Editorial

This special section of Genes and Nutrition presents a baseline analysis of ethical and legal issues undertaken within the EU FP7 research project Food4Me, which investigates the feasibility today of the vision for delivering personalized nutrition. Four major topics are addressed: Do we know enough for offering personalized nutritional advice? How can personal, cultural, and scientific perspectives on food and health be integrated? How does personalized nutrition affect individual autonomy? Which urgent ethical and legal matters stand out when personalized nutrition is commercialized?     

Do we know enough? A scientific and ethical analysis of the basis for genetic-based personalized nutrition

This article discusses the prospects and limitations of the scientific basis for offering personalized nutrition advice based upon individual genetic information. Two divergent scientific positions are presented, with an ethical comment. The crucial question is whether the current knowledge base is sufficiently strong for taking an ethically responsible decision to offer personalized nutrition advice based upon gene–diet–health interaction. According to the first position, the evidence base for translating the outcomes of nutrigenomics research into personalized nutritional advice is as yet immature. There is also limited evidence that genotype-based dietary advice will motivate appropriate behavior changes. Filling the gaps in our knowledge will require larger and better randomized controlled trials. According to the second position, personalized nutrition must be evaluated in relation to generally accepted standard dietary advice—partly derived from epidemiological observations and usually not proven by clinical trials. With personalized nutrition, we cannot demand stronger evidence. In several specific cases of gene–diet interaction, it may be more beneficial for individuals with specific genotypes to follow personalized advice rather than general dietary recommendations. The ethical comment, finally, considers the ethical aspects of deciding how to proceed in the face of such uncertainty. Two approaches for an ethically responsible way forward are proposed. Arguing from a precautionary approach, it is suggested that personalized dietary advice should be offered only when there is strong scientific evidence for health effects, followed by stepwise evaluation of unforeseen behavioral and psychological effects. Arguing from theoretical and applied ethics as well as psychology, it is also suggested that personalized advice should avoid paternalism and instead focus on supporting the autonomous choice of each person.     

Coercive treatment and autonomy in psychiatry

There are three lines of argument in defence of coercive treatment of patients with mental disorders: arguments regarding (1) societal interests to protect others, (2) the patients' own health interests, and (3) patient autonomy. In this paper, we analyse these arguments in relation to an idealized case, where a person with a mental disorder claims not to want medical treatment for religious reasons. We also discuss who should decide what in situations where patients with mental disorders deny treatment on seemingly rational grounds. We conclude that, in principle, coercive treatment cannot be defended for the sake of protecting others. While coercive actions can be acceptable in order to protect close family and others, medical treatment is not justified for such reasons but should be given only in the interest of patients. Coercive treatment may be required in order to promote the patient's health interests, but health interests have to waive if they go against the autonomous interests of the patient. We argue that non-autonomous patients can have reasons, rooted in their deeply-set values, to renounce compulsory institutional treatment, and that such reasons should be respected unless it can be assumed that their new predicaments have caused them to change their views.     

Left–Right-Position,party affiliation and regional differences explain low COVID-19 vaccination rates in Germany

Established vaccine hesitancy measurement instruments, such as the Vaccine Hesitancy Determinants Matrix, are not sufficiently equipped to adequately and consistently measure political and ideological attitudes. Focusing on Germany, which is a particularly interesting case since it witnessed the establishment of the by far most well-organized and sustained ‘anti-Covid’ movement in Europe, this quantitative study explores the impact of political ideology and partisanship on the degree of vaccine hesitancy based on four surveys (February—October 2021) among more than 30,000 individuals. We demonstrate that party affiliation, political ideology and region of residence all impact vaccine hesitancy. In fact, they turn out to have a greater impact than two factors often analysed with respect to vaccine hesitancy: gender and educational background. Further interaction models show that the effect of political ideology on vaccine hesitancy is moderated by age, gender and region of residency. For instance, while the more rightwing a young individual is, the more hesitant they are towards SARS-CoV-2 vaccination—for older individuals, this is not the case. Our findings are relevant for future investigators measuring vaccine hesitancy and policy makers contemplating the differential impact of complex public health interventions: as the impact of political and ideological attitudes on vaccine hesitancy are not adequately captured by established vaccine hesitancy measurement instruments, we recommend its modification to include a clear and harmonised definition of the political-ideological dimension of vaccine hesitancy together with pre-validated measurement items that improve future studies. In addition, we reason that vaccine hesitancy, while being an outcome of complex socio-political factors, is in itself an indicator for societal cohesion and anomie, the degree of which is associated with trust in (health) policy makers, (public) health authorities, health service providers, etc. Therefore, we further recommend that vaccine hesitancy questions should be integrated in pertinent national surveys.     

