How do professionals preserve coherent identities when polycrisis destabilizes the moral, social, and epistemic foundations of their work? Drawing on interviews with forty physicians conducted between March and November 2021 during the COVID-19 pandemic, we theorize moral outrage as a central mechanism through which professionals interpret and respond to contradictory social evaluations. We argue that moral outrage is activated when simultaneous distrust, admiration, and social rejection undermine established identity meanings, generating a sensemaking dilemma. This emotion catalyzes two forms of identity work: solidarity-oriented work, which reaffirms collective moral purpose, and boundary-reinforcing work, which reasserts professional norms and distinctions. These processes help restore identity coherence amid evaluative volatility, yet they also risk amplifying professional insularity and profession–society divides. By positioning moral outrage as a driver of identity maintenance, we extend theories of professional identity, boundary dynamics, and moralized sensemaking under systemic threat.
The proliferation of unused embryos at the end of IVF cycles has sparked ethical debates regarding their disposal, especially regarding their donation for family-building purposes. How do Canadian and US reproductive health professionals represent embryo donation for family-building purposes? Ethnographic research was conducted in Canada and the United States from August 2023 to April 2024. 21 reproductive health professionals were interviewed (one CAN lawyer, one CAN embryologist, two CAN social workers, one CAN psychologist, three CAN doctors, one CAN third-party coordinator, one US embryologist, three US doctors, one US nurse, and seven US embryo donation coordinators). An issue at the core of our interlocutors’ concerns was the logistical difficulty associated with this practice. A pivotal issue was related to privacy, how much and which information should be disclosed to patients. Another important aspect concerned legal disputes around who is responsible in cases where either donors or recipients may change their minds. A crucial concern is the well-being of children born through embryo donation. In the absence of national guidelines, these issues were managed differently from clinic to clinic, pointing to the need for national standards and early counseling.
For two decades, stem cells have been hailed as ‘the holy grail’ of modern medicine and presented by frontier research centers as the future cure for life-threatening and devastating diseases. Stem cell research has received massive funding and given rise to high hopes. But what do people unaffiliated with frontier research turn to stem cells for? If we conceptualize an issue as a socio-technical assemblage that brings together publics, technologies and concerns, what kind of issue does stem cell medicine become among various publics? One way of approaching this is to explore what is searched for online when people search for information about stem cells. Drawing on data from Google, the globally most used search engine, we explore search patterns to characterize the kinds of socio-technical issues that stem cell medicine have become for the people looking for information about this topic. We identify a disconnect between global search patterns and the representation and goals propagated by leading research institutions, and describe it as an issue-misalignment. Whereas frontier medicine focuses on future treatments for devastating and debilitating diseases, online search patterns suggest that Google users increasingly associate stem cells with already commercially available (and not always clinically proven) treatments for much more mundane conditions such as knee problems, arthritis, pain and hair loss. We argue that this issue-misalignment points towards important but overlooked dimensions of innovation dynamics in frontier medicine, which might in turn inspire researchers in the stem cell community to think differently about the responsibilities they have in relation to future patients, and which publics to address.
Multilevel random-effects (RE) models are standard in social and geographical epidemiology. They rest on the assumption of exchangeability, which means that, before seeing the data, we have no reason to distinguish one group from another: group means become draws from one common distribution. RE models were developed for repeated measurements within individuals where a shared physiology underwrites the assumption, and partial pooling improves prediction. A silent transfer later applied the same machinery to schools, hospitals, neighbourhoods and, recently, to intersectional strata. There the transfer breaks down. Social positions are produced by directional forces such as racism, not drawn from a common distribution. Within a group, the variation between individuals is not measurement error but meaningful individual heterogeneity shaped by unmeasured life courses. We review three readings of exchangeability, from the strictest to the most permissive, and they agree: social and intersectional categories are not exchangeable. Assuming it would require the absence of the very inequalities under study. In many intersectional analyses, shrinkage erases the small and deviating strata, where inequality lives. Modelling injustice as dispersion around a mean domesticates rather than denounces it. For describing realised health inequalities we recommend Simple-Means MAIHDA (S-MAIHDA). Each stratum is estimated from its own individuals, and uncertainty is reported rather than smoothed. RE models keep their legitimate uses, such as prediction, cluster-randomised trials and the propensity models of causal S-MAIHDA. Exchangeability is not a property of the software. It is a claim about the world, to be justified in every application.
In their recent article, Menon et al. study household out-of-pocket health expenditure (OOPE) in Kerala from 2017 to 2020. Using data from the Consumer Pyramids Household Survey, they show 32% reduction in OOPE during this period, largely explained by decline in medication spending. They attribute this reduction to Karunya Arogya Suraksha Padhathi (KASP), a publicly financed health insurance scheme in Kerala. In this commentary, we critically question this attribution. We show that the mechanisms of OOPE reduction postulated by Menon et al. are not supported by the findings of the article. In fact, previous rounds of the National Sample Survey show that any hospitalisation-focused insurance scheme such as KASP cannot be expected to produce large declines in OOPE. In our view, strengthening of government primary healthcare in Kerala since 2017 is a much more plausible explanation for the findings. For financial protection of patients in India, government primary healthcare services need to be improved at scale, with a focus on availability of free medications.
