The ethics of natural immunity exemptions to vaccine mandates: the Supreme Court petition.

The Supreme Court of the United States has recently been petitioned to revisit legal issues pertaining to the lawfulness of imposing a vaccine mandate on individuals with proof of natural immunity during the COVID-19 pandemic. While the petition accepts that the protection of public health during COVID-19 was an important governmental interest, the petitioners maintain that the imposition of a vaccine mandate on individuals with natural immunity was not 'substantially related' to accomplishing that purpose. In this short report, we outline how some of the petition's general arguments interact with points we raised in a 2022 article in this journal defending natural immunity exemptions, in light of new evidence. In particular, we reflect on new evidence pertaining to differences between vaccine-induced immunity, natural immunity, and so-called 'hybrid' immunity. We suggest that the nuanced nature of this evidence highlights the importance of making fine-grained judgements about proportionality and necessity when considering vaccine mandates. We conclude by claiming that if future pandemics necessitate the imposition of vaccine mandates, then those seeking to justify them should clearly articulate the relevance (and the evidence) for the comparative protection of vaccine-induced, natural, and hybrid immunity.

"More effective" is not necessarily "better": Some ethical considerations when influencing individual behaviour.

Chater & Loewenstein make a persuasive case for focusing behavioural research and policy making on s- rather than i-interventions. This commentary highlights some conceptual and ethical issues that need to be addressed before such reform can be embraced. These include the need to adjudicate between different conceptions of "effectiveness," and accounting for reasonable differences between how people weight different values.

A Taxonomy of Non-honesty in Public Health Communication.

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication.

Communicating distress: suicide threats/gestures among clinical and community youth.

Although self-injurious thoughts and behaviors are a global health concern, little is known about suicidal threat/gesture(s) where a person leads others to believe they want to end their lives when they have no intention to do so. This study assessed the lifetime prevalence of self-injurious thoughts and behaviors among both community adolescents (n = 1117) and in clinical youth (n = 191). Suicide threats/gestures were common among youth; 12.2% of community adolescents and 18.0% of clinical youth reporting having made a suicide threat/gesture, most commonly in the context of other self-injurious thoughts and behaviors. Across both samples, suicide threats/gestures were not uniquely associated with suicide attempts, and youth who reported suicide threats/gestures in the context of a history of self-harm or suicide plan(s) were no more likely to report a history of suicide attempt(s). Suicide threats/gestures were distinguished from suicide attempts in that they primarily fulfilled positive social functions, rather than autonomic functions. Findings suggest that suicidal threats/gestures are common in both community and clinical youth, and are not uniquely associated with suicide attempts, but rather function to communicate distress to others.

Neural Signatures of Error Processing in Depressed Adolescents with Comorbid Non-Suicidal Self-Injury (NSSI).

Non-suicidal self-injury (NSSI), as a highly prevalent psychiatric symptom in adolescents and young adults, is defined as the deliberate destruction of body tissue without suicidal intent. Impulsivity and dysfunctional response inhibition have been suggested to play a central role in adolescents' vulnerability to self-harm. To investigate the potentially distinct neurobiology of NSSI, we used a well-established Go/No Go task in which activation of the inferior frontal gyrus (IFG) and dorsal anterior cingulate cortex (dACC) is interpreted as a neural correlate of processing failed response inhibition. Task-based functional magnetic resonance imaging data were obtained from 14 adolescents with a diagnosis of major depression and a history of NSSI (MD-NSSI), 13 depressed adolescents without NSSI (MD-only), and 14 healthy controls (HC). In line with hypotheses of dysfunctional response inhibition, we observed increased rates of commission errors in MD-NSSI along with significantly reduced error-related activations of the dACC and IFG. Intact response inhibition, as reflected by low commission error rates not different from HC, was observed in MD-only, along with increased activation of the error-processing network. Our findings support the hypothesis of a distinct neurobiological signature of NSSI. Further research on biomarkers of NSSI could focus on behavioral and neural correlates of failed response inhibition.

Broad Medical Uncertainty and the ethical obligation for openness.

This paper argues that there exists a collective epistemic state of 'Broad Medical Uncertainty' (BMU) regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a 'Corrective Response'. We then consider some objections to this position (the 'Anti-Corrective Response'), including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing.

The unnaturalistic fallacy: COVID-19 vaccine mandates should not discriminate against natural immunity.

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to 'artificial' vaccine-induced immunity simply because it is 'natural' and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions.

Social Prescribing in National Health Service Primary Care: What Are the Ethical Considerations?

