This letter responds to the letter "Reexamining the UDDA: Are We Ready for Significant Change?," by Paul T. Menzel, in the same, July-August 2026, issue of the Hastings Center Report.
Susan Wolf et al.'s article "Filling the Network Gap in Research Ethics: Analyzing Ethical Issues at Scale in Big Team Science" aims to provide analysis of ethics at the level of scientific teams. But is the emphasis on formal teams the appropriate target? In this commentary, I argue that we ought to take a much broader view, looking at the "interstitial spaces" of scientific research, including the informal networks of power and esteem that shape scientific careers, the formation and function of large teams, receipt of funding, and publication. I claim that these informal networks do as much, if not more than, formal organizing efforts in structuring scientific inquiry and norms. I conclude that an ethics of team science will be richer, more rigorous, and more effective if it treats the culture of science as a central object of study and then asks which kinds of formal organizing principles best promote and protect our ethical commitments.
However helpful have been the papers, reports, and books Erik Parens has produced while at The Hastings Center, conversation with him has always been even better. In both his writing and conversation, he goes to core values. As Erik departs Hastings-retiring as of the end of June 2026 to commit himself more fully to teaching, his original professional love-the loss of these conversational interactions will be felt profoundly, not just at Hastings but in bioethics broadly.
Long-standing frameworks for the ethics of biomedical research are being challenged on multiple fronts by seismic shifts in the way science is practiced. One such shift, which is the focus of "Filling the Network Gap in Research Ethics: Analyzing Ethical Issues at Scale in Big Team Science," by Susan Wolf and colleagues in this issue of the Hastings Center Report, is the evolution of biomedical research toward very large scientific teams. The authors seek to fill a gap in research ethics frameworks that arises with the conduct of big team science, at the mesolevel of research networks. However, I suggest ways that their focus on the ethical issues of traditional science such as authorship and data sharing and their confining of the concept of big teams to multiple but similarly constituted groups at research labs or institutions limit the scope of ethical inquiry in ways that potentially diminish the future utility of their analysis.
Large, multi-institutional research networks pose genuine challenges for accountability, authorship, data sharing, mentorship, reproducibility, trust, and governance. In responding to the article "Filling the Network Gap in Research Ethics: Analyzing Ethical Issues at Scale in Big Team Science," by Susan Wolf et al., this commentary welcomes attention to those challenges but argues that labeling them as a new domain of research ethics requires more conceptual and normative precision. The article moves unevenly among research ethics, responsible conduct of research, bioethics, organizational theory, and responsible innovation while offering a definition of network ethics that is insufficiently differentiated from existing frameworks. Many examples cited are better understood as responsible conduct of research and research integrity problems amplified by scale, institutional plurality, and network topology. A persuasive account of network ethics must specify its unit of analysis, distinguish ethical from managerial and procedural problems, and identify the principles, duties, and accountability structures that justify a distinct framework. This commentary therefore recommends reframing the agenda as ethical governance and responsible conduct of network research at scale.
This letter responds to the article "Defining Death Anew: Reexamining the Twentieth-Century Brain Death Debates and the Uniform Determination of Death Act," by Anne E. Clinton, and the responding commentary, "The Enigma of Brain Death," by Robert D. Truog in the November-December 2025 issue of the Hastings Center Report.
A recent article by physician Ronald Dworkin, echoing research from the last five years, suggests that physicians find little value in clinical ethics consultations. At the same time, clinical ethicists have worked to create more structures and standards to ground the field's professionalization in health care. Why the disconnect? We suggest three reasons: internal professionalization work is opaque to those outside of the discipline, weak external accreditation requirements imply a lack of professionalization of ethics, and the fundamental nature of clinical ethics is distinct from other disciplines.
In "Can I Get a Witness? The Ethical Dimensions of Family Presence in Patient Suffering," Jennifer Blumenthal-Barby and colleagues ask whether there is a duty for family members to be present at the bedside of an unconscious or minimally conscious patient. In responding to the article, I argue that the authors' presumption against a general duty for this bedside presence follows in part from the level of generality at which the question is posed. As the categories "family," "unconscious," and "suffering" are too heterogeneous to generate a single, action-guiding obligation of bedside presence, I suggest that the question should be reframed as one concerning whether surrogate decision-makers should be thought of as incurring narrower role-specific obligations that sometimes require bedside presence. In surfacing the practical circumstances in which questions surrounding perceived family absence are typically raised by clinicians, this reply also suggests an overlooked dimension of such conflicts: they may signal uncertainty about the conditions under which surrogate authority is being exercised. The possibility that this uncertainty underlies clinicians' occasional frustration can become an important conceptual foothold for clinical ethics facilitation.
