Several philosophers have advanced epistemic reasons for using the policy in certain cases. Here we introduce epistemic considerations against no-platforming that are relevant for the reflection on the cases at issue. We then contend that three recent epistemic arguments in favor of no-platforming fail to factor these considerations in and, as a result, offer neither a conclusive justification nor strong epistemic support for no-platforming in any of the relevant cases. Moreover, we argue that, taken together, our epistemic considerations against no-platforming and the three arguments for the policy suggest that no-platforming poses an epistemic dilemma . While advocates and opponents of no-platforming alike have so far overlooked this dilemma, it should be addressed not only to prevent that actual no-platforming decisions create more epistemic harm than good, but also to put us into a better position to justify the policy when it is indeed warranted. The term ‘no-platforming’ can be understood in different ways. In the philosophical literature relevant here it is often construed narrowly as the policy of refusing individuals the opportunity to present their views at certain venues, particularly academic institutions such as universities, on the basis of the perceived abhorrent or misguided nature of the individuals’ viewsIn recent years, there has been a flurry of philosophical research on academic freedom  when S is disinvited or not invited to present a talk at U because there is a policy forbidding S or her group from talking there, or (c) when S is disinvited or not invited to present a talk at U because the potential host (or an authority exerting influence on the host) is concerned about the controversy it would cause.No-platforming comes in different varieties. It would occur, for instance, (a) when a problematic speaker not be no-platformed because this would undermine philosophy’s “essential role in society as a discipline in which sensitive and controversial issues are investigated with patience, care, and insight”  cases of potential no-platforming such that neither set of reasons clearly outweighs the other in the cases at issue, resulting in a difficult choice situation. Currently, we thus can’t tell, by appeal to general epistemic principles that we will discuss below, whether our epistemic reasons  justify or strongly support rather than contradict no-platforming in any here relevant case. While advocates and opponents of no-platforming alike have so far overlooked this point, it ought to be addressed. For doing so helps us prevent that no-platforming creates more epistemic harm than good, and puts us into a better position to justify the policy when it is indeed warranted.We have three goals. We will first introduce a set of epistemic considerations veritistic version of epistemic consequentialism  A produces on average more true (or approximately true) beliefs of interest for a subject S than B.moral grounds for no-platforming that override the epistemic considerations against the policy that we will introduce. In fact, we may even have stronger epistemic reasons that override our particular epistemic points. So, we won’t rule out that sometimes, all-things-considered, no-platforming is justified even when it is epistemically harmful in the ways we will outline.Two clarifications are in order. First, in discussing epistemic reasons for and against no-platforming, we will adopt a Goldman, .7 It holNo-platforming is used internationally to stop a wide range of problematic speakers including individuals advocating views perceived as transphobic, anti-feminist, racist, sexist, Islamophobic, creationist, etc., from giving talks at universities Ditum, . Recent 9While seemingly most of these examples are instances of no-platforming from the political left, no-platforming also comes from the political right McMahan, . Recent 10individuals whose presence/talks would break the law in a functioning democracy individuals who are known to offer only positions/arguments devoid of meaning, and to intend to bedazzle audience members ignorant of relevant terminologies and discursive norms .Independently of the political motivations for no-platforming, we don’t deny that in some cases the policy is justified all-things-considered. For instance, we grant the prudence and overriding moral importance of preventing the following three kinds of speakers from giving talks at universities :some other cases beyond those involving speakers of type (1)–(3) in which principled epistemic considerations clearly speak in favor of the policy. It is these epistemic considerations and this existential claim that we shall critically assess. But before that, we review epistemic reasons against no-platforming. Doing so will provide us with some useful tools to then critically evaluate considerations advanced in favor of the policy.We will here exclude speakers of type (1)–(3) from consideration because the no-platforming of them strikes us as hardly controversial. We take it that the more interesting and controversial cases in the no-platforming debate concern speakers other than those of type (1)–(3). We assume that the advocates of the three arguments in favor of no-platforming to be discussed below are also primarily concerned with cases other than situations involving speakers of type (1)–(3). That is, we take these philosophers to argue that while no-platforming might be problematic in some cases, there are at least The recent philosophical literature on no-platforming doesn’t contain a detailed discussion of epistemic grounds against the policy. We want to remedy this by reviewing three epistemic reasons against no-platforming that are derived from an integration of (i) considerations from John Stuart Mill’s (1859/2001) influential discussion on freedom of speech, (ii) psychological data, and (iii) insights from the philosophy of science on the value of viewpoint diversity. While (i)–(iii) aren’t new, their integration and application to the debate on no-platforming will yield a novel contribution to this debate. Again, our claim here is not that the points to follow constitute decisive, all-things-considered arguments against no-platforming in any particular case. We submit them instead as epistemic considerations against the policy that should be taken into account when weighing the costs and benefits of it.One familiar Millean point from the debate on free speech is that the hosting of some problematic speakers may yield epistemic benefits by providing the audience with the opportunity to hone their analytical ability. Below Sect.  we will By offering opportunities for scrutinizing problematic speakers in person and in a supervised setting, universities help to equip students with the tools to undermine such speakers’ conclusions when encountering them in- or outside of academic settings. This is an obvious epistemic benefit. There are, of course, alternative ways of exposing students to controversial or false views for educational purposes than via hosting problematic speakers. For instance, faculty members might present them to students in their own words, or they might play ‘devil’s advocate’, i.e., adopt an opponent’s view on an issue for the sake of argument. However, these alternatives are likely to be less epistemically effective. This is because only genuine advocates of a controversial view are fully committed to it and so motivated to expend significant effort to support it. For instance, when faced with counterevidence, perhaps only genuine advocates of a view are persistently likely to consider rejecting auxiliary assumptions rather than the view itself, as they care about it. This reluctance to swift revisions can facilitate a thorough exploration of the proposal’s tenability  likely to distort that view. Students without access to skilled authentic defenses of it will then be trained to engage only with caricatures of the view. This, in turn, precludes the students from learning how convincingly to refute it in its actual shape(s), in- and outside of consensual university environments. Engaging with a devil’s advocate is thus for students often the epistemically inferior alternative compared to confronting the actual ‘devil’ in a supervised setting.No doubt, there are problematic views that seem so easily refuted that exposure to their champions might be a waste of resources. But two points are worth keeping in mind. First, if we take the mentioned empirical research at face value, we should expect our own opinions about the strength of offensive positions to be at least somewhat skewed by our opposite positions too. In fact, since the views affected by no-platforming tend to elicit particularly strong aversive responses, with respect to these views, motivated cognition is perhaps especially likely to incline us to underestimate the degree of rational support they enjoy. Second, even if the currently best version of a problematic position is easily refuted, it isn’t unreasonable to assume that some of its advocates will develop and strengthen it over time. In systematically no-platforming speakers defending problematic positions, we discount the possibility of that happening and again risk insufficiently preparing students for successfully undermining false but possibly carefully defended views.per se. Some kinds of viewpoint homogeneity in academia might have pedogogical benefits  in which a speaker might be allowed/disallowed to speak need to be taken into account too. For instance, lecture formats are more easily hijacked by cranks to the exclusion of pedagogical benefits as compared to classroom discussions in which a genuine expert who can rebut the speaker’s views joins students. Excluding a problematic speaker from certain lecture formats might thus sometimes be justified on epistemic grounds. This doesn’t undermine our point here that in other contexts involving other talk formats  no-platforming such a speaker might undercut the epistemic benefits mentioned.lack of viewpoint diversity, which is facilitated by no-platforming, risks undermining that strategy and thereby weakens the reliability of academic belief formation.The second consideration against no-platforming that we want to highlight is closely related to the point just made. It is that in using the policy, we decrease the scope of social criticism that beliefs held and acquired at universities are exposed to. This is problematic for reasons often emphasized by philosophers of science working on viewpoint diversity  as a result of politically motivated, one-sided information processing rather than an accurate assessment of competence. Moreover, even speakers advocating views completely flawed might still motivate us, their opponents, to make explicit, keep in mind, and fully understand the justification for our own beliefs and background assumptions Longino, , even exOur final epistemic consideration against no-platforming builds on the preceding two points. It is that when a university decides to no-platform speakers that challenge the consensual views at that university, these speakers may recycle the preceding arguments to claim that they have been wrongfully silenced and victimized by that academic institution to the epistemic detriment of academia. Generally, we have little sympathy with such charges. But the problem is that at least sometimes they might be supported with the above-mentioned points on the epistemic value of authentic dissent and diverse social criticism. As a result, they can become effective means to induce distrust in the public about the reliability of academic