Abstract

The ochlocratic trap is the tendency to have moral decisions conform to popular majority opinion regardless of their ethical implications. This decision-making method in bioethics can significantly impede moral progress, weakening the foundation for sustainable healthcare systems. Instead of allowing popular opinion to form the basis of our morality, the scientific method can provide a framework for making strong ethical decisions. The consequences of weak morality are profound, resulting in poorly sustainable systems lacking human empathy and economic viability. Treating ethical issues like scientific problems can foster a more rigorous, evidence-based discussion, leading to better medical care globally.

Keywords: Ochlocratic Trap; Bioethics; Medical Ethics; Healthcare Providers

Article Type

Review Article

Introduction

The term “ochlocratic trap” is derived from the Greek term “ochlos,” which translates to “crowd.” This term refers to the potentially problematic scenario when the majority’s views unduly influence decision-making, potentially leading to ethically compromising situations. It can occur when public opinion unduly influences decisions or when majority opinion within the healthcare field results in a herd mentality [1]. This issue becomes especially conspicuous within medical ethics, where historical incidents are a stark reminder of the disastrous outcomes that can ensue when the majority’s acceptance overrides ethical considerations. The ochlocratic trap is letting the mob rule moral decision-making.

One of the most poignant instances is the infamous Tuskegee syphilis experiment, conducted between 1932 and 1972. In this study, hundreds of African-American men were denied treatment for syphilis to study the natural progression of the disease. Despite the gross violation of ethical principles, including informed consent and non-maleficence, this experiment continued for an alarming 40 years [2]. A significant portion of the medical community initially overlooked these violations, arguably falling into the ochlocratic trap, as the study had gained acceptance among the majority. A similar occurrence occurred during the US government’s human radiation experiments during the Cold War era. Under the guise of medical treatment, scientists exposed unsuspecting patients to radiation to understand its effects. This included injecting pregnant women with radioactive iodine and feeding mentally disabled children oatmeal laced with radioactive iron, all conducted under the majority’s acceptance at the time [3,4]. The ethical transgressions of these experiments, like the Tuskegee experiment, were initially ignored, demonstrating the potency of the ochlocratic trap. In both these cases, an ochlocratic mindset allowed the majority’s acceptance to justify gross ethical misconduct. These examples serve as sobering reminders of the detrimental impact of the ochlocratic trap on medical ethics and the importance of individual critical judgment in healthcare decision-making.

Morality and Sustainability

A healthcare system that upholds ethical principles is more likely to be sustainable in the long run. When healthcare providers and policymakers prioritize ethical decision-making, it can lead to better patient outcomes, increased trust in the system and improved overall quality of care. On the other hand, a lack of ethical considerations, such as corruption or discrimination, can undermine the sustainability of a healthcare system by eroding public trust and hindering equitable access to care.

Incorporating sustainability into healthcare is a moral principle that requires balancing immediate needs with long-term impacts. For example, rapid digitization enables more efficient care delivery and risks environmental harm and ethical issues from excessive reliance on technology [5]. While digitization can increase the performance of healthcare delivery systems, if poorly implemented, it can create moral hazard through improper implementation or environmental harm [6,7]. On the one hand, fairness suggests meeting pressing needs and maximizing health benefits now, but sustainability requires conserving resources for future generations. Resolving this tension is challenging. Short-term procurement logistics can undermine long-term system stability by wasting resources on ineffective treatments or depleting collective goods like antibiotics. However, discounting future impacts seems morally questionable, too.

Deliberating these trade-offs openly using accountability for reasonableness principles is essential but complex for sustainability issues regarding such issues as aging, decentralization and resource utilization [8]. Predicting long-term scientific, economic and social changes is difficult. Ultimately, sustainability necessitates expanding our moral view beyond today’s patients to maintain a health-enabling environment. However, balancing those duties against immediate needs poses profound philosophical dilemmas. Still, ignoring sustainability risks the viability of healthcare systems, especially ones that are economically unstable or unable to meet needs reasonably over time. More interdisciplinary cooperation on ethics and sustainability is critical for developing healthcare that is morally and environmentally viable [9].