Recent debates about AI "guardrails" in mental health have framed a problem as one of detecting delusion. This paper argues that such framing misunderstands both psychiatry and large language models. In clinical practice, delusion is not simply a false belief but a structure of conviction that stabilizes meaning under conditions of uncertainty. Large language models, by contrast, generate coherence rather than evaluate truth. When these systems interact with users seeking orientation, they do not merely fail or succeed at detection-they participate in the conditions under which belief forms. The ethical risk is therefore not misclassification but premature coherence: the subtle reinforcement of interpretations before they can be examined. Drawing on phenomenology and clinical psychiatry, this paper proposes that safety in AI systems should be understood as the protection of provisionality-the preservation of the human capacity to remain uncertain long enough to think.
In "Can I Get a Witness? The Ethical Dimensions of Family Presence in Patient Suffering," Jennifer Blumenthal-Barby and colleagues ask us to scrutinize "the instinct to blame families" who are absent from the care of their seriously ill loved ones. In this commentary, I use a common framework of differential diagnosis to consider the reasons for and implications of clinician reactions to absent families. As we better understand what might be driving the absence of family members, we might also find hints at the sources of our own judgment. As with most differential diagnoses in medicine, this analysis can also help to inform how we support those families and manage our own instincts.
This letter responds to the letter "Reexamining the UDDA: Are We Ready for Significant Change?," by Paul T. Menzel, in the same, July-August 2026, issue of the Hastings Center Report.
For patients who are suffering, the bedside presence of a family member can provide comfort, and many people hold that there is moral value in being present with a conscious, suffering patient. Yet what is the moral significance of the absence of family members when a patient is minimally conscious or unconscious and not aware of their absence? Clinicians are often troubled when family members and surrogate decision-makers who are able to spend a significant amount of time at an unconscious, seriously ill patient's bedside do not do so. Clinicians feel frustrated that they must bear the burden of witnessing the patient's actual or perceived suffering while the family escapes this burden and therefore appears to fail to uphold a duty to the patient. What are we to make of this point of view? What is the source of this frustration? What is the nature of the perceived duty? Is it morally defensible to request or require family members to be present with an unresponsive patient to bear witness to their actual or perceived suffering? If so, on what grounds?
This commentary responds to Jennifer Blumenthal-Barby and colleagues' article, "Can I Get a Witness? The Ethical Dimensions of Family Presence in Patient Suffering." The authors examine clinicians' moral distress when family members are absent from the bedside of dying patients and assess moral arguments for requiring family presence. We concur with their skepticism toward any strong obligation for family members to be physically present when continued treatment is considered burdensome or futile. We extend the authors' analysis by arguing that institutional culture shapes expectations of the "good patient," the "good family," and the "good death." Drawing on sociology, anthropology, and philosophy, we suggest that clinicians' distress may arise not only from family absence but also from tensions between institutional norms and the moral worlds families inhabit. We conclude by calling for epistemic humility and greater critical reflection on the impact of institutional norms on moral judgments.
Stigmatizing language in medical documentation is a barrier to achieving patient-centered care and health justice: it can contribute to patient distrust and alienation, and it appears more frequently in the charts of patients from marginalized groups, especially Black patients, impacting the future care they receive. One powerful avenue to address this issue is within undergraduate medical education; however, while some have investigated educational interventions to improve accuracy and technical proficiency in charting, there is significantly less focus on instruction surrounding the ethical and social consequences of documentation. We contend that incorporating activities designed to elicit critical thinking about language, power, and structural injustice can encourage students to reflect upon and improve their documentation practices and can arm them with a critical lens through which to view the documentation generated by their peers and preceptors as they progress through training and establish the habits that will persist throughout their careers.
Artificial intelligence is reshaping clinical decision‐making in ways that challenge assumptions about patient‐centered care, moral responsibility, and professional judgment. Encoding Bioethics: AI in Clinical Decision‐Making , by Charles Binkley and Tyler Loftus, begins where ethical reflection on this topic should begin—in the trenches of clinical care. Together with the National Academy of Medicine's publication An Artificial Intelligence Code of Conduct for Health and Medicine: Essential Guidance for Aligned Action , which came out after the book, Encoding Bioethics goes a long way toward offering physicians, patients, developers, and health‐system leaders actionable guidance. Through explanation, probing questions, and case studies, Binkley and Loftus illuminate the ethical difficulties posed by opacity, bias, and shifting clinical roles. Yet their analysis stops short of identifying the governance tools and operational structures that are essential for achieving patient‐centered, morally responsible AI that strengthens clinical judgment. This review essay argues that bridging ethics and practice requires attention to psychological safety, organizational dynamics, and implementation science to ensure that AI supports—not supplants—ethical care.