belief-formation that can’t easily be dismissed, and feeds into many lay people’s suspicion that non-epistemic reasons such as political convictions guide academic theory-formation, -testing, and -acceptance.This distrust or skepticism is highly epistemically pernicious. It leads subjects to become resistant to a key public output of academic research such as scientific conclusions  while also reinforcing the common “lack of confidence” in academia among significant  portions of the public in some Western democracies such as, for example, the UK or US  offer a conclusive justification or strong epistemic support for the no-platforming of problematic speakers in each of the cases that advocates of the arguments focus on. For, in each of these cases, the epistemic costs of no-platforming and (correlatively) the epistemic benefits of avoiding the policy that we mentioned in the preceding section would need to be weighed against the epistemic benefits of using no-platforming that the arguments mention. But this hasn’t happened yet. All three arguments remain thus inconclusive on the existential claim that they involve.Having introduced epistemic grounds for avoiding no-platforming, we shall now apply them in a critical discussion of three recent epistemic arguments in favor of the policy. The authors that we will discuss aren’t claiming that an across-the-board policy of no-platforming problematic speakers would be epistemically beneficial—they agree that there are particular instances of no-platforming that have bad veritistic consequences, and, of course, they agree that non-epistemic, for instance, moral reasons against/for the policy might override epistemic concerns. Rather, the authors’ focus is  on the following existential claim:p. Specifically, an invitation to speak in such settings confers credibility on a speaker, Levy holds, because it selects this individual from other potential speakers as the one whose utterances deserve a hearing. This increase in credibility varies with the range of potential selectees and the venue’s prestige. But since most academic settings tend to be relatively exclusive, the fact that a speaker has been selected to speak in such a setting itself provides her audience with evidence that her testimony constitutes good evidence. On this basis, Levy offers an epistemic argument for no-platforming on some occasions: “If someone is likely to speak in favor of a view we know to be false, we have grounds to no-platform them, because we know that providing them with a platform by itself provides higher-order evidence in favor of that view”, and this is, given the falsity of the view, “misleading” . Still, Levy concludes that his point does “show that we may support refusing a platforming to a particular speaker on a particular occasion without abandoning the legacy of the Enlightenment” (ibid: 500), which is earlier in the text identified with purely epistemic values (ibid: 490).In a subsequent paper, he : p. 500 pro tanto. We assume that Levy would uphold this claim even for some speakers not excluded by our considerations in Sect. 17Thus, while in , Levy clNotice first that while Levy’s arguments draw support from the evidentialist literature on disagreement as evidence  doesn’t restrict experts’ teaching or research practice, but rather (ii) promotes disciplinary knowledge and standards.Given (1)-(2), the no-platforming of these speakers is justifiable by appeal to the university’s epistemic goals.Simpson and Srinivasan clearly commit to the existential claim that there are some controversial cases of potential no-platforming when epistemic considerations justify no-platforming, namely cases in which we have a problematic speaker who is disciplinarily incompetent in that they reject disciplinary axioms. How plausible is this view?Simpson and Srinivasan : p. 186 Point (2) (i) of Simpson and Srinivasan’s argument is problematic especially if we keep in mind the epistemic value of authentic dissent for teaching and research. For suppose you are a disciplinary expert and want your students to improve their analytical abilities and disciplinary self-awareness by critiquing your discipline’s axioms. If, by the university’s decision, all problematic speakers questioning those axioms were no-platformed, this would interfere with your teaching goals. For, as argued above, confronting a teacher who is playing the devil’s advocate and so mimicking a dissenter is less epistemically useful compared to confronting an authentic dissenter, especially when the view defended contradicts the teacher’s own commitments such as her disciplinary axioms. Hence, while Simpson and Srinivasan’s argument rests on the idea that the authority of academics to teach and research should be preserved, their rationale for no-platforming seems in tension with this very idea, at least if the academics don’t themselves make the no-platforming decisions.Of course, academic teachers might in some cases as an exercise of their institutional authority want to shut down talks by invited speakers, thinking that this is most conducive to the realization of educational aims. But as noted, studies suggest that when we are considering morally or politically controversial views, motivated cognition is likely to skew our opinion on the falsity or wrongness of them. If so, then academics’ judgments on whether it would be conducive to students to be exposed to certain views might in fact be less reliable than these academics themselves take them to be. Indeed, given what we know about motivated cognition, academics might in each case at issue form decisions on no-platforming of axiom skeptics that in fact inadvertently contradict their own teaching goals. That is, it is be no means clear that in such cases academics’ conscious decisions on no-platforming would capture the kind of teaching goals that the academics themselves endorse. It remains an open question whether the no-platforming of axiom skeptics, in each of the relevant cases, does or does not restrict experts’ teaching or research practice. Simpson and Srinivasan’s point (2) (i) thus isn’t yet established.19reduce disciplinary knowledge and standards. For suppose that in the discipline of gender studies the moral permissibility of homosexuality is axiomatic and that, as recommended by Simpson and Srinivasan, axiom dissenters are excluded from giving academic talks in the discipline. At university, gender studies students and faculty will then not be able to confront authentic advocates of the view that homosexuality is morally impermissible. This (to reiterate a by now familiar thought) reduces their chance of developing strong arguments against it. The no-platforming of axiom skeptics thus makes it less likely that students and experts within a given discipline acquire the skill to defend their most basic disciplinary assumptions convincingly.As for Simpson and Srinivasan’s point (2) (ii), there is reason to believe that the no-platforming of axiom skeptics wouldn’t promote but justify the no-platforming of speakers , this existential claim is insufficiently supported. We currently can’t tell whether, in these cases, no-platforming maximizes or decreases the net epistemic goods that Simpson and Srinivasan highlight, as the relevant costs and benefits haven't been weighed up against each other yet.20In sum, we grant that in some cases no-platforming might be justified by the epistemic goals of a university. These are, for instance, the cases that we mentioned in Sect. Fantl  offers aFirst, if we know that the speakers brought in to toughen up the students or teach them tolerance are uttering falsehoods, then we are prioritizing those other values over the value of truth because we are allowing falsehoods an inroad to the university that they wouldn’t otherwise have. […]accurate perceptions of genuine betrayal. Therefore, in toughening students up or teaching them tolerance, we end up ensuring that they don’t respond accurately to real harms. We ignore the value of truth because we teach students to inaccurately judge the intrinsic harms done to them by our coddling of the peddlers of false and marginalizing speech. It is only by refusing to invite relevant offensive speakers to campus that we in fact give due respect to truth—the single ultimate value ? Fantl assumes that inviting a problematic speaker and granting them minimal respect constitutes a s Fantl, : p. 199.feel betrayed, they haven’t in fact been betrayed. Suppose that the party inviting a problematic speaker issues the invitation on the explicit basis of the kind of epistemic considerations we discussed above , and this is communicated to the students. The speaker would then be offered a minimally respectful treatment. But the university wouldn’t thereby affirm the speaker’s view(s),Moreover, there arguably are invitations of problematic speakers, where, even if some students might still We grant that when such a framing does not occur, or problematic speakers are not invited for the epistemic, educational reasons mentioned, Fantl’s epistemic consideration might still justify no-platforming. But it would then need to be shown that in the cases at issue, the epistemic costs that he highlights outweigh those mentioned in Sect. for and against no-platforming in each of the particular cases at issue in the three arguments assessed. Moreover, neither one of the two sets of points obviously outweigh the other. At any rate, no one has so far shown that one overrides the other in any relevant case. For all we can tell at the moment, then, the points made for either side are equally strong, and so it remains unclear how to decide in any particular (here relevant) case whether the totality of epistemic reasons support the no-platforming of a problematic speaker, leaving us in a difficult choice situation. We call this the epistemic dilemma of no-platforming.22The three arguments for no-platforming just discussed correctly identify cases in which hosting problematic speakers comes with certain epistemic costs. Yet, there are good reasons to hold that the no-platforming is in these cases epistemically costly too. Specifically, with respect to controversial applications of the practice , no-platforming (1) reduces people’s exposure to authentic dissenters, (2) threatens to reduce the reliability of academic belief formation, and (3) fuels the public’s distrust in academia and scientific testimony. The preceding discussion thus provides plausible epistemic considerations both harms of unbridled political diversity  in academia  (a) the speaker’s likelihood of providing a genuine educational opportunity to students, (b) the speaker’s contribution to the university’s total invited speaker profile, (c) the speakers’ impact on future audiences, (d) the impact of a no-platforming decision on the public’s perception of the university, and so on. It isn’t easy to see how to weigh all these very different concerns, let alone adjudicate on no-platforming on their basis by resorting to simple general principles. At any rate, the matter clearly calls for further philosophical work . Other epistemic costs/benefits, however, pertain more holistically to an entire speaker series . Relatedly, a single problematic speaker’s accusation against a university that this university disinvited her on political grounds carries far less weight if the university has already welcomed relevantly similar problematic speakers. Complicating the decision-making further, an invitation to give a talk may less significantly increase the credibility of false or misguided views if the speaker advocating them is already widely trusted. Having said that, even a small boost of credibility across a very large non-academic audience may do more epistemic harm than a large boost of that kind across a small audience. From an epistemic consequentialist point of view, no-platforming decisions are thus highly complex. They have to factor in concerns about  because doing so may ultimately put us into a better position to support our no-platforming of those who merit it.We would like to end by emphasizing that at no point have we argued that, for instance, creationists, climate change deniers, Holocaust deniers, racists, etc. should be given a platform. In fact, we have granted that they might often be rightly prevented from speaking. What we have said is that the no-platforming of problematic speakers is in some cases likely to be epistemically costly in certain ways, and these costs should be taken into account when reflecting on the policy. This is (