Avoiding the ochlocratic trap by applying a scientific framework to these issues allows a thorough analysis without the flighty whims of emotion, peer pressure, or cancel culture. While taking into account emotional impacts, solid decision-making requires a more structured approach. The scientific method provides the foundation for this by starting out with a hypothesis, establishing a method to test the hypothesis, examining the results and then coming to a conclusion.

The Impact of Popular Opinion on Economic Viability

Popular opinion plays a significant role in shaping public policies [10]. In health care, popular opinion can influence economic viability by shaping resource allocation, affecting stigma reduction efforts and shaping the cost-effectiveness of healthcare interventions. While popular opinion can help inform project managers on issues important to the community, it can also run contrary to sustainable project development [11]. It’s a mixed bag. This implies that a morally just healthcare system needs to incorporate public opinion yet not let public opinion be the only measure of economic viability or sustainability.

Application of the Scientific Method to Bioethics

Medical ethics, like science, is fundamentally an endeavor to discover truth through rigorous investigation and reasoning. Practicing clinicians face a diverse array of complex ethical dilemmas that call for decision-making that transcends merely following the majority opinion of the general public. Applying the scientific method to bioethics is a four-step process as follows:

1. Hypothesis: a hypothesis around the ethical issue of concern is formulated
2. Methods: decisions are made on what data to collect and how to analyze
3. Results: the data and analysis are summarized
4. Conclusions: the final conclusion may be left to the leader or be a team vote

Case Studies

Organ Allocation

The conflict between popular opinion and moral judgment arises in organ allocation, which embodies the need for an evidence-based approach akin to scientific inquiry. For example, in the US, every day, an average of 17 patients succumb to their illnesses while waiting for an organ transplant due to a stark mismatch between supply and demand. As of July 2023, over 93,000 people are on the national transplant waiting list in the US Yet, in 2022, only about 25,000 transplants were performed. While this was a new annual record, most patients must wait about 4 years before undergoing renal transplantation [12,13]. Determining which patients should receive available organs necessitates a delicate balance between fairness (ensuring equal access) and utility (maximizing the benefits of each organ transplant). While artificial intelligence systems may help, their primary purpose is prioritizing who will and who won’t get access to limited resources [14].

Mandatory Vaccination

Another ethical dilemma surrounding renal transplantation during the COVID-19 epidemic was whether or not it was ethical to require vaccination before transplantation. About a third of transplant centers had the requirement. In this case, one analysis of newspaper articles on the topic found that the pros and cons of vaccination were equally discussed [15]. The authors of this analysis felt that the popular press gave a “false balance” by presenting both sides equally instead of emphasizing the benefits of vaccination more heavily. The question remains: are the minority of centers that require vaccination morally correct, or are they falling into the ochlocratic trap of following the majority opinion of medical professionals? Or, on the other hand, are the majority of centers that did not institute an absolute vaccination requirement morally correct, or did they fall into the ochlocratic trap of following majority public opinion? Using the scientific method to resolve this ethical issue requires making a hypothesis, rigorously collecting data and having an open debate without censorship. Finally, a critical analysis of the points raised by the debate is carefully analyzed without respect to the majority opinion.

End-of-life Care

Another example that mirrors the meticulous scrutiny demanded in science is the ethical decision-making process in end-of-life care. Approximately 1.2 million individuals in the US are receiving hospice care as of 2023 and medical professionals grapple with the responsibility of striking a balance between preserving life and respecting a patient’s autonomy, often with significant quality of life implications. The patient’s desires and the medical prognosis must be weighed to reach ethically sound decisions. While public opinion in specific locales may favor euthanasia in some cases, is the decision to go ahead an ochlocratic trap or sound ethical practice?

