The January-February issue of the Report introduced a number of new features designed to provide opportunities for further give-and-take in our pages. In this issue, we put to use our revamped letters to the editor, Exchange, with a set of commentaries on another of the January-February articles, Daniel Callahan's “Obesity: Chasing an Elusive Epidemic.” Commentaries in Other Voices and special reports are planned and solicited, in consultation with scholars in the field and with the guest editors of the special reports, but our hope is that Exchange will provide an opportunity for unsolicited voices in the Report. Of course, Callahan's controversial article is all too good for drumming up unsolicited commentary: Callahan argued that the rise in obesity requires an aggressive public health campaign that employs some stigmatization of obesity.

The alarming rates of smoking, obesity, and substance abuse pose an enormous challenge for parents and public health officials: how do we prevent children and adolescents from adopting unhealthy behaviors? One new option that may soon be available is the use of nicotine vaccines. Immunological therapies to help smokers stop smoking have shown promise in phase I and II trials; similar therapies could combat smoking addiction before it starts. Nicotine vaccines are distinctive because they confer protection not against infection—the normal target for vaccines—but against enticing pleasures that lead to unhealthy behaviors. As a result, using them preventively in children would be likely to arouse some novel ethical concerns that should be addressed before the vaccines become commonly available and their off-label use as a preventive measure becomes a real option.

In this paper, we consider whether it would be ethical for parents to vaccinate their children against smoking if a nicotine vaccine were to be proven effective as a preventive intervention for children or adolescents. We begin by explaining the current state of nicotine vaccine science and suggesting some likely ethical concerns about allowing parents to have their children receive a vaccine. We then present a preliminary argument for making vaccination permissible, at least if nicotine vaccination substantially reduces the probability that someone subsequently becomes a smoker. We consider a series of possible ethical objections, which are useful for identifying the conditions under which it would be ethical for parents to vaccinate their children against smoking. We conclude that it would be permissible for parents to give their child a nicotine vaccine if the following conditions were met: the vaccine is expected to result in a net benefit to each individual vaccinated, the expected harms from the side effects of the vaccine are lower than the nonvoluntary harms caused by smoking, and there are no other, less manipulative methods available that are as effective at preventing smoking initiation.

By endorsing the use of a vaccine that makes the experience of puffing on a cigarette deeply distasteful, Lieber and Millum have taken the first few tentative steps into a future filled with medical interventions that manipulate individual preferences. It is tempting to embrace the careful arguments of “Preventing Sin” and celebrate the possibility that the profound individual and social costs of smoking will finally be tamed. Yet there is something unsettling about the possibility that parental discretion may be on the cusp of a radical expansion, one that involves a new and unexplored approach to behavior modification.

The report from the Presidential Commission for the Study of Bioethical Issues is clear that the public health services research conducted in Guatemala mid-century was wrong, but its focus on individual responsibilities is inadequate for the structural and institutional factors at the root of that research.

Ethically Impossible”: STD Research in Guatemala from 1946 to 1948, released in September 2011 by the Presidential Commission for the Study of Bioethical Issues, 1 responds to President Obama's request for a “thorough fact-finding investigation” into research carried out by the U.S. Public Health Service in Guatemala from 1946 to 1948. “Ethically Impossible” offers a detailed narrative of what happened in Guatemala and a self-described “unvarnished ethical analysis.” I argue, however, that being “ever vigilant” to prevent exploitation, as well as learning as a society from this past and honoring the memory of Guatemalan victims, requires a more complex ethical analysis than the commission offers in this report. Specifically, we need to identify the structural injustices that innervated the social relations and the institutions fundamental to the moral landscape of this 1940s research, and we need to expand our understandings of moral responsibility accordingly. The report posits three “longstanding and widely accepted moral principles” as the framework for evaluating this research: (1) to treat persons fairly and with respect, (2) not to harm (or risk harming) persons unless the risk is reasonable and the benefit proportional, and (3) not to treat persons as means to others’ ends. As critically important as the three principles are to research ethics writ large, they alone are unfitting tools for addressing the kind of structural and institutional moral factors that are so important in these PHS studies.