Purpose: It is widely known that the risk of lifestyle-related diseases can be reduced by reviewing lifestyles, and a variety of efforts for their prevention, such as health education, are being implemented. This study examined community residents’ lifestyle awareness, examining their views on their health and lifestyles, age, and lifestyle-related diseases.Methods: Study subjects were 180 healthy people (28 men and 152 women) who participated in a health checkup. Participants answered a questionnaire about their awareness of health and lifestyle and their views of disorders. Subsequent measurements of speed of sound (SOS), acceleration plethysmography (APG), and visceral fat area (VFA) were also obtained.Results: The results of the study suggest that age was correlated with some health-related attitudes and behaviors. When health awareness among members of a group is high, it is necessary to provide them with the required information and continuing intervention to motivate them to continue their health improvement.Conclusion: It seems that health awareness influences lifestyle, and its improvement slows the progress of lifestyle-related diseases and reduces the effects of aging. It is widely known that the risk of lifestyle-related diseases can be reduced by reviewing lifestyles, and a variety of efforts for their prevention, such as health education, are being implemented . Those s—indices of lifestyle-related diseases. Results may help improve their awareness in general, including dietary habits and physical activities , acceleration plethysmography (APG), and visceral fat area (VFA) scorestivities  and effeStudy participants included 180 healthy people (28 men and 152 women)  who partThe Institutional Review Board approved and monitored this study. Each participant provided written informed consent.To evaluate bone quality, speed of sound (SOS) was measured using quantitative ultrasound  in a calcaneus region. Although the gold standard method to evaluate BMD is dual-energy X-ray absorptiometry (DXA) , SOS is Arterial stiffness was evaluated using acceleration plethysmography . Each subject rested in a sitting position for about 5 minutes before the APG was measured at the second fingertip of the right hand. The APG consisted of four systolic waves; a-, b-, c-, and d-waves . The a-pThe VFA was measured using bioelectrical impedance . BIA is an accurate, noninvasive method for measuring body composition, especially aqueous components in humans, and for calculating VFA by using inputted information of age, sex, height, weight, and waist circumference. Previous studies have shown that BIA values are well correlated with values measured using computed tomography (CT) . While tStatistical significance was assessed using multiple regression and Pearson’s correlation coefficient analysis by software (IBM SPSS Statistics 21).In this study, the older one was, the more often they thought that health management was more appropriate. Also, the older they were, the less likely they could talk to someone about their concerns and receive health support.P = 0.002), “Do you have someone to alleviate your worries to promote your health and its management?” (P = 0.016) and “Do you think that obesity is a disorder?” (P = 0.012) was negatively associated with age when assessed using multiple regression analysis.As shown in P = 0.039) and “Do you think that exercise and nutrients only play a secondary role for health?” (P = 0.006) was positively associated with age. “Do you have someone to alleviate your worries to promote your health and its management?” (P < 0.000), “Do you think that obesity is a disorder?” (P = 0.004), and “Do you think that obesity is by nature?” (P = 0.045) was negatively associated with age when assessed using multiple regression analysis  in men and women. Also, VFA was correlated with “Do you think that obesity is by nature?”  in men and women  stated they always pay attention to the nutritional value of meals, which is higher compared to the young group  (15%) . This alElderly people answered “No” to the question: “Are there any persons around you to alleviate your worries over your health and its management” , which sIt is known that psychological health is related to the lifestyle. People need to have someone to advise them or alleviate their worries to promote their own health and QOL . HoweverQuestions regarding their views of disorders were also asked. The higher the age, the lower the rate of subjects or females who answered “Yes” to the question: “Do you think that obesity is a disorder?” There were a large number of elderly people who stated that obesity is not a disorder.Osteoporosis is another major health problem and a cause of morbidity and mortality from fracture . The bonIn the results of the present study, the SOS, APG, and VFA scores of community residents were not significantly correlated with their awareness of lifestyles and health. Since people usually undergo health checkups based on their own free will, their health awareness tends to be high, and they are expected to voluntarily become involved in health-promoting activities . HoweverParticipants in the present study who underwent health checkups also had no lifestyle-related diseases. In the future, it will be necessary to conduct further surveys on a continuing basis to examine changes in their awareness.It is easier for highly motivated people to improve their daily habits , with thTherefore, health checkups serve as an opportunity for examinees to review their lifestyles and promote their own health. When we give health checkups, it is necessary to consider intervention methods according to age.The results of the present study suggest that the age of people is correlated with some health-related attitudes and behaviors. When health awareness among members of a group is high, it is necessary to provide them with the required information and continuing intervention to motivate them to continue their health improvement. Although health awareness was not correlated with SOS, APG, or VFA scores—indices of lifestyle-related diseases, it was strongly associated with the age in our study. It is clear that health awareness influences the lifestyle, and its improvement slows the progress of lifestyle-related diseases and reduces the effects of aging.This study found that age was associated with some health consciousness and health behaviors. It was necessary to provide information and motivation to the group for continued high health awareness and suggests that future intervention should be provided.The study was supported by volunteer participants and nurses.The author declared no potential conflicts of interest concerning the research, authorship, or publication of this article.


It is well recognized that many metabolic enzymes play essential roles in cancer cells in producing building blocks such as nucleotides, which are required in greater amounts due to their increased proliferation. On the other hand, the significance of enzymes in preventing the accumulation of their substrates is less recognized. Here, we outline the evidence and underlying mechanisms for how many metabolites normally produced in cells are highly toxic, such as metabolites containing reactive groups , or metabolites that act as competitive analogs against other metabolites . Thus, if a metabolic pathway contains a toxic intermediate, then we may be able to induce accumulation and poison a cancer cell by targeting the downstream enzyme. Furthermore, this poisoning may be cancer cell selective if this pathway is overactive in a cancer cell relative to a nontransformed cell. We describe this concept as illustrated in selenocysteine metabolism and other pathways and discuss future directions in exploiting toxic metabolites to kill cancer cells. Metabolism is an aspect of cancer biology that is attractive in terms of therapy. First, it has been known for a long time that the metabolism of cancer cells differs from that of normal cells in many ways. A widely known metabolic alteration in cancer cells is high glucose consumption and high levels of lactate production with a lack of oxidative phosphorylation, referred to as the Warburg effect , 2. AnotMuch of cancer metabolism research has centered on the idea of targeting the “cellular building blocks” that cancer cells require, and there are notable examples of clinical efficacy Fig. . Cancer While the approach of starving a cancer cell of essential metabolites is both logical and proven, there are also some important factors that can limit the effectiveness of this strategy in killing a cancer cell. First, when the biosynthetic pathway for an essential metabolite is disrupted, there may be mechanisms by which a cell can salvage it through a secondary route Fig. . This caSecond, a metabolic enzyme that appears to be essential in tissue culture may not end up being essential in a more physiological (in vivo) context, as typical culture media conditions do not accurately reflect the diversity and quantity of metabolites that are available in the human bloodstream . Uric acAs illustrated, there are multiple reasons why targeting a particular enzyme that produces cellular building blocks may not be effective to kill a cancer cell. Thus, even when this enzyme appears to be important to a cancer cell, either due to the product it makes or due to it being increased in expression and/or activity, targeting it may not translate to effective therapy. Here, we outline an alternative approach: the notion of killing cancer cells not by impairing the production of biosynthetic building blocks, but rather by inducing an accumulation of toxic intermediates that lie within metabolic pathways. Assuming a standard linear metabolic pathway that involves the stepwise chemical conversion of a series of metabolites, the loss of an enzyme that converts toxic metabolite “b” to a nontoxic metabolite “c” may result in the accumulation of “b” to toxic levels in the cell Fig. . This apFirst, we describe many metabolites normally produced in our cells that have highly toxic properties. We illustrate potential mechanisms for their toxicity, such as the presence of highly reactive groups that allow them to covalently modify cellular components, or their similarity to other metabolites that make them de facto competitive inhibitors. Second, we describe recent findings that demonstrate this approach, with an emphasis on the selenocysteine biosynthesis pathway, which we have recently shown to allow cancer cell-specific poisoning. Finally, we discuss future directions for applying this approach across many metabolic pathways to uncover novel Achille’s heels in different cancers.It