Physician Assisted Euthanasia

Consider the following scenario to illustrate how the scientific method can be applied to an ethical dilemma in healthcare. In this scenario, a palliative care physician faces a patient diagnosed with terminal cancer suffering severe pain. The patient has expressed interest in physician-assisted dying-a practice that personally conflicts with the physician’s moral stance. To navigate this complex issue, the physician can engage in the four-step scientific process:

1. Hypothesis: The physician proposes an initial hypothesis: “Despite my beliefs against physician-assisted dying, it may be ethically permissible if it alleviates the patient’s suffering and aligns with their personal autonomy”
2. Methods: The physician sets up a structured method for inquiry. First, data will need to be gathered. The physician begins by gathering all pertinent information to validate or refute the hypothesis. This encompasses the clinical aspects, such as patient prognosis and quality of life and extends to ethical guidelines, legal parameters and societal perspectives. The physician also considers the views of colleagues, the patient’s family and the broader medical community. Then, the physician designs a structured way of analyzing the data. One good way is the six thinking hats method, where a problem is viewed through several different lenses, including emotional, positive, creative, negative, objective and logical [16,17]. A decision is made regarding who will make the final judgment
3. Results: Armed with the data and analysis method, the physician follows the process and resolves the ethical dilemma. After ensuring that accurate data has been collected, participants in the analysis will then look at it from several angles and then come to a conclusion based on their analysis. While public opinion may be a consideration, it rarely will be the only consideration
4. Conclusion: The feedback and perspectives from the debate prompt the physician to reassess their initial hypothesis. Depending on the discourse, they may need to adjust their ethical stance regarding physician-assisted dying in this particular case

Resource Allocation

Let’s consider another example: the case of prioritizing patients for ICU beds during the COVID-19 pandemic when demand far exceeded supply.

1. Hypothesis: The healthcare team might hypothesize, “The most critically ill patients should be given priority for ICU beds to maximize the utility of limited resources”
2. Methods: The team agrees upon what data is most important to gather and how it will be collected. For example, it may determine patient prognosis, age and comorbidities, along with available resources, are essential. The team will then also agree on a structured method of analysis. This may include a numerical statistical analysis and an analysis of the ethical implications
3. Results: The team works through the process. Data is analyzed numerically and the ethical issues undergo a structured debate. The group considers ethical principles like justice, utility and individual rights
4. Conclusion: Depending upon their agreed-upon methods, the team may have the leader decide on the final conclusion, or they may have the group vote on a conclusion

These case examples underscore the usefulness of a scientific approach in navigating ethical challenges in healthcare. The scientific approach to bioethics starts out with a hypothesis, then complex data is collected and the issue is openly discussed. Finally, the most ethical course of action can be decided. Clinicians must constantly be alert for groupthink bias and ask themselves if they fall into an ochlocratic trap. These examples underscore that medical ethics requires a depth of analysis and an evidence-based approach parallel to scientific inquiry that goes beyond merely surveying public opinion. The goal in each case is to arrive at ethically sound, evidence-based decisions that respect individual rights and overall societal good rather than merely following the majority’s view. Hence, medical ethics, much like science, must guard against the pitfalls of the ochlocratic trap. While following popular opinion is safe since most people agree with the action, history has shown that blindly following public opinion can lead to unethical behavior.

The Necessary Evolution of Bioethics

Scientific understanding is fluid, ever-evolving and continuously refined as new evidence emerges. Similarly, ethical considerations are not static but must adapt and evolve in response to societal changes, new discoveries, technological advancements and our growing understanding of diverse cultural perspectives and values. This dynamism underpins the interplay between scientific knowledge and ethics. It’s crucial for physicians and healthcare providers to ensure that their ethical deliberations and actions are evidence-based. As technology advances, it is possible to do many things that may not be ethical. For example, should we order another CT scan “just to be sure” even when the evidence says not to? Should the standard of care change and if yes, are we responsible for changing only after an expert position statement is published? Or are we ethically bound to change earlier? Following the scientific approach to ethics helps resolve these questions. Technology is constantly evolving and as healthcare professionals, we must take the lead in examining the bioethical implications. For example, how do we ensure that genetic editing technologies such as CRISPR follow ethical principles? In the case of medical research, we had to wait over 50 years for bioethical principles to be put in place. With the fast pace of technological advances, we must be able to address ethical issues faster and with the greater certainty that comes from a scientific approach. There is an urgent need for the field of medical ethics to remain responsive to evolving scientific advancements. It’s not merely about adhering to a fixed set of ethical principles but requires a scientific approach that continuously reevaluates and refines them in light of new evidence. Ultimately, the interplay between science and ethics should serve the overarching goal of improving patient care, promoting health equity and ensuring respect for all individuals’ rights and dignity.