An article by Melissa Gymrek and colleagues, published this January in Science, described how the researchers used surname inferences from commercial genealogy databases and Internet searches to deduce the identity of nearly fifty research participants whose supposedly private data were stored in large, publicly available datasets. This news comes just months after the Presidential Commission for the Study of Bioethical Issues published a report that expressed serious concerns about personal privacy and security in whole genome sequencing. The bioethics commission (on which we serve as chair and vice-chair) highlighted the importance of reconciling the enormous public benefits anticipated from research in this area with the potential risks to individuals’ privacy, and it offered several policy proposals to help balance the potential of scientific progress with privacy and respect for persons.

The human subjects research protections laid out in the federal regulations are triggered by the identifiability of data. The participants in the Gymrek et al. study were not “readily identifiable”; however, the data proved far more easily identifiable than expected. With rapidly evolving technology, a precise definition of that notion may be impossible. But if we move the debate from the rhetoric of identifiability to the ethical principles of public beneficence and the centrality of respecting all persons, we find that the real ethical focus must be on promoting generalizable progress while at all times respecting individual privacy.

As Jonathan Haidt explains in The Righteous Mind, it is often our moral intuitions that come first, rapidly or even automatically, with ethical reasoning coming later. Haidt's book is one of many that have come out in recent years highlighting the relevance of psychology (and its close cousin, neuroscience) for understanding human morality. As a behavioral scientist, I have devoured many of these books. I am fascinated by human nature and love trying to understand why all of us behave and think the way we do. But as a physician ethicist, I often find myself reading these books with a parallel agenda: not just to understand human nature, but also to see whether this line of research has relevance for my work as an ethicist. My bottom line: Understanding moral psychology ought to be a required component of ethics training, not because the science will help us to differentiate between right and wrong, but because it will better equip us to teach ethics in a way that promotes moral behavior in our students.

Medications of choice, necessary supplies, and evidence-based health care now seem like luxuries. The contrast between my experience at a well-funded health unit and the Lev El Lev (“heart to heart”) African Refugee Clinic in Tel Aviv, Israel, is staggering. The complex personal, social, health, psychological, educational, and economic difficulties create a unique ethical environment for the health care provider.

Can Congress require AIDS service organizations to pledge fidelity to the government's view opposing prostitution as a condition of receiving funding? This term, the Supreme Court will decide whether the First Amendment permits such censorship in USAID v. Alliance for Open Society International (AOSI).

The 2008 legislation reauthorizing the President's Emergency Plan for AIDS Relief (PEPFAR) requires host countries to support “activities promoting abstinence, delay of sexual début, monogamy, and fidelity.” PEPFAR's “conscience clause” allows organizations with a moral or religious objection to opt out of providing services to patients with a sexual orientation of which they disapprove. In addition, the law requires grantees to adopt “a policy explicitly opposing prostitution” and to refrain from any speech or activities the government deems “inconsistent” with that policy. The antiprostitution pledge extends not only to what a recipient says or does with PEPFAR funds, but even to what it says or does with its own private funds. The government, however, has not enforced the pledge against U.S.-based nongovernmental organizations partly because of a preliminary injunction granted by the lower courts. That injunction is now at risk if the Supreme Court upholds the loyalty oath.

Should public health authorities have access to your personal medical information without your permission? The usual justifications for requiring informed consent do not necessarily apply. That is not to say that consent may be avoided in all situations, just that the reasons for requiring consent in public health are different than for traditional medical treatment.

John Donne, poet laureate of the human body, was much troubled by its fate. Scorning Plato's picture of the body as the soul's prison, Donne imagined souls as leaving their bodies reluctantly and as yearning to return to the very one from which they had departed. In poems like “The Ecstasy,” he depicts the union of lovers’ souls, hints at a similar love of souls for bodies, and suggests that it is through the body—“his book”—that the lover comes to know love's spiritual mysteries. John Lantos also thinks bodies important, and that some among their possible fates, anyway, can be troubling.

A review of Controversial Bodies: Thoughts on the Public Display of Plastinated Corpses, edited by John D. Lantos.

Working at The Hastings Center has been a tremendous professional stepping stone for me. I have long wanted to work in publishing, and I'm leaving the Center to work for America's oldest publisher, John Wiley and Sons. But I feel that my time here has been more than that-that it has truly continued my education in ways I could not have anticipated. Thank you for letting me be part of your intellectual lives.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January-February 2013 issue.

A reply by the author of “Obesity: Chasing an Elusive Epidemic” to