may seem counterintuitive that endogenously produced metabolites, which in many cases form the building blocks of the cell, can be poisonous. However, when cross referencing known metabolites with toxicity databases such as TOXNET  or HSDB 2−•, H2O2, etc.) are thought to be mitochondrial respiration and the activities of NADPH oxidase, 2-oxoacid dehydrogenases, and superoxide dismutases (SOD1/2/3) [The major intracellular sources of reactive oxygen species  . In a noOD1/2/3) , 26. It OD1/2/3) , and it OD1/2/3) , suggestOD1/2/3) . While bOD1/2/3) , 31, whiOD1/2/3) , 33. TreOD1/2/3) , 35. PolOD1/2/3) , 37, speOD1/2/3) , and speOD1/2/3) , 40 can OD1/2/3) , which mOD1/2/3) . AutooxiOD1/2/3) . In addiOD1/2/3) , 45. A pOD1/2/3) .Some metabolites contain functional groups that are chemically reactive. As such, they can form adducts or react with macromolecules such as DNA and proteins, which can result in their detrimental modification and cellular toxicity Fig. . The aldSeveral metabolites are toxic due to their strong tendency to react with free thiol groups of proteins or glutathione Fig. . For exaOverall, many examples exist in the literature of metabolites that show reactivity toward biological macromolecules and thus exert their toxicity. In addition to further exploring the examples mentioned above, it may be possible in future efforts to predict toxic metabolites based on the presence of reactive groups, such as reactive aldehydes, and to explore these as a therapeutic strategy.Many enzymes have the capacity to catalyze not just one standard reaction, but also physiologically irrelevant secondary reactions, referred to as “promiscuous” reactions , 66. TheNeurotransmitters are endogenous chemicals that transmit signals from one neuron to another neuron, gland cell, or muscle cell . The ideSome metabolites have been known to have antiproliferative or toxic effects in cells, but their toxic mechanisms are not clearly understood. For example, dehydroepiandrosterone, an intermediate for steroid hormone synthesis, exerts growth inhibitory functions in hepatocytes , neuronaAs seen across the body of literature and summarized above, a variety of metabolites can be toxic to cells through various molecular mechanisms known and unknown. There are likely many other metabolites and mechanisms of toxicity yet to be uncovered. These examples lead us to posit that many metabolic enzymes in cells may be important not necessarily for what they produce, but for what they get rid of.As outlined in the previous section, many metabolites that are normally produced in cells have toxic properties, suggesting that their accumulation would be deleterious to a cell. This has an important implication for the function of metabolic enzymes—that enzymes that process a toxic metabolite in a pathway may serve an important detoxification function, as they prevent accumulation of toxic metabolites. This immediately suggests that it may be possible to induce poisoning of cancer cells with an accumulation of toxic metabolites that they themselves have produced, by targeting such “detoxification enzymes”. Thus, the detoxifying enzymes represent novel and druggable targets for killing cancer cells.But how can a therapeutic window exist for such a mechanism, so that the toxicity occurs primarily in cancer cells? In theory, the detoxification requirement would be in proportion to the production of the toxic metabolite in the first place. This can be analogized as a “kitchen sink” model Fig. , where tOur recent findings on the selenocysteine biosynthesis pathway  illustraThus, the SLC7A11/selenide production/SEPHS2 detoxification axis illustrates a kitchen sink mechanism of toxicity, and at the same time suggests potential advantages of a metabolite poisoning strategy to kill cancer cells. First, this pathway illustrates how in some instances the downstream building block product of a metabolic pathway per se may not be critical for the survival and proliferation of a cell, in contrast to the acute requirement for detoxification. Indeed, we demonstrated that the loss of all selenoproteins can be tolerated in normal cells indefinitely, whereas the toxic accumulation of selenide can acutely induce cell death in cancer cells. Second, it demonstrates how the factor that determines the requirement for detoxification is likely to be logical and predictable—in this case, the transporter involved in both selenium import and selenide production. This is a significant advantage, as one can easily predict which types of cancers may be amenable to SEPHS2 inhibitor treatment, either at the level of the cancer subtype or even at the individual patient level. This will help predict exactly which patients will benefit most from pharmacological inhibition of the detoxifying enzyme. Third, the level of toxic metabolite accumulation may be modulated by dietary input into the pathway, which can help increase or decrease efficacy to “dial in” the correct dosage of the toxic metabolite. We showed that supplementation with selenite in the tissue culture media synergistically enhanced the toxicity of SEPHS2 KO in cancer cells, suggesting that with this type of approach, pharmacological inhibition of the detoxifying enzyme may be combined with dietary supplementation with metabolic precursors to the toxic metabolite. Conversely, if the toxic metabolite accumulation from cancer cells is too great as to pose hazards to the patient, the toxicity may be tempered through dietary restriction of the upstream precursors. In conclusion, the toxic metabolite accumulation approach provides a method to induce acute poisoning to kill cancer cells, with additional potential advantages of predictability of susceptible cells and the opportunity for dietary modulation of the treatment.We have discussed in “The kitchen sink and achieving cancer-specific toxicity” the concept, proof of principle, and advantages of a toxic metabolite accumulation strategy to kill cancer cells. As a novel concept, this approach holds promise for uncovering novel classes of cancer targets and even clinical implications for diseases beyond cancer; however, there are also important caveats to consider. Here, we will discuss how this approach can be expanded in a systematic manner, but with caution.As described in “Toxic metabolites”, examples of toxic metabolites can be found sprinkled throughout the literature across various fields. In each case, the downstream enzyme(s) that are responsible for processing these metabolites are “detoxifiers” and potential targets for inducing toxicity in cells, and this may be selective toward certain cancer cells if they have an increased production rate for the toxic metabolite. Thus, it will be useful to catalog an extensive list of toxic metabolites (the “endotoxome”) and the set of downstream enzymes that process them. In this manner, once an extensive list has been curated, it may be possible to systematically analyze the metabolic activities of different cancers and use this to predict which toxic metabolite pathways can be targeted to achieve selective toxicity for a particular cancer. This sort of analysis may even be carried out on a patient to patient or individual tumor to tumor level based on gene expression analyses or metabolite profiling analyses of tumor biopsies. We predict that in the coming years many more studies and strategies involving individual detoxification enzymes may be uncovered, and over time systematic approaches may be developed.An important caveat to a systematic identification of toxic metabolites is that it is hard to determine an exact threshold to define a toxic metabolite vs a nontoxic metabolite. Even relatively nonreactive, nontoxic metabolites may become toxic at high enough concentrations. For systematic cataloging of toxic metabolites, empirical dose response testing of each “endogenous metabolite” in purified form across several types of cell lines would allow one to set a dose-defined threshold or hierarchy of toxic metabolites. However, procuring an extensive library of metabolites in purified form presents a significant challenge to this approach. As an alternative approach, toxic metabolites may be “functionally” defined and cataloged using the “kitchen sink” model. As described in “The kitchen sink and achieving cancer-specific toxicity”, if KO of a metabolic enzyme is deleterious, but can be rescued by the concomitant KO of the upstream enzyme (or transporter), this would indicate that the accumulation of the metabolite between those two enzymes was the cause for the toxicity Fig. . While fA second caveat to be considered in future studies is the transport of toxic metabolites into and out of cells. Certain toxic metabolites may be incredibly toxic inside cells but may not be easily identified, as media treatment of the metabolite may not readily enter cells to exert a toxic effect. The same metabolites that are not easily transported into and out of a cell may represent attractive targets for therapy as they are “trapped” within the cell, as opposed to another metabolite that may be readily exported from the cell before toxic accumulation is achieved.The third caveat is possible host toxicity. Even though the accumulation of a toxic metabolite should occur in a cancer cell-specific manner as described, it is possible that the toxic metabolites that accumulate in the tumor may spread to the host tissues. This risk further emphasizes the need to test examples of this approach in vivo, for example in tumor xenograft models. Conversely, the “spread” of toxicity may actually be a significant advantage in therapy when considering that tumors are known to be metabolically heterogeneous; thus, if a majority of tumor cells are selectively vulnerable to toxic metabolite accumulation, this may result in toxicity of neighboring invulnerable tumor cells, overcoming a universal limitation of chemotherapy.Despite these potential caveats, the notion of poisoning cancer cells with their own metabolites represents an unconventional, underexplored, and potentially highly efficacious method for killing cancer cells in a predictive and selective manner. We hope that this review serves as a blueprint for other groups to determine whether toxic metabolite exploitation opportunities exist in their metabolic pathway of interest. Furthermore, the relevance of toxic metabolites may extend beyond simply being an exploitable tool in cancer therapy. Since toxic metabolites are normally produced, their presence—however transient—may contribute to cellular wear and tear mechanisms. The formation of aldehydes and ROS-producing metabolites, for example, if reacting with DNA, may contribute to the daily burden of DNA damage in a cell. If they react with proteins, this can result in protein dysfunction and even misfolding events. DNA damage and protein misfolding are events thought to be universally present  to aging and age-dependent disorders such as Alzheimer’s disease. Any deregulation of transcription, transport, or other biological functions that result in an imbalance between toxic metabolite production and detoxification may therefore increase the level of cellular damage over time in an organism. Toxic metabolites may represent a large and underappreciated group of metabolites that, over time, can contribute to a variety of disorders; thus, the premises mentioned here may be applicable across a range of diseases. In closing, toxic metabolites may lie at the interface of metabolism and disease in many regards, and as outlined here, cancer is a prime avenue in which they may be harnessed for therapeutic benefit.