Conclusion

By embracing a scientific methodology in medical ethics, physicians and other healthcare workers can effectively navigate and avoid the pitfalls of the ochlocratic trap. The result is improved morality, better healthcare, more viable economics and increased long-term sustainability. This approach empowers people to make ethical decisions grounded in evidence. This active readiness to challenge prevailing norms and beliefs is fundamental to science and ethical inquiry. While the bedrock principles of ethics – autonomy, beneficence, non-maleficence and justice – remain as guiding lights, the field of bioethics cannot afford to be static. It must continuously evolve and adapt in response to technological advances, societal changes and expanding medical knowledge. For instance, the advent of precision medicine, artificial intelligence in healthcare and genetic editing technologies like CRISPR have introduced new ethical dilemmas that require thoughtful examination. Incorporating scientific principles into bioethics – such as formulating hypotheses, gathering data, conducting rigorous analysis and refining beliefs based on evidence -brings a systematic and rigorous approach to ethical decision-making. It promotes transparency and facilitates the inclusion of diverse perspectives in ethical discussions, thereby promoting fairness and inclusivity. As we move further into the era of digital medicine and personalized care, adopting a scientific approach to bioethics becomes increasingly vital. This methodology will play a key role in upholding and enhancing our commitment to patient-centered care, ensuring that we maintain the highest standards of medical ethics while adapting to the rapidly changing healthcare landscape. It will guide us in balancing the exciting possibilities of innovation with the timeless values of compassion, respect and dignity at the heart of the medical profession.

Conflict of Interest

The author has no conflict of interest to declare.

References

1. Heston TF. The ochlocratic trap. MSLaneous. 1989;18.
2. Brandt AM. Racism and research: the case of the Tuskegee syphilis study. Hastings Cent Rep. 1978;8(6):21-9.
3. United States advisory committee on human radiation experiments. the human radiation experiments. Oxford University Press. 1996.
4. Stephens S. Nationalism, nuclear policy and children in cold war America. Childhood. 1997;4(1):103-23.
5. Sharma GD, Yadav A, Chopra R. Artificial intelligence and effective governance: A review, critique and research agenda. Sustainable Futures. 2020;2:100004.
6. Heston TF, Khun C. The good, the bad and the ugly of chatgpt in medical education. SSRN J. 2023.
7. Chopra R, Agrawal A, Sharma GD, Kallmuenzer A, Vasa L. Uncovering the organizational, environmental and socio-economic sustainability of digitization: evidence from existing research. RMS. 2023.
8. Daniels N. Just health: meeting health needs fairly. Cambridge University Press. 2007.
9. Venkatapuram S. Global justice and the social determinants of health. Ethics Int Aff. 2010;24(2):119-30.
10. Burstein P. The impact of public opinion on public policy: a review and an agenda. Polit Res Q. 2003;56(1):29-40.
11. Valentin V, Bogus SM. Assessing the link between public opinion and social sustainability in building and infrastructure projects. J Green Building. 2015;10(3):177-90.
12. Michas F. Total active doctors in the US by state 2023. [Last accessed on: October 14, 2023]

https://www.statista.com/statistics/186269/total-active-physicians-in-the-us/

13. 2022 organ transplants again set annual records. 2023. [Last accessed on: October 14, 2023]

https://unos.org/news/2022-organ-transplants-again-set-annual-records/

14. Heston TF, Norman DJ, Barry JM, Bennett WM, Wilson RA. Cardiac risk stratification in renal transplantation using a form of artificial intelligence. Am J Cardiol. 1997;79(4):415-7.
15. Zenone M, Caulfield T. Newspaper coverage of COVID-19 vaccination requirement for organ transplant. JAMA Netw Open. 2022;5(12):e2248800.
16. De Bono E. Six thinking hats. Boston: little brown and company. 1985.
17. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8^th Oxford University Press. 2019.