Scientific research increasingly involves large, multidisciplinary teams networked across multiple institutions to develop new technologies. Despite the rise of complex research networks and big team science, there has been too little analysis to date of the ethical challenges facing these networks. The extensive literature on the ethical issues confronting individual researchers and small teams (the microlevel) and on the larger societal challenges flowing from research and new technology (the macrolevel) leaves a troubling gap in between, at the mesolevel of the research network involved in big team science. Yet the ability of complex networks to conduct research ethically-which is essential if the results are to be deemed reliable and trustworthy-depends on recognizing the ethical issues that emerge at this intermediate network level, identifying the values that should guide networks in addressing those issues, and equipping research leaders to build a culture supporting the ethical conduct of research across the laboratories and institutions that comprise the network. This paper calls out the problem, analyzing the gap and recommending next steps.
How should the state respond to people who commit low-level criminal offenses that stem from an untreated substance-use disorder? The issue has taken on a heightened importance amidst an ongoing national addiction crisis that has destabilized many U.S. communities and led to a myriad of harms. I offer a qualified defense for the use of legal mandates that require participation in drug treatment in lieu of jail time as one possible tool for reducing the public harms associated with chronic addiction. I argue that mandated treatment is effective, though less effective than many proponents argue. Beyond the effectiveness question, opponents contend that mandated treatment exacerbates structural inequalities, including the overpolicing of marginalized communities and underinvestment in voluntary treatment. Drawing on an egalitarian theory of justice, I argue that these structural inequalities present a compelling reason to constrain the use of mandates, but that they should be counterbalanced by a mixture of paternalistic and public safety concerns that make mandates one of several instruments in drug policy for addressing the pervasive harms from severe substance-use disorders.
In this same, May-June 2026, issue of the Hastings Center Report, Brendon Saloner suggests that mandated drug treatment can expand freedom and promote egalitarian social justice so long as three criteria are met. Drawing on our clinical experience in addiction medicine and a critical appraisal of the available evidence, we challenge this claim. We argue that Saloner's three criteria are unlikely to be met within jurisdictions that criminalize drug use and lack supports for people who use drugs. The criterion that mandated treatment be "likely to be beneficial" is undermined by the coercive nature of such interventions and the lack of evidence supporting their effectiveness when compared to voluntary care. Further, the application of mandated treatment risks extending carceral oversight to individuals charged with minor offenses, disproportionately affecting equity-denied populations. Finally, we question whether infringements on liberty through legal oversight can genuinely expand freedom, particularly when such measures exacerbate social instability and undermine the potential for voluntary engagement with care. We contend that meaningful expansion of freedom for people who use drugs is better achieved through voluntary, community-based treatment models supported by robust social infrastructure. A radical reorientation of drug policy-away from coercion and toward supportive, person-centered care-is necessary to achieve the ethical aims of reducing harm, promoting autonomy, and advancing egalitarian social justice.
In December 2023, the U.S. Food and Drug Administration approved gene-editing therapies as sickle cell disease treatments. Such approvals for gene-editing not only mark radical scientific innovations for populations living with sickle cell disease (SCD) across the United States but also generate an expectation of a potential cure-the end or eradication of an illness and its effects. This essay, however, cautions against framing gene-editing therapy as a "cure" for SCD. Our argument illustrates that, even if gene editing is proven to permanently normalize the hematologic function of the body, there are other painful aspects of SCD that gene editing is unable to transform. Scientific researchers and health care practitioners could benefit from further bioethical consideration of the effects of using curative language with regards to SCD. The curative framing can easily generate misunderstandings in patient-provider communication and elicit unrealistic expectations. Raising awareness about the importance of how gene-editing therapies for SCD are described and about the need to discuss their limitations can prevent further harm.
In "Mandated Drug Treatment in the Criminal Legal System-a Blunt but Necessary Tool?," in this issue of the Hastings Center Report, Brendan Saloner examines the empirical evidence surrounding mandated treatment, weighs pragmatic ethical arguments for and social justice arguments against the practice, and ultimately supplies a qualified defense of it. This commentary augments Saloner's egalitarian social justice perspective by outlining the legal principles of the police power and the parens patriae power, then uses this framework to illustrate the legal and ethical risks of mandated and involuntary treatment, and finally responds to Saloner's call for an affirmative vision of a more proportionate response.