Dear Editor,1 is most welcome but deserves comment, despite rightly stressing the mandatory needs for: a) trained providers or specialized services; and b) the belt-and-braces strategy, combining psychological support with pharmacotherapy (nicotine substitutes using patches plus lozenges)1.The concern for improving smoking cessation in pregnant women2; and b) In France, during the World No-Tobacco Day, in the main entrance of a university hospital, midwives ran a booth with the banner: ‘Acupuncture, an alternative to nicotine replacement therapy in smoking cessation’3. As a matter of fact, since 2017, nicotine substitutes packages have a big red label that reads ‘nicotine + pregnancy = danger’ and a pictogram with a black subtitle that reads ‘do not use during pregnancy unless no therapeutic alternative’. Worse, the French Department of Health flied in the face of evidence and common sense, even rejected pledges by the Institute of Medicine and NGOs to withdraw these devastating warnings4. Moreover, warnings are ‘icing on the cake’ as too many professionals overlook: a) the deleterious effects of compensatory uptake of harmful by-products  when trying to quit without nicotine substitutes5; and b) that smoking with nicotine substitutes does not cause an increase in nicotine concentration, and they overestimate by a factor of 10 the nicotine deadly dose6. Frequently, at follow-up visits my patients report that their pharmacists warned them against smoking with patches or challenged my prescriptions as being too high; with my warnings to pharmacist and medical regional councils usually being ignored.Indeed, the present state of affairs is a ‘shipwreck’: a) in the US, only 1 in 5 pregnant smokers is offered nicotine substitutes, and 1 in 4 does not receive any intervention to quit1. No need to Ask, look at fingers and smell. Advising is pointing the finger of blame, as though these women are dumb; advising to quit can only decrease further an already poor self-esteem. Why Assessing readiness to quit? Tobacco is the worst drug and no smoker expects to be able to quit. All smokers fear quitting, having made a series of attempts, with always the same results: suffering and despair.However, the International Health Maintenance Organizations’ 5 As  approach is flawed, it is the opposite of the motivational interviewing that is rightly promoted by Diamanti et al.7; and e-cigarette smoke in mice produces DNA damage, inhibits DNA repair, causes lung adenocarcinomas, and bladder urothelial hyperplasia8.First, one needs to simply reassure and reassure: ‘I do not require you to quit, but only to take the treatment of smoking with patches, which is less dangerous than without, and do increase the dose as needed’; craving and desire to smoke result in pain and suffering due to lack of nicotine; ‘Hasten slowly, you will naturally quit when there is no craving and cigarettes become distasteful’. Indeed, fixing a quit-date is a programmed failure! Can doctors set a date for their patients to become pain free? Second, one needs to educate smokers to self-increase the dose of nicotine substitutes (patches and faster-acting forms) until the craving is suppressed and cigarettes become distasteful. Third, there is no evidence yet for the efficacy of e-cigarettes versus proactive evidence-based treatment. Switching to vapor does not qualify as cessation9 created the term ‘agnotology’  to highlight the misrepresentation of facts by the tobacco industry to fool ordinary people. This seems to be a case of the ‘pot calling the kettle black’.Proctor


This paper argues that assessing personal responsibility in healthcare settings for the allocation of medical resources would be too privacy‐invasive to be morally justifiable. In addition to being an inappropriate and moralizing intrusion into the private lives of patients, it would put patients’ sensitive data at risk, making data subjects vulnerable to a variety of privacy‐related harms. Even though we allow privacy‐invasive investigations to take place in legal trials, the justice and healthcare systems are not analogous. The duty of doctors and healthcare professionals is to help patients as best they can—not to judge them. Patients should not be forced into giving up any more personal information than what is strictly necessary to receive an adequate treatment, and their medical data should only be used for appropriate purposes. Medical ethics codes should reflect these data rights. When a doctor asks personal questions that are irrelevant to diagnose or treat a patient, the appropriate response from the patient is: ‘none of your business’. Factors that contribute to strained healthcare systems include ageing populations, the rising prevalence of chronic illnesses, the expense of cutting‐edge technology, and austerity cuts to public health budgets. Faced with scarcity, societies need to find ways to distribute medical resources as fairly as possible, in a way that can be justifiable to those who lose out—the patients who do not receive the best possible treatment, or who, owing to long waiting lists, receive it later than what would have been ideal.1Global health risks. Mortality and burden of disease attributable to selected major risks (2009). Retrieved from http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf The realization that individuals’ choices can have a significant impact on their health has inspired proposals to distribute medical resources, or costs, according to criteria that take into account personal responsibility. What is most attractive about proposals that factor in personal responsibility is that, in the spirit of luck egalitarianism, they seem to treat all citizens equally and fairly. They distribute resources according to factors (putatively) within the control of those who lose out, rather than according to factors over which people have little or no influence . Under such a scheme, everyone seems to have an equal chance to receive the best possible treatment available, if only they make the right choices. To those who lose out and receive less than others , resource allocators have a seemingly adequate justification: 'you could have received the same care if you had made better choices'. Proposals like these might be all the more tempting in the digital age, given how much more data it is possible to collect and analyse.Increasing evidence suggests that individual lifestyle choices such as smoking, physical inactivity, bad eating habits and unsafe sex are among the top risk factors for disease burden.2Journal of Medical Ethics, 36, 661–665.Sharkey, K., & Gillam, L. (2010). Should patients with self‐inflicted illness receive lower priority in access to healthcare resources? Mapping out the debate.  They conclude that the debate has stagnated and is in need of new views. This paper puts forward an as‐yet unexplored argument: that assessing patients’ responsibility for their health with the objective of limiting access to healthcare on the basis of that information would be too privacy‐invasive to be morally justifiable. Of course, doctors will often have to ask patients about their habits and behaviour to diagnose and treat them appropriately, and some of those questions can be very sensitive. In this paper, I am concerned only with the collection and use of such sensitive information for the purposes of limiting access to healthcare according to criteria of responsibility . Such a privacy intrusion would put patients at risk, damage the doctor–patient relationship, and would likely not even serve justice. I argue that patients have a right to refrain from sharing with their doctor personal information that is not relevant for their diagnosis and treatment, and that medical ethics codes should include a principle of data minimization.I will not go through all the arguments that have been proposed in favour and against considering responsibility within healthcare allocation. Kerith Sharkey and Lynn Gillam have mapped out the literature, categorizing the arguments on both sides of the debate.23British Medical Journal, 334(7583), 21.Glantz, L. (2007). Should smokers be refused surgery?  The second reason maintains that it is inappropriate for healthcare professionals to judge or punish patients, and that doctors should only take into account medical considerations.4Heart, 75(6), 544–545. Sharkey & Gillam, op. cit.; Shelley, E. (1996). Coronary artery bypass surgery in smokers.  On this point, Glantz contends that ‘[w]ithholding surgery from smokers (…) distorts the modern doctor–patient relationship, which is based on partnership’.5Glantz, op. cit.Two reasons that relate to the doctor–patient relationship can be found in the literature against factoring in personal responsibility in the allocation of healthcare. The first claims that such policies would undermine patients’ trust in healthcare professionals, and even impel patients to lie to their doctors. Leonard Glantz, for instance, argues that denying medical treatment to smokers would make it more likely that patients might lie to their doctors about their smoking.These considerations are often expressed more as comments in passing, rather than as detailed arguments. My objective in this paper is to argue that at least part of the reason why patients would lose trust in healthcare professionals, and why it would be inappropriate for doctors to assess the personal responsibility of their patients, is related to privacy issues.6Journal of Contemporary Health Law and Policy, 12, 147–153.Harris, J. (1995). Could we hold people responsible for their own adverse health? The only mention of privacy I have found in the literature on the ethics of assessing personal responsibility in healthcare settings is by John Harris, and it is a short parenthetical consideration. He writes that, even if it were possible to collect all the relevant information that would be necessary to assess responsibility, ‘there remains the question of whether it would be desirable for other reasons (which would include privacy and the dangers of abuse)’.Given that confidentiality is one of doctors’ fundamental duties towards their patients, it seems that privacy concerns are particularly important in medical contexts, and their neglect is a conspicuous mistake.37Encyclopedia of bioethics (p. 2632). New York, NY: Macmillan.Oath of Hippocrates. (1995). In W. Reich (Ed.),  The prominence of confidentiality in ethics codes signals the importance of privacy in medical settings, but in order to fully respect and protect privacy, it is not enough to refrain from disclosing information about patients. As I will argue, it is also important to minimize the collection of information, and to use sensitive information only for appropriate purposes .Past and present medical ethics codes usually recognize duties of confidentiality—that is, duties of non‐disclosure of information shared in the context of a fiduciary, contractual or professional relationship such as that of the doctor and patient. Confidentiality is a tool to protect patients’ privacy. Concerns about medical privacy go as far back as the Hippocratic Oath, which included a vow not to speak of what is seen and heard in the course of treatment.One loses informational privacy when others access personal information about oneself. Personal information is the kind of information we have good reason to keep to ourselves, or to share only with a few trustworthy others. It is the kind of information that can make one vulnerable to embarrassment, discrimination and other types of harm such as identity theft.Privacy is valuable for both intrinsic and instrumental reasons. Peeping Toms make us uncomfortable—even when they are not a threat in any way. Instrumentally, privacy is valuable insofar as it contributes to other desirable goals, such as physical and financial security. If people do not know where you live or work, it is harder for them to physically stalk you. If people do not know your full name and credit card number, it is harder for them to steal your money. Privacy protects us from other harms such as discrimination, public shame and reputational damage. It contributes to autonomy by giving us enough physical and mental space to be ourselves and to develop our views without undue external influence. In short, privacy protects us from the burdens and risks of social interaction, and in so doing fosters certain worthwhile pursuits.Medical privacy is a particularly important kind of privacy. Disease not only leaves us vulnerable to worry, pain, deterioration of the body, and possibly even death—it also leaves us vulnerable to social harms such as stigma, discrimination, shame and exploitation. The information that someone needs medical care is to social predators what the smell of blood is to sharks.8The Guardian Retrieved from