Policy Points Social prescribing is proposed as a way of improving patients' health and well-being by attending to their non-clinical needs. This is done by connecting patients with community assets (typically voluntary or charitable organizations) that provide social and personal support. In the United Kingdom, social prescribing is used to improve patient well-being and reduce use of National Health Service resources. Although social prescribing schemes hold promise, evidence of their effects and effectiveness is sparse. As more information on social prescribing is gathered, it will be important to consider the associated ethical issues for patients, clinicians, link workers, and community assets.

Prospective Intention-Based Lifestyle Contracts: mHealth Technology and Responsibility in Healthcare.

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual's role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare.

Differential neural processing of unpleasant sensory stimulation in patients with major depression.

An altered processing of negative salient stimuli has been suggested to play a central role in the pathophysiology of major depression (MD). Besides negative affective and social stimuli, physical pain as a subtype of negative sensory stimulation has been investigated in this context. However, the few neuroimaging studies on unpleasant sensory stimulation or pain processing in MD report heterogeneous findings. Here, we investigated 47 young females, 22 with MD and 25 healthy controls (HC) using fMRI (3.0 T). Four levels of increasingly unpleasant electrical stimulation were applied. Ratings of stimulus intensity were assessed by a visual analogue scale. fMRI-data were analyzed using a 2 × 4 ANOVA. Behavioral results revealed no group differences regarding accuracy of unpleasant stimulation level ratings and sensitivity to stimulation. Regarding neural activation related to increasing levels of unpleasant stimulation, we observed increasing activation of brain regions related to the pain and salient stimulus processing corresponding to increasingly unpleasant stimulation in controls. This modulation was significantly smaller in MD compared to controls, particularly in the dorsal anterior cingulate cortex, the somatosensory cortex, and the posterior insula. Overall, brain regions associated with the processing of unpleasant sensory stimulation, but also associated with the salience network, were highly reactive but less modulated in female patients with MD. These results support and extent findings on altered processing of salience and of negative sensory stimuli even of a non-painful quality in female patients with MD.

The scientific and ethical feasibility of immunity passports.

There is much debate about the use of immunity passports in the response to the COVID-19 pandemic. Some have argued that immunity passports are unethical and impractical, pointing to uncertainties relating to COVID-19 immunity, issues with testing, perverse incentives, doubtful economic benefits, privacy concerns, and the risk of discriminatory effects. We first review the scientific feasibility of immunity passports. Considerable hurdles remain, but increasing understanding of the neutralising antibody response to COVID-19 might make identifying members of the community at low risk of contracting and transmitting COVID-19 possible. We respond to the ethical arguments against immunity passports and give the positive ethical arguments. First, a strong presumption should be in favour of preserving people's free movement if at all feasible. Second, failing to recognise the reduced infection threat immune individuals pose risks punishing people for low-risk behaviour. Finally, further individual and social benefits are likely to accrue from allowing people to engage in free movement. Challenges relating to the implementation of immunity passports ought to be met with targeted solutions so as to maximise their benefit.

Cortical thickness and resting-state cardiac function across the lifespan: A cross-sectional pooled mega-analysis.

Understanding the association between autonomic nervous system [ANS] function and brain morphology across the lifespan provides important insights into neurovisceral mechanisms underlying health and disease. Resting-state ANS activity, indexed by measures of heart rate [HR] and its variability [HRV] has been associated with brain morphology, particularly cortical thickness [CT]. While findings have been mixed regarding the anatomical distribution and direction of the associations, these inconsistencies may be due to sex and age differences in HR/HRV and CT. Previous studies have been limited by small sample sizes, which impede the assessment of sex differences and aging effects on the association between ANS function and CT. To overcome these limitations, 20 groups worldwide contributed data collected under similar protocols of CT assessment and HR/HRV recording to be pooled in a mega-analysis (N = 1,218 (50.5% female), mean age 36.7 years (range: 12-87)). Findings suggest a decline in HRV as well as CT with increasing age. CT, particularly in the orbitofrontal cortex, explained additional variance in HRV, beyond the effects of aging. This pattern of results may suggest that the decline in HRV with increasing age is related to a decline in orbitofrontal CT. These effects were independent of sex and specific to HRV; with no significant association between CT and HR. Greater CT across the adult lifespan may be vital for the maintenance of healthy cardiac regulation via the ANS-or greater cardiac vagal activity as indirectly reflected in HRV may slow brain atrophy. Findings reveal an important association between CT and cardiac parasympathetic activity with implications for healthy aging and longevity that should be studied further in longitudinal research.

Passport to freedom? Immunity passports for COVID-19.

The COVID-19 pandemic has led a number of countries to introduce restrictive 'lockdown' policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people's civil liberties. We make tentative recommendations for the ethical introduction of immunity passports.

"I just finally wanted to belong somewhere"-Qualitative Analysis of Experiences With Posting Pictures of Self-Injury on Instagram.