Ethical issues raised by personalized nutrition based on genetic information

Four principles are taken as basis for the ethical analysis: autonomy, nonmaleficence, beneficence, and justice. Health is understood as a limited aspect of wellbeing. Food is understood as an important aspect of wellbeing, not only an instrument for health. Modern society is characterized by a tendency to identify wellbeing with external rather than subjective circumstances, to identify wellbeing with health, and to create exaggerated health expectations. Based upon this understanding, aspects of personalized nutrition are discussed: genetic testing, counselling, and development of special dietary products. Today the predictive value of genetic tests for personal nutrition is limited, and experimental at best. Recommendations for the future: Personalized nutrition must be based on solid knowledge. Phenotypic analyses should be used when adequate. When a genetic test can have a clear advantage, this should be preferred. Opportunistic screening should only be used when clearly beneficial. Specially trained persons should collect information from genetic tests and carry through councelling on a personal basis. Marketing of genetic tests directly sold to the public should be discouraged. Development of special products for personalized nutrition may be necessary in some cases. However, this may also lead to a medicalization of diet.     

Sick autonomy

Complex social and economic forces have placed patient autonomy at the center of medical ethics, and thereby displaced an older ethic of physician beneficence. This development arose, and is sustained, by waning trust in the traditional doctor-patient relationship. As patients have increasingly become clients and consumers, a contract basis for medical care has put the ancient covenant of care in jeopardy. Here, a philosophical approach to harmonize the apparent conflicting claims of patient autonomy and physician beneficence is offered by demonstrating that autonomy need not be understood as protecting a threatened identity. If persons are regarded as atomistic, certain defensive notions of individualistic rights-based autonomy prevail; if a relational construction of personal identity is employed instead, then respect for autonomy becomes part of a wider morality of relationship and care. By reconfiguring trust within this latter understanding of personhood, bioethics better balances its concerns over choices and actions with those of relationship and responsibility. Neither atomistic autonomy nor the ethics of responsibility can claim hegemony, for they are mutually interdependent, and a complete account of medicine's moral axis requires that they be integrated. This reorientation is crucial for reasserting the ethos of clinical medicine, whose fundamental mandate remains the care of others.     

The ‘Obligation’ to Screen and its Effect on Autonomy

In the United States, disease screening is offered to the public as a consumer service. It has been proposed that the act of “consumption” is a manifestation of agency and that the decision to consume is an exercise of autonomy. The enthusiasm of the American public for disease screening and the expansion in the demand for all sorts of disease screening in recent years can be viewed as an expression of such autonomy. Here, we argue that the enthusiasm for disease screening witnessed in the American public today may be more a reflection of the constraint on autonomy than its facilitation. It is our opinion that the articulation of socio-historical processes has contributed to a moral imperative which is reflected in the decision making of individuals around disease screening. We suggest medical and health professionals have a responsibility to facilitate the exercise of individual autonomy in health care decision making as an integral component of professional obligation. These professionals need to problematise healthcare activities that constrain individual autonomy.     

Consumers on the Internet: ethical and legal aspects of commercialization of personalized nutrition

Consumers often have a positive attitude to the option of receiving personalized nutrition advice based upon genetic testing, since the prospect of enhancing or maintaining one’s health can be perceived as empowering. Current direct-to-consumer services over the Internet, however, suffer from a questionable level of truthfulness and consumer protection, in addition to an imbalance between far-reaching promises and contrasting disclaimers. Psychological and behavioral studies indicate that consumer acceptance of a new technology is primarily explained by the end user’s rational and emotional interpretation as well as moral beliefs. Results from such studies indicate that personalized nutrition must create true value for the consumer. Also, the freedom to choose is crucial for consumer acceptance. From an ethical point of view, consumer protection is crucial, and caution must be exercised when putting nutrigenomic-based tests and advice services on the market. Current Internet offerings appear to reveal a need to further guaranty legal certainty by ensuring privacy, consumer protection and safety. Personalized nutrition services are on the borderline between nutrition and medicine. Current regulation of this area is incomplete and undergoing development. This situation entails the necessity for carefully assessing and developing existing rules that safeguard fundamental rights and data protection while taking into account the sensitivity of data, the risks posed by each step in their processing, and sufficient guarantees for consumers against potential misuse.     

Can people detect the trustworthiness of strangers based on their facial appearance?

Although cooperation can lead to mutually beneficial outcomes, cooperative actions only pay off for the individual if others can be trusted to cooperate as well. Identifying trustworthy interaction partners is therefore a central challenge in human social life. How do people navigate this challenge? Prior work suggests that people rely on facial appearance to judge the trustworthiness of strangers. However, the question of whether these judgments are actually accurate remains debated. The present research examines accuracy in trustworthiness detection from faces and three moderators proposed by previous research. We investigate whether people show above-chance accuracy (a) when they make trust decisions and when they provide explicit trustworthiness ratings, (b) when judging male and female counterparts, and (c) when rating cropped images (with non-facial features removed) and uncropped images. Two studies showed that incentivized trust decisions (Study 1, n = 131 university students) and incentivized trustworthiness predictions (Study 2, n = 266 university students) were unrelated to the actual trustworthiness of counterparts. Accuracy was not moderated by stimulus type (cropped vs. uncropped faces) or counterparts' gender. Overall, these findings suggest that people are unable to detect the trustworthiness of strangers based on their facial appearance, when this is the only information available to them.     