https://www.theguardian.com/technology/2017/may/31/hackers-publish-private-photos-cosmetic-surgery-clinic-bitcoin-ransom-paymentsHern, A. . Hackers publish private photos from cosmetic surgery clinic. Patients can face many harms as a result of medical data breaches. If a prospective employer has information on a job applicant suggesting some medical concerns, they might be tempted to discriminate against her and hire someone else. Such discrimination would be very hard to prove, as the victim might have no reason to suspect that she is a victim. Insurance companies could take advantage of medically relevant information, such as genetic tendencies, to charge some people more than others. Pharmaceutical companies could engage in price discrimination by identifying people who desperately need a medicine that can be bought only from them, and charge them more for it. Hackers could commit identity theft. Criminals could extort patients, threatening to expose sensitive images or information about them. In 2017, for instance, a criminal group accessed sensitive data from a Lithuanian cosmetic surgery clinic and extorted patients, asking for a bitcoin ransom. Hackers then published more than 25,000 private photos, including nude ones, and personal data that included passport scans and national insurance numbers.9CNN Retrieved from https://edition.cnn.com/2016/03/01/opinions/data-is-a-toxic-asset-opinion-schneier/index.htmlSchneier, B. (2016). Data is a toxic asset, so why not throw it out? As these examples show, collecting and storing sensitive data with devices connected to the internet is riskier than when records were kept on paper. Personal data is sensitive, hard to safeguard, and coveted by many—insurance companies, banks, prospective employers, hackers and criminals, governments and intelligence agencies, among others. In an economy that is more and more dependent on data, personal information is valuable. But it is also vulnerable, which in turn makes patients and any institution storing sensitive data vulnerable as well. A data breach could lead to many disasters for the institution responsible for the data—from loss of reputation to a lawsuit, potentially costing a hospital a fortune. In cyberspace, attackers have an advantage over defenders. While the attacker can choose the moment and method of attack, the defender has to protect against every kind of attack at all times.10Forbes Retrieved from https://www.forbes.com/sites/danmunro/2015/12/31/data-breaches-in-healthcare-total-over-112-million-records-in-2015/ ‐ 5118fabc7b07Munro, D. . Data breaches in healthcare totaled over 112 million records in 2015.  While the number of patients affected was lower in 2017, the number of healthcare data security incidents was higher than in previous years, and seems to be on the rise, suggesting that patients’ health records are increasingly at risk.11Largest Healthcare Data Breaches of 2017 (2018). Retrieved from https://www.hipaajournal.com/largest-healthcare-data-breaches-2017/ In 2019, ProPublica reported that the medical records of more than 5 million patients in the United States and millions more around the world are unprotected on the internet.12ProPublicahttps://www.propublica.org/article/millions-of-americans-medical-images-and-data-are-available-onthe-internetGillum, J., Kao, J., & Larson, J. . Millions of Americans' medical images and data are available on the internet. Anyone can take a peek.  The best way to protect patients and medical institutions from privacy disasters is to collect and store as little sensitive data as possible.Data breaches are so common in medical settings that it is unrealistic to suppose that the safety of patients’ data can be guaranteed. In 2015, over 112 million health records were breached in the United States alone.413Data minimization is a requirement of the new European General Data Protection Regulation (enforceable as of 25 May 2018). A further weighty element to take into consideration in medical settings is patient vulnerability. Patients in the doctor’s office and in hospitals are typically not at their best. Stripped of makeup, fancy clothes, and other social veils, they are often feeling unwell, worried about their condition, and at the mercy of medical professionals to provide them with the care they need. Their negotiation capacities are by and large limited by their circumstances. If protecting one’s privacy is difficult on a good day and under ideal conditions, it is even harder to do under challenging circumstances. Given this extreme situation of vulnerability on the part of patients, it is the duty of healthcare professionals to minimize privacy losses, show consideration towards patients, and avoid any unnecessary exposure.A defence of data minimization in medical settings starts with noting the sensitivity of medical data, the risk involved in collecting and storing data, and the devastating consequences that a data breach can bring about.The Telegraph reported that the U.K.’s National Health Service (NHS) sold 13 years of hospital data covering 47 million patients to insurance companies.14The Telegraphhttps://www.telegraph.co.uk/news/health/news/10656893/Hospital-records-of-all-NHS-patients-soldto- insurers.htmlDonnelly, L. . Hospital records of all NHS patients sold to insurers. Consider going to the doctor’s office on account of a stomach pain. After asking all the relevant questions—where does it hurt, do you feel any nausea, etc.—the doctor starts collecting information that does not seem directly relevant to your health issue. She might ask about your sexual preferences, your shopping habits, or the make and model of your car. When you ask for an explanation regarding these tangential questions, she responds that the hospital requires that information in order to sell it to insurance companies. We would clearly consider such behaviour an unjustified intrusion into the patient’s privacy. The example is slightly exaggerated, just to show that there seem to be implicit norms and expectations as to the kind of data that doctors should collect and the purposes that they should use the data for. But the example is not as outlandish as one would hope: in 2014, The doctor is in a privileged position with respect to the patient: she has personal access to him in a position of authority. Meanwhile, the patient is in a vulnerable position. He is likely feeling unwell and scared about his health, and he needs the doctor to access adequate treatment. To use that position of authority for anything other than to help the patient seems unjustifiable.Yet the principle that doctors do not collect more information than what is strictly necessary is nowhere to be seen in medical ethics codes. The World Medical Association’s International Code of Medical Ethics, for example, recognizes the right to confidentiality, but does not mention the importance of minimizing privacy intrusions. In contrast, the American Medical Association states that physicians should ‘minimize intrusion on privacy’, but does not specify what that entails. In the U.K., the Caldicott Principles recommend that healthcare professionals  ‘use the minimum necessary personal confidential data’, but it is unclear what is meant by ‘use’. The Principles do not mention the collection of data, only using and sharing it. It is also unclear what is meant by ‘minimum necessary’. I contend that ethical codes should recognize a duty not to collect sensitive information that is not necessary for diagnosis and treatment. A data minimization principle should recommend that healthcare professionals limit personal data collection, storage and usage to data that is necessary for diagnosing and treating patients . Patients should also be allowed to ask questions and make consultations that can remain off the record at their request (as long as there is no risk to other people).Ethical codes that do not mention or are not explicit enough on the importance of data minimization for the protection of privacy are out of date. They need to be updated, first, because they do not take into account the risks of data collection in the digital age, and, second, because such neglect amounts to a remnant of more authoritarian times in medicine, when it was up to doctors what to ask and do, and patients had less of a say in managing their risks and health. Giving up personal information can constitute a serious privacy loss, as well as a risk, and patients should be free to keep to themselves information that is not necessary for obtaining adequate treatment.It might not always be easy to determine what is medically necessary information and what is not. Sometimes the job of a physician can resemble that of a detective. On occasion, the answers to questions that might seem irrelevant might contain the key to the puzzle of what is making a patient sick, and past behaviour can be a major part of assessing a patient’s medical condition. Physicians could be at risk of poor clinical care if they did not gather enough medical data.As long as questions are made with the objective of healing the patient, data collection is justified. Relevant questions are those that will help the doctor to diagnose and treat. There are two ways in which the patient’s right to privacy could be violated: if the doctor collected more data than she would if she only had diagnosis and treatment for that patient in mind, or if the data collected was used for purposes other than the diagnosis and treatment of the patient without his or her consent.15Privacy in context. Technology, policy, and the integrity of social life. Stanford, CA: Stanford University Press.Nissenbaum, H. (2010).  Ensuring that personal information flows appropriately is just as important as data minimization. Context is what determines that appropriateness, and in the doctor’s office, what is appropriate is to collect and use data for the purposes of diagnosis and treatment, as well as for medical research, if patients have given their consent for such use. Along with a principle of data minimization, then, medical codes should include a principle establishing appropriate uses of data. Medical data should be used for medical purposes, with few justifiable exceptions.16Medical purposes may not be the only appropriate and justifiable use of medical data. On occasion, medical data might need to be shared with the police in the course of a criminal investigation, for example. Such exceptions are rare, and not commercial in nature. It should not be sold to third parties, and it should not be used to assess patients’ responsibility.Helen Nissenbaum’s framework of contextual integrity helps to explain the importance of using medical data for the treatment and diagnosis of that data subject.517I am grateful to an anonymous reviewer for this objection. Privacy risks to patients would increase significantly if personal responsibility were to be given consideration within healthcare because significantly more data would be gathered on them—and, in particular, some of the data (e.g. on habits) would be particularly attractive to insurance companies, data‐brokers and hackers, among others. The greater the amount of data that is collected, the more accurate the responsibility assessment, and the greater the privacy risks.One might think that patients’ privacy is already at risk, given that, in order to provide them with adequate treatment, sensitive medical information will necessarily be collected and stored. It is reasonable to ask what, if anything, would change if personal responsibility were to be taken into account.18Science, 241(4865), 540–545.House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health.  In his critique of luck egalitarianism, Jonathan Wolff argues that people are humiliated when they are forced to reveal things about themselves that they find shameful. According to him, ‘in a society of equals no one would be prepared to carry out, or submit to, such inspections, even if they were required by justice’.19Philosophy and Public Affairs, 27(2), 97–122.Wolff, J. (1998). Fairness, respect, and the egalitarian ethos. If doctors had in mind the goal of investigating responsibility, it is very likely that this would lead them to ask more questions than they would otherwise. Patients would need to be asked about their sexual practices and partners, eating habits, alcohol consumption and drug use, visits to the gym, hygiene practices, work, level of stress, and social network, as social isolation and bad relationships are among the many health risk factors over which individuals have some degree of control.20Journal of Clinical Ethics, 7(3), 268–276.Atterbury, C. E. (1996). Anubis and the feather of truth: Judging transplant candidates who engage in self‐damaging behavior.  