort of off the shelf use of things like the trolley problem, or overly simplistic mental models, I guess, that we're used to in normative ethics. What's your take on this? I mean, I sort of can gather a little bit, but how do you feel about how do we move from sort of these traditional modes of thinking in terms of normative ethics and sort of the classic sort of normative ethics world to the more applied ethics world that we deal with?
Yeah, so just a bit of personal history. I was actually a fan of thought experiments for a while. During the early years of my PhD, I was reading them a lot and I was thinking about them a lot. But then I had this contact with one of Catriona MacKenzie's paper at Macquarie University. And she basically argues that there is limited use of thought experiments and applied ethics, because again, they miss many of nuances. And it just doesn't do the job that we we expect from them. And that actually changed my mind a bit. And then that was probably the sort of my critical journey into whether or not thought experiments can be used or not. And I, at the moment, I'm a bit critical, actually, of the use of thought thought experiments in the paper. I mentioned some of those reasons. But yeah, I think I have sympathy with the with the people who are, we want to, who want to raise questions about the usefulness and the merits of invoking thought experiments in our moral deliberation. Again, I'm not saying that we shouldn't use them, I think there is some use probably, there is probably some pedagogical use, or maybe some heuristic use in the way to, to talk about ethical issues in abstract. But when we talk about applied issues, issues that have concrete implications for people, then I think we should be extra careful, or at least, we should be mindful of the nuances that we we lose
Right? Just kind of shifting gears a little bit. Your research tends to focus on ethics of dementia ethics of long term care. Obviously, this paper, as we've noted, is about the non clinical use of antipsychotics. What did your motivation come from, for this paper? And I guess, for your broader kind of research enterprise?
Yeah. So I had this interest in the way that medications are used in dementia care in for people with dementia and in geriatric context. And again, that also is because of my background to some extent, so I'm a pharmacist by training. And that area of practice was always interesting to me, in the sense that it raised a lot of questions about what is the value behind many of the prescription practices in geriatric contexts. In many cases, we seem to ignore the value laden questions about those practices. And we just continue doing them. But if we think about them, and more critically, then it compels us to find reasons and to find explanations for why they shouldn't change. And if we think that they should change, and we have to provide reason. So that was the kind of internal dialogue that I had in the early in my early practice, in my early pharmacy practice. And then then, through my further studies, Bioethical Studies, and my PhD at Macquarie, then that interests grew and became probably the main focus of my current research.
And so where do you want to you mentioned your current research. So where does this paper fit within your sort of larger thinking about your current research and where you want to take things in your research?
Yeah, so in a couple of ways, I want to I want to expand on this paper, and also, this paper aligns with some of the themes that I want to more broadly pursue. So one of them is patient safety. And I think one neglected area is that we think of patient safety, mostly from a narrow clinical perspective, like, like, just in terms of adverse effects, but we do not take into account the values that people have. And some of the some of the practices that we think are unsafe for patients are actually probably not safe from patients perspective. So and here, this aligns with that theme like this is this can be a paper in patient safety more broadly construed. So that's, again, again, I'm looking at the justifications and the type of arguments that we invoke in patient safety discourse. Another area that this paper aligns with is the fallacious arguments that are commonly made, when medications are used and in justifying the medications and in in rationalizing certain prescription practices. Again, this is probably to some extent because of my pharmacy background, but I think that this contributes to, to that research a as well a bit. Yeah, and also some of the more theoretical interests that I have, like I am interested in, in the use of ethical theory in, in clinical practice. And here I'm touching on whether or not we can make, we can make use of the ontology and consequentialism through lesser evil justification, which again, I'm a bit critical. Yeah. So in, in a couple of ways this, this paper aligns with my research areas. And my interests.
It's really interesting. We're seeing now for the discussions here in Australia. But honestly, globally, as populations are getting older, on average, these questions around long term care around caring for older populations are becoming front and center and much more sort of difficult to avoid. What do you see as sort of some of the main challenges from an ethics perspective that that we're facing now? And that we're going to face into the future with regards to long term care with regards to older populations?
Yeah. So a couple of challenges come to my mind. One of them is actually I borrow this idea from Nancy Decker from the University of Washington. And she argues that we have this midlife bias in our ethical assessments. And this means that many of the ethical frameworks and values that we abide by and promote are developed from the perspective of people who are in their mid life. So she argues that we have to go beyond that when we talk about people and later stages of life, we have to rely on more specific framework, frameworks that are tailored or perhaps are developed for that specific aim. So that's one challenge that I think we are facing with.
So it's, it's an epistemic challenge. Yeah.
Yeah. And, again, we we are at midlife stages of our lives,
for better or worse.
Yeah. So it's a challenge for us to think about that we because we are not Yes, yet there. So yeah. And we have to incorporate the the views and at least we have to investigate the views of people in the later stages of life. But I think that again, a more practical challenge here is that in many cases, we have some epistemic limitations, we can we do not have epistemic access to their life wards, because they, I mean, I'm more specifically talking about people with dementia, right? Like, our our access to the Life board is a bit limited. I mean, not a bit probably is limited. So that's one of the challenges. So I think I have sympathy with the with going beyond the middle life bias. But there are challenges, both practical and epistemic. And another challenge that come to my mind is that there's not that much specific ethical work on aged care, and on on life at the later stages. At Life, and at the later stage.
Yeah, there's a lot of end of life care ethics. Yeah. But not not in between. Exactly.
Yeah. So I think, yeah, that's the challenge that I'm facing as well, like, there's not that much literature. So I mean, here, in this paper, I'm the first one actually, to critically examine the lesser evil justification in the context of aged care facilities. And in many other areas, I think there's this. I'm not sure if it's fair, but there's, there's not that much. There's limited attention to the ethical questions. I mean, maybe partly, it's because of the way that our funding system is set up. Or maybe people are just not interested. So yeah, I would say one of the challenges that I face at the moment is that there's not that much serious scholarship, right on the topic.
So So look, I think this is I think this is a terrific sort of call to our listeners and folks tuning in to contact you, if they are interested in this in this area of research. Again, it's not going away, for better or worse. And I think some of these, the questions that you're asking are unbelievably challenging, because I think they push us towards not just thinking in terms of ethics, but in terms of thinking in terms of epistemology, but also just in terms of thinking through sort of life experience and challenging, you know, what we think in terms of empirical bioethics, which is sort of asking and having conversations with people, what does that look like, in the context of persons with dementia, so on and so forth? So undoubtedly, you're, you're gonna have your hands full for a long, long time to come. And I'm, I gotta say, I'm grateful from a social perspective, society's perspective that you are tackling these these questions.
Yeah. Thanks. Again, I just reiterate your point that if people are interested in things that I research on, yeah, certainly please get in touch and I'd love To make connections.
I want to wrap things up by thanking you the listeners to listen to this episode of The she research podcast. You can find the paper that we discussed today it's going to be linked in the episodes notes, along with the transcript of our discussion. SHE pod is produced by she network and edited by Regina Botros. You can find our other episodes on Spotify, radio, public anchor, or wherever you get your podcasts of quality and maybe even some of your podcasts of ill repute. I'm your host Diego Silva. Thanks again for listening. Bye. Have a great day.