Individualization,inequality, and labor: a qualitative approach

In this paper, we show how we came to explore Beck’s theory of individualization in the light of a qualitative study of livelihood strategies in post-2008 Spain and Cyprus. We observed that experiences of downward social mobility in contexts of welfare retreat and precarious labor conditions were compelling people to build marketed individualities and to create individual biographies with recourse to a highly individualized rhetoric. However, analysis of a very diverse sample of subjects from different socio-economic backgrounds showed us that individualization theory must be conceptualized within a framework of social structures, and that Beck’s individualization theory fails to recognize its persistence in contemporary societies. We therefore propose looking at individualization as a contemporary process through which class differences are expressed. Only in this way can it serve as a useful theoretical tool with which to understand the workings of contemporary capitalism and the ways in which new values and moral frameworks are being formed.     

The social context of well-being

Large samples of data from the World Values Survey, the US Benchmark Survey and a comparable Canadian survey are used to estimate equations designed to explore the social context of subjective evaluations of well-being, of happiness, and of health. Social capital, as measured by the strength of family, neighbourhood, religious and community ties, is found to support both physical health and subjective well-being. Our new evidence confirms that social capital is strongly linked to subjective well-being through many independent channels and in several different forms. Marriage and family, ties to friends and neighbours, workplace ties, civic engagement (both individually and collectively), trustworthiness and trust: all appear independently and robustly related to happiness and life satisfaction, both directly and through their impact on health.     

Parent Civic Beliefs,Civic Participation,Socialization Practices,and Child Civic Engagement

We examined civic engagement in middle childhood and the degree to which parents’ civic beliefs (i.e., social trust and civic efficacy), civic participation, and socialization practices were associated with indicators of children's civic engagement (i.e., social responsibility and civic values). Survey data were collected from 359 racially, ethnically, and economically diverse upper elementary students and their parents from six schools in Southern California. The results of path analyses indicated that higher levels of parent social trust were associated with higher levels of community responsibility and civic values in children. Additionally, parent social trust, civic efficacy, and civic participation were indirectly associated with children's community responsibility and civic values through children's perception of their parents as civic role models. Findings suggest that parents’ civic beliefs and civic participation are meaningful to children's civic engagement.     

Trust,Identity, and Civic Hope

This article concerns the phenomenon of trust-in others who are familiar and in humanity in general. I make a case that the foundations of both forms of trust are rooted in formative experiences. Trust springs from the sense of security we develop in early nurturing relationships. In friendships and peer relationships we learn about loyalty, accountability, and the reciprocity between trust and trustworthiness. However, trust among friends is an insufficient basis for social trust. To nurture a faith in humanity, children need to interact and cooperate with people who are different from them and values of equality, tolerance, and empathy have to be high priorities in their families.     

The Effects of Within- and Between-Group Competition on Trust and Trustworthiness among Acquaintances

Several studies have indicated that between-group competition is a key stimulator of trust and trustworthiness. Another important but neglected type of competition may also affect trust and trustworthiness: within-group competition, especially competition among acquaintances. The present study investigated the effects of both within- and between-group competition on trust and trustworthiness, which were measured using an investment game played by acquaintances. We found that, compared to the participants'' performance in the non-competition condition, when individuals were motivated to compete with their in-group members or the other groups for financial rewards, they demonstrated more trust. When individuals were motivated to compete with their in-group members, they exhibited lower trustworthiness than in non-competition and between-group competition. In addition, within-group competition decreased the trustor''s payoff while both within- and between- group competition increased the trustee''s payoff. Finally, we found that males trusted their group members more than females.     

A personal view on systems medicine and the emergence of proactive P4 medicine: predictive, preventive, personalized and participatory

Systems biology and the digital revolution are together transforming healthcare to a proactive P4 medicine that is predictive, preventive, personalized and participatory. Systems biology - holistic, global and integrative in approach - has given rise to systems medicine, a systems approach to health and disease. Systems medicine promises to (1) provide deep insights into disease mechanisms, (2) make blood a diagnostic window for viewing health and disease for the individual, (3) stratify complex diseases into their distinct subtypes for a impedance match against proper drugs, (4) provide new approaches to drug target discovery and (5) generate metrics for assessing wellness. P4 medicine, the clinical face of systems medicine, has two major objectives: to quantify wellness and to demystify disease. Patients and consumers will be a major driver in the realization of P4 medicine through their participation in medically oriented social networks directed at improving their own healthcare. P4 medicine has striking implications for society - including the ability to turn around the ever-escalating costs of healthcare. The challenge in bringing P4 medicine to patients and consumers is twofold: first, inventing the strategies and technologies that will enable P4 medicine and second, dealing with the impact of P4 medicine on society - including key ethical, social, legal, regulatory, and economic issues. Managing the societal problems will pose the most significant challenges. Strategic partnerships of a variety of types will be necessary to bring P4 medicine to patients.     