It would not be necessary to collect any of that information merely to treat a patient who needs a liver transplant. Yet every extra data point collected puts patients’ privacy at greater risk. Even if such sensitive information were to be anonymized, the more data points we have on individuals, the easier it is to identify them.21JAMA, 311(24), 2479–2480. 10.1001/jama.2014.4228Weber, G. M., Mandl, K. D., & Kohane, I. S. (2014). Finding the missing link for big biomedical data.  In some cases, only two or three data points are necessary to identify someone.22Sci. Rep., 3, 1376; de Montjoye, Y. A., Radaelli, L., Singh, V. K., & Pentland, A. S. (2015). Identity and privacy. Unique in the shopping mall: On the reidentifiability of credit card metadata. Science, 347(6221), 536–539.de Montjoye, Y. A., Hidalgo, C. A., Verleysen, M., & Blondel, V. D. (2013). Unique in the crowd: The privacy bounds of human mobility. Consider the case of someone who was once an alcoholic and now needs a liver transplant. As Colin E. Atterbury points out, if we were to assess the personal responsibility of drinkers, we would need to determine how much they drank, whether they knew that amount to be excessive, whether they drank out of habit or addiction, their genetic predisposition to addiction (with genetic data being some of the most sensitive data that can be gathered about someone), what their social network was like, and more.Given that patients may lie about their habits or engage in self‐deception, it might be necessary to corroborate their word with other sources of information. It would be helpful to gain access to data collected by social media, files held by data‐brokers, and data from wearables such as digital watches. Such research would be expensive and time‐consuming. When scarcity is one of the main justifications for introducing personal responsibility as a criterion for allocating medical resources, spending valuable resources carrying out medically unnecessary and invasive research on patients rather than on curing them seems unpalatable.23Forbes Retrieved from https://www.forbes.com/sites/kashmirhill/2013/12/19/data-broker-was-selling-lists-of-rape-alcoholism-and-erectile-dysfunction-sufferers/ ‐ 761e73d21d53. For more on the trade of medical data, see Tanner, A. (2017). Our bodies, our data. How companies make billions selling our medical records. Boston, MA: Beacon Press.Hill, K. . Data broker was selling lists of rape victims, alcoholics, and 'erectile dysfunction sufferers'.  Data about personal responsibility can reveal much about individuals’ characters, habits and relationships. From gambling websites to payday loan websites, there are innumerable businesses and other agents lustful to learn about people’s vulnerabilities and weaknesses of will. The best way the healthcare profession can protect their patients’ medical privacy is to collect the bare minimum information that is needed to treat them—nothing more.The more detailed people’s dossiers are, the more profitable they are, which, in the current data economy, makes it more likely that they will be stolen or sold. Detailed information about people’s genetic tendencies and habits could be very valuable. Crossing the boundaries of moral limits, data‐brokers have been known to sell lists of rape victims, alcoholics, HIV patients, and erectile dysfunction sufferers.6While critics might grant that assessing personal responsibility in healthcare settings would be invasive and constitute a data risk for patients, they might still think that those downsides are necessary to achieve justice. On this view, it is seen as unfair that people who take care of themselves may be assigned lower medical priority on account of factors outside their control, while people who act irresponsibly with their health may be assigned the same or higher priority. Furthermore, people who do not make much use of the healthcare system on account of their healthy habits may feel that, through their taxes, they are paying for others’ recklessness. In order to achieve justice, the critic might argue, a proper investigation is necessary, just like we allow for such investigations in the context of a legal trial in the justice system.However, if we allow suspected criminals the privilege against self‐incrimination, it would be unfair not to allow that right to patients. There is something perverse in forcing a person to do something that goes against her own interest. While the right against self‐incrimination might rule out forcing patients to confess to bad habits, an independent investigation into patients’ lifestyles might still be in order, just as investigations are carried out in legal trials.The justice system and the healthcare system are not analogous, however. In a legal trial, someone has been accused of breaking the law. If the defendant denies being guilty, an investigation must ensue to ascertain who is wrong or lying—the defence or the prosecution—and who is owed what. The investigation is part and parcel of treating citizens as equals—the prosecutor’s word is given the same weight as the defendant’s word, as both have to prove their case. Judges and juries are impartial parties that assess the relevant evidence and make a decision. Judges and juries owe their loyalty to neither prosecutors nor defendants—only to justice.24American Journal of Bioethics, 6(2), 65–71.Pellegrino, E. D. (2006). Toward a reconstruction of medical morality.  To transform doctors into judges or gatekeepers to resource allocation would be to betray the healing relationship.In contrast, for the doctor–patient relationship to be one of trust and cooperation, healthcare professionals owe their loyalty to their patients—not to the system. The assessment of responsibility in healthcare settings would introduce a kind of conflict of loyalty for healthcare professionals. The job of healthcare professionals is to be on the side of patients, doing what they can to improve their patients’ health. If they had to judge the responsibility of patients, they would be forced to ask questions knowing that the patient’s answers may have a negative effect on his health by positioning him lower on the waiting list, for example. The business of the doctor is to heal, not to judge, and in order to be good at her job, a doctor has to be her patients’ advocate. Here I am advancing a view of the doctor–patient relationship akin to ‘the healing relationship’ articulated by Edmund Pellegrino, according to which the common goal of healing is the essence of the medical endeavour.25Physiol. Rev., 93(3), 1207–1246.Benedetti, F. (2013). Placebo and the new physiology of the doctor–patient relationship. The interaction between patients and doctors can have significant health effects. If the patient feels positively about his doctor, the interaction may produce placebo effects, thereby helping the patient improve his health. If the patient feels negatively about his interaction with healthcare professionals—if he feels judged, or that his privacy is being violated—those feelings might induce nocebo effects that have a negative impact on his health.It could be argued that responsibility could be assessed without implicating doctors. A specialized external medical team could do it, for instance, or a hospital manager. But patients would likely still feel distrust towards the healthcare system, even if their doctors were not directly involved in assessing their responsibility. They might also consider doctors as accomplices of a harsh system. If patients perceive the healthcare system as a judgmental and merciless one, they are unlikely to think any better of healthcare professionals working for such a system.Doctors Without Borders. When an organization implements a policy thought to be unethical, people expect ethical employers to resign or rebel; otherwise, they are likely to be considered accomplices. When, in 2012, the Spanish government passed a law to exclude illegal immigrants from the healthcare system, more than 1,500 doctors refused to comply, making a public pledge that they would offer medical care to anyone who needed it. In their campaign, doctors appealed to their ‘right to cure’.26El País Retrieved from https://elpais.com/politica/2012/08/26/actualidad/1346001950_940230.htmlSevillano, E. G., García de Blas, E., & Rico Motos, C. . Crearemos una red que atienda a todos.  Healthcare professionals who value their patients’ medical needs above any other consideration are more likely to be perceived as benevolent and trustworthy by such patients.People’s integrity and trustworthiness is partly appraised on the basis of the organizations they work for—think of Nazi officers (as an extreme case), Facebook employers , or, as a positive example, physicians working for Furthermore, who carries out the invasive research is irrelevant from the point of view of privacy. When citizens go to court, they are expecting to receive a just outcome. Invasive research into people’s private lives is often necessary to find out the relevant facts that are in turn necessary for juries and judges to serve justice. The privacy invasion is justified because it is necessary in order to attain what citizens want when they go to court: justice. In contrast, when citizens go to the hospital, they want healing. Any privacy invasion that is unnecessary to fulfil that purpose seems unjustified—particularly given that privacy invasions put people in danger.27Ethics, 109(2), 287–337.Anderson, E. S. (1999). What is the point of equality?  Personal responsibility criteria may not be as impartial as they seem at first glance, as they are not neutral with respect to different lifestyles, often falling prey to moralizing social biases.28Journal of Medical Ethics, 44, 53–58; Wilkinson, S. (1999). Smokers' rights to health care: Why the 'restoration argument' is a moralising wolf in a liberal sheep's clothing. Journal of Applied Philosophy, 16(3), 255–269.Friesen, P. (2018). Personal responsibility within health policy: Unethical and ineffective.  We value some risky lifestyles and stigmatize others for reasons having nothing to do with justice. For example, we tend to look more benevolently upon people who freely choose to live in a city with dangerous levels of air pollution than upon alcoholics. In liberal democracies, unless a crime has been committed, there is no legitimate authority to judge a person’s values and life choices except that person herself.Moreover, the proposal that someone other than doctors judge patients’ responsibility does not avoid the criticism of intrusion made to luck egalitarianism. Elizabeth Anderson has argued that assessing people’s responsibility ‘makes demeaning and intrusive judgments of people’s capacities to exercise responsibility and effectively dictates to them the appropriate uses of their freedom’.29Atterbury, op. cit.A final consideration related to the legal trial objection has to do with proportionality and punishment. In criminal systems, the death penalty either does not exist at all, or is reserved for the very gravest crimes. Yet denying someone medical assistance or assigning them lower priority could mean sentencing them to death. Even if one believed that the healthcare system is an appropriate place to determine matters of justice, surely death or serious injury is a disproportionate punishment for not taking better care of oneself. Illness seems like punishment enough. Besides, if we punished the sick, we would only be punishing the unlucky ones, as other people engaging in equally risky practices  do not get sick. What makes the difference between a minority of drinkers who develop cirrhosis and a majority who do not is partly luck .7This paper has argued that assessing personal responsibility in healthcare settings for the allocation of medical resources would be too privacy‐invasive to be morally justifiable. In addition to being an inappropriate intrusion into the private lives of patients, it would put patients’ sensitive data at risk, making data subjects vulnerable to a variety of privacy‐related harms. Even though we allow privacy‐invasive investigations to take place in legal trials, the justice and healthcare systems are not analogous. The duty of doctors and healthcare professionals is to help patients as best they can—not to judge them. If we allow suspected criminals the privilege against self‐incrimination, surely we should not force patients to give information that will be used against their best interest. Patients should not be forced into revealing any more personal information than what is strictly necessary to receive an adequate treatment, and medical data should only be used for appropriate purposes. Medical ethics codes should reflect these data rights. In medical settings, when you are asked personal questions that are irrelevant to your diagnosis or treatment, an appropriate response is: ‘none of your business’.The author declares no conflict of interest.