Non-suicidal self-injury (NSSI) is a common phenomenon among adolescents, but is often not disclosed due to fear of stigmatization. Social media is frequently used to publish photos of NSSI and share experiences with NSSI. Objectives of this study were to find out more about the motivation for publishing NSSI content and to investigate the effect that sharing this content on social media has on young people. In the current study, we interviewed N=59 participants (mean age = 16.7 years [SD = 1.2 years]; 72.9% female), who had all posted NSSI content within the past month on the social media platform Instagram. Semi-structured interviews were conducted via the Instagram messaging app. Interviews were analyzed qualitatively, assisted by the Software Atlas.ti 7. Participants were asked about their motivation for and their experiences with posting NSSI content online. Motivations for posting pictures online were mainly social (connecting, disclosure, communicating), while self-focused reasons like documenting NSSI or recovery were also mentioned. All participants reported having received positive reactions (being offered help, connecting, receiving empathy), as well as negative comments (harassment, being misunderstood) to their own NSSI content by other Instagram users. Participants' reactions to other users' NSSI content on Instagram was often identification with the content or being triggered, but also wanting to offer help or sometimes even being deterred from NSSI. None of the participants mentioned successful referral to professional help through their online NSSI activity. One target for future interventions could therefore be social media, or other online platforms, where adolescents might be more easily reached. Mental health practitioners should be aware of their clients' online activity and encourage reflection upon positive and negative effects of viewing or sharing NSSI content online.

Designing and using incentives to support recruitment and retention in clinical trials: a scoping review and a checklist for design.

BACKGROUND: Recruitment and retention of participants are both critical for the success of trials, yet both remain significant problems. The use of incentives to target participants and trial staff has been proposed as one solution. The effects of incentives are complex and depend upon how they are designed, but these complexities are often overlooked. In this paper, we used a scoping review to 'map' the literature, with two aims: to develop a checklist on the design and use of incentives to support recruitment and retention in trials; and to identify key research topics for the future. METHODS: The scoping review drew on the existing economic theory of incentives and a structured review of the literature on the use of incentives in three healthcare settings: trials, pay for performance, and health behaviour change. We identified the design issues that need to be considered when introducing an incentive scheme to improve recruitment and retention in trials. We then reviewed both the theoretical and empirical evidence relating to each of these design issues. We synthesised the findings into a checklist to guide the design of interventions using incentives. RESULTS: The issues to consider when designing an incentive system were summarised into an eight-question checklist. The checklist covers: the current incentives and barriers operating in the system; who the incentive should be directed towards; what the incentive should be linked to; the form of incentive; the incentive size; the structure of the incentive system; the timing and frequency of incentive payouts; and the potential unintended consequences. We concluded the section on each design aspect by highlighting the gaps in the current evidence base. CONCLUSIONS: Our findings highlight how complex the design of incentive systems can be, and how crucial each design choice is to overall effectiveness. The most appropriate design choice will differ according to context, and we have aimed to provide context-specific advice. Whilst all design issues warrant further research, evidence is most needed on incentives directed at recruiters, optimal incentive size, and testing of different incentive structures, particularly exploring repeat arrangements with recruiters.

Can acute suicidality be predicted by Instagram data? Results from qualitative and quantitative language analyses.

BACKGROUND: Social media has become increasingly important for communication among young people. It is also often used to communicate suicidal ideation. AIMS: To investigate the link between acute suicidality and language use as well as activity on Instagram. METHOD: A total of 52 participants, aged on average around 16 years, who had posted pictures of non-suicidal self-injury on Instagram, and reported a lifetime history of suicidal ideation, were interviewed using Instagram messenger. Of those participants, 45.5% reported suicidal ideation on the day of the interview (acute suicidal ideation). Qualitative text analysis (software ATLAS.ti 7) was used to investigate experiences with expressions of active suicidal thoughts on Instagram. Quantitative text analysis of language use in the interviews and directly on Instagram (in picture captions) was performed using the Linguistic Inquiry and Word Count software. Language markers in the interviews and in picture captions, as well as activity on Instagram were added to regression analyses, in order to investigate predictors for current suicidal ideation. RESULTS: Most participants (80%) had come across expressions of active suicidal thoughts on Instagram and 25% had expressed active suicidal thoughts themselves. Participants with acute suicidal ideation used significantly more negative emotion words (Cohen's d = 0.66, 95% CI: 0.088-1.232) and words expressing overall affect (Cohen's d = 0.57, 95% CI: 0.001-1.138) in interviews. However, activity and language use on Instagram did not predict acute suicidality. CONCLUSIONS: While participants differed with regard to their use of language in interviews, differences in activity and language use on Instagram were not associated with acute suicidality. Other mechanisms of machine learning, like identifying picture content, might be more valuable.