Rationale for an integrated approach to genetic epidemiology

Conclusion: Genetic knowledge is now in the public domain and its interpretation by the media and the citizens brings the issues into the public forum of discussion for the necessary ethical, legal and socio-cultural evaluation of its application. Science is being perceived by some as dangerous and as requiring international regulation. Others feel that genetic knowledge will be the breakthrough that will permit medical progress and individual autonomy with regards to personal health and lifestyle choices. The mapping of the human genome has already yielded valuable information on an increasing number of diseases and their variants. Prevailing popular and journalistic archetypes ("imaginaires") used in the media are perceived by the producers as slowing down the possible application of genetic knowledge. The answers to these dilemmas are not readily apparent nor are they prescribed by classical philosophy of medicine. Since genetic knowledge eventually resides with the individual who carries the genes of disease and/or susceptibility, a logical approach to integration of this knowledge at a societal level would seem to reside with individual education and decision-making. The politics of the ensuing social debate could transform the current social contract since an individual's interests need to be balanced against those of his or her immediate family in the sharing of information. The ethical foundations of such a contract requires the genetic education of "Everyone" as a matter of urgent priority. Genetic education should not serve ideological power struggles between the medical establishment and the ethical-legal alliance. Instead, it should ensure the transfer of knowledge to physicians, to patients, to users, to planners, to social science and humanities researchers and to politicians, so that they may make "informed" and free decisions....     

Reflections on determining competency

Psychiatrists are the health care professionals most frequently called upon to determine the competency of a patient to refuse treatment. The motives for determining competency vary in morally significant ways. This paper explores what I term 'the ideal motivational situation' for determining a patient's competency: a desire to respect the patient's autonomy, a desire to promote the patient's overall best interests, and a belief that when these two motives conflict the patient's autonomy should not be dismissed out of hand as a partial patient interest which is naturally outweighed by the totality of his or her interests. I claim that in a liberal, democratic society autonomy ought to trump best interests and be the sole criterion of patient competence. I conclude by offering an essentially aesthetic criterion for determining autonomy.     

Evolution of trust and trustworthiness: social awareness favours personality differences

Interest in the evolution and maintenance of personality is burgeoning. Individuals of diverse animal species differ in their aggressiveness, fearfulness, sociability and activity. Strong trade-offs, mutation-selection balance, spatio-temporal fluctuations in selection, frequency dependence and good-genes mate choice are invoked to explain heritable personality variation, yet for continuous behavioural traits, it remains unclear which selective force is likely to maintain distinct polymorphisms. Using a model of trust and cooperation, we show how allowing individuals to monitor each other's cooperative tendencies, at a cost, can select for heritable polymorphisms in trustworthiness. This variation, in turn, favours costly 'social awareness' in some individuals. Feedback of this sort can explain the individual differences in trust and trustworthiness so often documented by economists in experimental public goods games across a range of cultures. Our work adds to growing evidence that evolutionary game theorists can no longer afford to ignore the importance of real world inter-individual variation in their models.     

Unfakeable facial configurations affect strategic choices in trust games with or without information about past behavior

Background

Many human interactions are built on trust, so widespread confidence in first impressions generally favors individuals with trustworthy-looking appearances. However, few studies have explicitly examined: 1) the contribution of unfakeable facial features to trust-based decisions, and 2) how these cues are integrated with information about past behavior.

Methodology/Principal Findings

Using highly controlled stimuli and an improved experimental procedure, we show that unfakeable facial features associated with the appearance of trustworthiness attract higher investments in trust games. The facial trustworthiness premium is large for decisions based solely on faces, with trustworthy identities attracting 42% more money (Study 1), and remains significant though reduced to 6% when reputational information is also available (Study 2). The face trustworthiness premium persists with real (rather than virtual) currency and when higher payoffs are at stake (Study 3).

Conclusions/Significance

Our results demonstrate that cooperation may be affected not only by controllable appearance cues (e.g., clothing, facial expressions) as shown previously, but also by features that are impossible to mimic (e.g., individual facial structure). This unfakeable face trustworthiness effect is not limited to the rare situations where people lack any information about their partners, but survives in richer environments where relevant details about partner past behavior are available.