The aim of this qualitative study of fatherhood group sessions offered as part of child health care services for new parents was to examine the activities, roles, and topics initiated by the leader and describe fathers' participation. Eight new fathers took part in three audio‐ and video‐recorded sessions led by a male leader. Three qualitative content analysis approaches were used to analyze the data. The analysis showed that the group leader took on four leadership roles, mainly that of discussion leader, but also expert, friend, and organizer. When the group leader acted as discussion leader, fathers participated by discussing challenges and changes in their new situation. Challenges were related to raising the child, partner relationships, everyday life, and gender equality. Fathers also discussed changes in their partner relationships and an increased focus on practicalities in daily life. Fatherhood groups can help new fathers form social networks and can create space for fathers to work through challenging topics, such as gender equality in parenting. The discussion leader's choice of role is crucial to creating the space for such discussions. In Sweden, gender equality goals are emphasized in national, government‐led, public health awareness programs  were all biological parents of the children. One father had an upper secondary school education, two were university students, and five had completed university. Two were born in the Middle East and the rest in Sweden. For six fathers, this was their first child, and for the rest, it was their second. Seven cohabitated with their partners, and one lived alone. The participants met for three sessions that adhered in content to the national goals for PE groups: helping parents prepare for the transition to parenthood, increasing knowledge about child development, facilitating co‐parenting relationships, and developing social networks  to the sessions. The participating fathers , (ii) video recording (one session), (iii) direct observation with field notes , and (iv) verbatim transcripts of the three audio recordings. In qualitative research, observational methods provide a thorough description of participants and their activities. Furthermore, they are suitable for capturing the natural setting of clinical practice   Patton, .Audio‐ or video‐recorded material, observations, and field notes were collected by two of the authors for 5 weeks in April and May 2015, and the audio and video recordings were transcribed by one of the authors. The recordings were made with a single camera and an audio recorder positioned prior to the commencement of the sessions. Recorded material varied in length (90–105 min/session) and comprised a total of 4 h and 45 min  and determine the proportion of leader activity and time allowed for fathers' responses (research question 4). The duration of different leader activities was calculated with MAXQDA11. After each step, M.R. and K.F.F. checked and confirmed the analyses.We used three approaches to qualitative content analysis outlined in Hsieh and Shannon, : convent3.6Throughout the study, we adhered to the ethical principles of the British Psychological Society : respect44.1discussion leader, expert, friend, and organizer . He offered a list of contact information to participants, gave homework assignments, and initiated planning for independent group meetings: “Does the group intended to continue meeting? Is one of you willing to be responsible for that?”4.2In the first and the last group sessions, the leader spent most of his time – 35% to 50% – in his role as discussion leader. The fathers had the opportunity to speak between half and two‐thirds of the total time at these sessions , family, partner time, individual free time, and sleep. Lectures and conversations were the main teaching techniques. The role that the leader adopted and the topic he presented led to differing responses from the fathers. Responses ranged from quiet listening to active participation via discussing, reflecting, making statements, and asking questions Table .4.3In their verbal responses to topics initiated by the leader, fathers took up perceived challenges and changes Table .4.4Fathers discussed several challenges, such as how to manage and raise their child, how to handle their relationship with their partner, everyday life, and aspects of gender equality.4.4.1Challenges that fathers brought up included how to provide the best care for their child, how to raise their child, and how to interpret and understand their child's personality. The fathers discussed the anxiety they felt about their child's overall health and well‐being when the child was not eating or sleeping properly. They asked questions such as the following during the discussion: “How is it possible to manage everything when you have a second child?” (Father 1), and “How is it possible to raise a baby girl to become a strong and independent individual?” (Father 2).4.4.2Fathers discussed how challenging it was to get communication with their partners to work and described how this difficulty led to conflicts almost every day: “We have disputes about minor things. We never had that many conflicts before!” (Father 3). Fathers could also perceive that their partners had unspoken expectations. It was especially hard to handle these expectations when they and their partners were short on sleep and did not have enough time with each other: “Your partner expects you to be able to interpret thoughts, needs, and feelings!” (Father 3).One participant said that his partner had gone through a lot of physical challenges during pregnancy and childbirth. He therefore stressed the importance of showing understanding, paying attention, and being gentle.4.4.3Fathers brought up a number of everyday challenges, such as achieving balance in life. Balancing family life, working life, and personal time caused constant feelings of stress and a bad conscience at home and at work. One father explained, “I never know if I'm doing the right thing. I have bad conscience since I'm not at home together with them [the mother and child]. At work, I feel stressed by the need to get home as soon as possible” (Father 1). Other challenges included structuring life, managing planning, solving everyday problems, and getting routines to work: “Before we were structured, we had a plan and could get things done. But all that collapsed when the baby came” (Father 5).4.4.4Some fathers brought up their belief that there is a difference between mothers and fathers. They described mothers as comforters, the ones who know the routines and what the child needs  and fathers as entertainers, the ones who make funny faces to get the child to laugh.It was challenging to take equal responsibility for the child and household work. One father stressed the importance of avoiding the traditional man's trap of working longer than normal. The men then discussed the dangers of the traditional woman's trap, taking full responsibility for the child and housework. “I have female friends who are active feminists fighting for equality between women and men,” said one participant. “After they had their children, they stayed at home, took most of the responsibility, and used all of the paid parental leave [did not divide the paid parental leave equally with their partners]” (Father 2).The fathers accepted that given the importance of breastfeeding, it would be hard for them to take the first part of parental leave. However, they stressed the need for parents to make equal use of parental leave in order to spend equal time with their child. They brought up a number of factors outside their immediate control that made it hard to achieve this goal, including social structure, family budget, and salaries. One said, “The way things turn out depends on the social structure in society. It's common for women to take the majority [of parental leave], since in general their salary is lower” (Father 6).All the participating fathers had attended traditional PE groups with their partners as part of antenatal care. They discussed the advantage of continuing to attend such groups, which might promote the exchange of information, experiences, and opinions with other mothers and fathers. Moreover, it would also provide an opportunity to ask a health care professional questions about a variety of topics, which could reduce parental anxieties and worries. One father joked that if you attend a PE group, “You don't need to tire out your friends with questions and worries regarding your child” (Father 4). On the other hand, one father problematized attendance: “Once my partner and I attended a PE group at the CHC services. I was the only man there. I felt different, uncomfortable, and unequal” (Father 6).The fathers expressed a willingness to continue holding independent fatherhood group meetings since they felt it was good to meet and discuss aspects of fatherhood.4.5Fathers discussed changes that had come with parenthood, such as changes to the couple relationship. The most significant change in the fathers' relationship with their partners was becoming closer and more connected because of their joint parenthood “project.” They also explained that their relationship had shifted to focus on everyday practicalities, which they perceived as dominating life. One father stated that his partner had changed. “She's always here and now. When [the baby] has just fallen asleep, I want to take advantage of it, relax and slow down…. Then she says: lay him down and start making dinner. She's become so practical” (Father 3).The fathers also described a stronger connection to their immediate and extended families. For example, after becoming parents they regarded meeting and celebrating holidays together with the extended family as more fun. One father said, “With a child, the Christmas celebration will change – there will be more joy and fun. Santa Claus can visit again” (Father 4).5Audio and video recordings revealed that the leader took on four different roles. When he adopted the role of discussion leader, he created time and space for discussions. In this role, he also strove to create intragroup trust and the prerequisites for active and open response by stressing the importance of confidentiality and the value of sharing experiences. Fathers responded by discussing challenges and changes in their new situation. The results showed that the topics and activities in the fatherhood group sessions followed the national guidelines for PE groups .All authors meet the criteria for authorship, have contributed significantly, and have approved the final article.